Dementia and Risk of 30‐Day Readmission in Older Adults After Discharge from Acute Care Hospitals

Characteristics associated with 30-day post-stroke readmission within an academic urban hospital network

OBJECTIVES

Hospital readmissions are associated with poor health outcomes including illness severity and medical complications. The objective of this study was to identify characteristics associated with 30-day post-stroke readmission in an academic urban hospital network.

MATERIALS AND METHODS

We collected data on patients admitted with stroke from 2017 through 2022 who were readmitted within 30 days of discharge and compared them to a subset of non-readmitted stroke patients. Chart review was used to collect demographics, characteristics of the stroke, co-morbid conditions, in-hospital complications, and post-discharge care. Univariate analyses followed by regression analysis were used to assess characteristics associated with post-stroke readmission.

RESULTS

We identified 4743 patients with stroke (18 % hemorrhagic, mean age 70.1 (standard deviation (SD) 17.2), 47.3 % female) discharged from the stroke services, of whom 282 (5.9 %) patients were readmitted within 30 days of index hospitalization. Univariate analyses identified 18 significantly different features between admitted and readmitted patients. Regression analysis revealed characteristics associated with readmission included private insurance (odds ratio (OR) 0.4, confidence interval (CI) 0.3-0.6, p < 0.001), comorbid peripheral vascular disease (PVD) (OR 2.7, CI 1.3-5.5, p = 0.009), malignancy (OR 1.6, CI 1.0-2.6, p = 0.04), seizure (OR 3.4, CI 1.4-8.2, p = 0.007), thrombolytic administration (OR 0.4, CI 0.2-0.7, p = 0.003), undergoing thrombectomy (OR 5.4, CI 2.9-10.1, p < 0.001), and higher discharge modified Rankin Scale score (OR 1.2, CI 1.0-1.3, p = 0.047).

CONCLUSIONS

Our data demonstrate that thrombectomy, high discharge Rankin score, comorbid malignancy, seizure or PVD, and lack of thrombolytic administration or private insurance predict readmission.

Profiles of healthcare use of persons living with dementia: A population-based cohort study

AIM

Persons living with dementia are a heterogeneous population with complex needs whose healthcare use varies widely. This study aimed to identify the healthcare use profiles in a cohort of persons with incident dementia, and to describe their characteristics.

METHODS

This is a retrospective cohort study of health administrative data in Quebec (Canada). The study population included persons who: (i) had an incident dementia diagnosis between 1 April 2015 and 31 March 2016; (ii) were aged ≥65 years and living in the community at the time of diagnosis. We carried out a latent class analysis to identify subgroups of healthcare users. The final number of groups was chosen based on clinical interpretation and statistical indicators.

RESULTS

The study cohort consisted of 15 584 individuals with incident dementia. Four profiles of healthcare users were identified: (i) Low Users (36.4%), composed of individuals with minimal healthcare use and fewer comorbidities; (ii) Ambulatory Care-Centric Users (27.5%), mainly composed of men with the highest probability of visiting cognition specialists; (iii) High Acute Hospital Users (23.6%), comprised of individuals mainly diagnosed during hospitalization, with higher comorbidities and mortality rate; and (iv) Long-Term Care Destined Users (12.5%), who showed the highest proportion of antipsychotics prescriptions and delayed hospitalization discharge.

CONCLUSIONS

We identified four distinct subgroups of healthcare users within a population of persons living with dementia, providing a valuable context for the development of interventions tailored to specific needs within this diverse population. Geriatr Gerontol Int 2024; 24: 789-796.

Racial/Ethnic Disparities in Hospital Readmission and Frequent Hospitalizations Among Medicare Beneficiaries With Alzheimer's Disease and Related Dementia: Traditional Medicare Versus Medicare Advantage

OBJECTIVES

Examine racial/ethnic disparities in 30-day readmission and frequent hospitalizations among Medicare beneficiaries with dementia in traditional Medicare (TM) versus Medicare Advantage (MA).

METHODS

In this case-control study, we used 2018-2019 TM and MA claims data. Participants included individuals 65+ with 2 years of continuous enrollment, diagnosis of dementia, a minimum of 4 office visits in 2018, and at least 1 hospitalization in 2019, (cases: TM [n = 36,656]; controls: MA [n = 29,366]). We conducted matching based on health-need variables and applied generalized linear models adjusting for demographics, health-related variables, and healthcare encounters.

RESULTS

TM was associated with higher odds of 30-day readmission (OR = 1.07 [CI: 1.02 to 1.12]) and frequent hospitalizations (OR = 1.10 [CI: 1.06 to 1.14]) compared to MA. Hispanic and Black enrollees in TM had higher odds of frequent hospitalizations compared with Hispanic and Black enrollees in MA, respectively (OR = 1.35 [CI: 1.19 to 1.54]) and (OR = 1.26 [CI: 1.13 to 1.40]). MA was associated with lower Hispanic-White and Black-White disparities in frequent hospitalizations by 5.8 (CI: -0.09 to -0.03) and 4.4 percentage points (PP; CI: -0.07 to -0.02), respectively. For 30-day readmission, there was no significant difference between Black enrollees in TM and MA (OR = 1.04 [CI: 0.92 to 1.18]), but Hispanic enrollees in TM had higher odds of readmission than Hispanics in MA (OR = 1.23 [CI: 1.06 to 1.43]). MA was associated with a lower Hispanic-White disparity in readmission by 1.9 PP (CI: -0.004 to -0.01).

DISCUSSION

MA versus TM was associated with lower risks of 30-day readmission and frequent hospitalizations. Moreover, MA substantially reduced Hispanic-White and Black-White disparities in frequent hospitalizations compared with TM.

Determinants of hospital readmissions in older people with dementia: a narrative review

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.

Social Services Post-discharge and Their Association With Readmission in a 2016 Swedish Geriatric Cohort

OBJECTIVES

To describe the social services received by a 2016 Swedish cohort after discharge from inpatient geriatric care and to analyze the association between level of social services post-discharge and 30-day readmission.

DESIGN

Observational, closed-cohort study.

SETTING AND PARTICIPANTS

All patients admitted to 1 of 3 regionally operated inpatient geriatric care settings in Region Stockholm, Sweden, in 2016 (n = 7453).

METHODS

Individual-level data from medical records and population registries were linked using unique personal identification numbers. Descriptive statistics were reported for 4 levels of municipal social services post-discharge: long-term care, 1 to 50 home help hours per month, >50 home help hours per month, and no home help. Multinomial logistic regression was performed to analyze the association between level of social services post-discharge and 3 outcomes within 30 days: readmission, death without readmission, or neither readmission nor death.

RESULTS

Results show that almost 11% of patients were discharged to long-term care and 54% received municipal home help services. Individuals with no municipal home help or with 1 to 50 hours per month were more likely to be readmitted within 30 days compared with those in long-term care. Living with more than 50 hours of help was not associated with an increased likelihood of 30-day readmission.

CONCLUSIONS AND IMPLICATIONS

Patients who received inpatient geriatric care are significant users of municipal social services post-discharge. Living in long-term care or with extensive home help appears to be a protective factor in preventing readmission compared with more limited or no home help services. Care transitions for this frail patient group require careful social care planning. Supporting individuals discharged with fewer social service hours may help reduce readmissions.

Multimorbidity and prior falls correlate with risk of 30-day hospital readmission in aged 80+: A prospective cohort study

BACKGROUND/PURPOSE

Thirty-day hospital readmission rate significantly raised with advanced age. The performance of existing predictive models for readmission risk remained uncertain in the oldest population. We aimed to examine the effect of geriatric conditions and multimorbidity on readmission risk among older adults aged 80 and over.

METHODS

This prospective cohort study enrolled patients aged 80 and older discharged from a geriatric ward at a tertiary hospital, with phone follow-up for 12 months. Demographics, multimorbidity, and geriatric conditions were assessed before hospital discharge. Logistic regression models were conducted to analyse risk factors for 30-day readmission.

RESULTS

Patients readmitted had higher Charlson comorbidity index scores, and were more likely to have falls, frailty, and longer hospital stay, compared to those without 30-day readmission. Multivariate analysis revealed that higher Charlson comorbidity index score was associated with readmission risk. Older patients with a fall history within 12 months had a near 4-fold increase in readmission risk. Severe frailty status before index admission was associated with a higher 30-day readmission risk. Functional status at discharge was not associated with readmission risk.

CONCLUSION

In addition to multimorbidity, history of falls and frailty were associated with higher hospital readmission risk in the oldest.

Outcomes among hospitalized patients with dementia and behavioral disturbances when physical restraints are introduced

BACKGROUND

Physical restraint use among patients hospitalized with dementia and behavioral disturbances has not been studied nationally in the United States.

METHODS

National Inpatient Sample database years 2016 through 2020 were used to compare physically restrained and unrestrained patients with dementia and behavioral disturbances. Multivariable regression analyses were used to assess patient outcomes.

RESULTS

There were 991,605 patients coded for dementia with behavioral disturbances. Among these, physical restraints were used with 64,390 (6.5%) and not with 927,215 (93.5%). Patients in the restrained group were younger (mean age ± standard error: 78.7 ± 0.25 vs. 79.9 ± 0.34 ; p < 0.01) and more often male (59.0% vs. 45.8%; p < 0.01) compared to the unrestrained group. A higher proportion of Black patients were in the restrained group (15.2% vs. 11.8%; p < 0.01). Larger hospitals also made up a more significant proportion of restrained versus unrestrained patients (53.3% vs. 45.1%; p < 0.01). Those with physical restraints had longer lengths of stays (adjusted mean difference [aMD] = 2.6 days CI [2.2-3.0]; p < 0.01) and higher total hospital charges (aMD = $13,150 CI [10,827-15,472]; p < 0.01). There were similar adjusted odds for in-hospital mortality (adjusted odds ratio [aOR] = 1.0 [CI 0.95-1.1]; p = 0.28) and lower odds of being discharged to home after hospitalization (aOR = 0.74 [0.70-0.79]; <0.01) for patients with physical restraints compared to those without.

CONCLUSION

Among patients hospitalized with dementia and behavioral disturbances, those with physical restraints had greater hospital resource utilization outcomes. Attempts to limit physical restraint use whenever possible may improve outcomes in this vulnerable population.

Association of physical restraint duration and undesirable outcomes amongst inpatients comorbid with dementia and pneumonia in acute care settings

AIMS AND OBJECTIVES

This study aimed to examine the association between physical restraint duration and undesirable outcomes amongst inpatients comorbid with dementia and pneumonia in acute care hospitals.

BACKGROUND

Physical restraints are frequently used in the management of patients, especially amongst patients with dementia. No previous study investigated the potential undesirable effects of physical restraints in patients with dementia.

METHODS

This was a cohort study using a nationwide discharge abstract database in Japan. Patients aged ≥65 years with dementia hospitalised for pneumonia or aspiration pneumonia between April 1, 2016 and March 31, 2019 were identified. The exposure was physical restraint. The primary outcome was hospital discharge to the community. Secondary outcomes included hospitalisation costs, functional decline, in-hospital mortality, and institutionalisation for long-term care.

RESULTS

A total of 18,255 inpatients with pneumonia and dementia in 307 hospitals were included in this study. Of them, 21.5% and 23.7% had physical restraint during full and partial days of hospital stays, respectively. Discharge to the community incidence rates was lower in the full-restraint vs. the no-restraint group (27 vs. 29 per 1000 person-days; HR, 1.05 [95% CI, 1.01-1.10]) and the partial-restraint vs. the no-restraint group (17 vs. 29 per 1000 person-days; HR, 1.79 [95% CI, 1.71-1.87]). The risks of functional decline were higher in the full-restraint vs. the no-restraint group (27.8% vs. 20.8%; RR, 1.33 [95% CI, 1.22, 1.46]) and the partial-restraint vs. the no-restraint group (29.2% vs. 20.8%; RR, 1.40 [95% CI, 1.29, 1.53]).

CONCLUSIONS

The use of physical restraints was associated with a lower incidence rate of discharge to the community and an increased risk of functional decline at discharge. Further research is needed to judge the benefit-risk balance of physical restraints in acute care settings.

RELEVANCE TO CLINICAL PRACTICE

Understanding the risk of physical restraints allows medical staff to improve the process of decision making in everyday practice. No Patient or Public Contribution.

REPORTING METHODS

The reporting of this article conforms to the STROBE statement.

Disparities in 30-day readmission rates among Medicare enrollees with dementia

BACKGROUND

Readmissions contribute to excessive care costs and burden for people living with dementia. Assessments of racial disparities in readmissions among dementia populations are lacking, and the role of social and geographic risk factors such as individual-level exposure to greater neighborhood disadvantage is poorly understood. We examined the association between race and 30-day readmissions in a nationally representative sample of Black and non-Hispanic White individuals with dementia diagnoses.

METHODS

This retrospective cohort study used 100% Medicare fee-for-service claims from all 2014 hospitalizations nationwide among Medicare enrollees with dementia diagnosis linked to patient, stay, and hospital factors. The sample consisted of 1,523,142 hospital stays among 945,481 beneficiaries. The relationship between all cause 30-day readmissions and the explanatory variable of self-reported race (Black, non-Hispanic White) was examined via generalized estimating equations approach adjusting for patient, stay, and hospital-level characteristics to model 30-day readmission odds.

RESULTS

Black Medicare beneficiaries had 37% higher readmission odds compared to White beneficiaries (unadjusted OR 1.37, CI 1.35-1.39). This heightened readmission risk persisted after adjusting for geographic factors (OR 1.33, CI 1.31-1.34), social factors (OR 1.25, CI 1.23-1.27), hospital characteristics (OR 1.24, CI 1.23-1.26), stay-level factors (OR 1.22, CI 1.21-1.24), demographics (OR 1.21, CI 1.19-1.23), and comorbidities (OR 1.16, CI 1.14-1.17), suggesting racially-patterned disparities in care account for a portion of observed differences. Associations varied by individual-level exposure to neighborhood disadvantage such that the protective effect of living in a less disadvantaged neighborhood was associated with reduced readmissions for White but not Black beneficiaries. Conversely, among White beneficiaries, exposure to the most disadvantaged neighborhoods associated with greater readmission rates compared to White beneficiaries residing in less disadvantaged contexts.

CONCLUSIONS

There are significant racial and geographic disparities in 30-day readmission rates among Medicare beneficiaries with dementia diagnoses. Findings suggest distinct mechanisms underlying observed disparities differentially influence various subpopulations.

All-Cause Readmission or Potentially Avoidable Readmission: Which Is More Predictable Using Frailty, Comorbidities, and ADL?

Background and Objectives

Readmission-related health care reforms have shifted their focus from all-cause readmissions (ACR) to potentially avoidable readmissions (PAR). However, little is known about the utility of analytic tools from administrative data in predicting PAR. This study determined whether 30-day ACR or 30-day PAR is more predictable using tools that assess frailty, comorbidities, and activities of daily living (ADL) from administrative data.

Research Design and Methods

This retrospective cohort study was conducted at a large general acute care hospital in Tokyo, Japan. We analyzed patients aged ≥70 years who had been admitted to and discharged from the subject hospital between July 2016 and February 2021. Using administrative data, we assessed each patient's Hospital Frailty Risk Score, Charlson Comorbidity Index, and Barthel Index on admission. To determine the influence of each tool on readmission predictions, we constructed logistic regression models with different combinations of independent variables for predicting unplanned ACR and PAR within 30 days of discharge.

Results

Among 16 313 study patients, 4.1% experienced 30-day ACR and 1.8% experienced 30-day PAR. The full model (including sex, age, annual household income, frailty, comorbidities, and ADL as independent variables) for 30-day PAR showed better discrimination (C-statistic: 0.79, 95% confidence interval: 0.77-0.82) than the full model for 30-day ACR (0.73, 0.71-0.75). The other prediction models for 30-day PAR also had consistently better discrimination than their corresponding models for 30-day ACR.

Discussion and Implications

PAR is more predictable than ACR when using tools that assess frailty, comorbidities, and ADL from administrative data. Our PAR prediction model may contribute to the accurate identification of at-risk patients in clinical settings who would benefit from transitional care interventions.

Comparisons of Cognitive Stimulation Therapy Between Community Versus Hospital-Based Settings: A Multi-Site Study

BACKGROUND

Non-pharmacological interventions such as Cognitive Stimulation Therapy (CST) have been shown to help persons living with dementia in improving cognitive function and recall. While previous CST interventions have been conducted largely with community populations, none have explored the outcomes of CST in larger healthcare settings. Our study explored differences of cognitive function, mood, and quality-of-life from CST groups both community and residential-based groups.

METHOD

Participants (N = 258) from academic and rural, hospital-based settings in Missouri engaged in 14-session psychosocial groups to aid reminiscence for enhanced cognitive function and recall.

RESULTS

Post-intervention cognitive function improvements occurred for community (t = -7.48, p < .001) and residential samples (t = -2.46, p < .05). Community groups showed significant improvement in overall mood related to their dementia (t = 6.37, p < .001).

CONCLUSION

Healthcare providers should consider CST as a supplemental intervention for older patients receiving usual care for dementia-related symptoms.

Impact of Dementia on Long-Term Hip Fracture Surgery Outcomes: An Electronic Health Record Analysis

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.

Patterns of staging, treatment, and mortality in gastric, colorectal, and lung cancer among older adults with and without preexisting dementia: a Japanese multicentre cohort study

BACKGROUND

Little is known about dementia's impact on patterns of diagnosis, treatment, and outcomes in cancer patients. This study aimed to elucidate the differences in cancer staging, treatment, and mortality in older cancer patients with and without preexisting dementia.

METHODS

Using cancer registry data and administrative data from 30 hospitals in Japan, this multicentre retrospective cohort study examined patients aged 65-99 years who were newly diagnosed with gastric, colorectal, or lung cancer in 2014-2015. Dementia status (none, mild, and moderate-to-severe) at the time of cancer diagnosis was extracted from clinical summaries in administrative data, and set as the exposure of interest. We constructed multivariable logistic regression models to analyse cancer staging and treatment, and multivariable Cox regression models to analyse three-year survival.

RESULTS

Among gastric (n = 6016), colorectal (n = 7257), and lung (n = 4502) cancer patients, 5.1%, 5.8%, and 6.4% had dementia, respectively. Patients with dementia were more likely to receive unstaged and advanced-stage cancer diagnoses; less likely to undergo tumour resection for stage I, II, and III gastric cancer and for stage I and II lung cancer; less likely to receive pharmacotherapy for stage III and IV lung cancer; more likely to undergo tumour resection for all-stage colorectal cancer; and more likely to die within three years of cancer diagnosis. The effects of moderate-to-severe dementia were greater than those of mild dementia, with the exception of tumour resection for colorectal cancer.

CONCLUSION

Older cancer patients with preexisting dementia are less likely to receive standard cancer treatment and more likely to experience poorer outcomes. Clinicians should be aware of these risks, and would benefit from standardised guidelines to aid their decision-making in diagnosing and treating these patients.

Effects of a financial incentive scheme for dementia care on medical and long-term care expenditures: A propensity score-matched analysis using LIFE study data

OBJECTIVE

Japan introduced a financial incentive scheme in April 2016 to improve hospital-based dementia care, but its effectiveness remains unclear. This study aimed to investigate the scheme's impact on medical and long-term care (LTC) expenditures, as well as on changes in care needs levels and daily living independence levels among older persons one year after hospital discharge.

METHODS

We linked medical and LTC claims databases, and retrospectively identified patients who received LTC needs certification and daily living independence assessments in Fukuoka, Japan. Case patients (received care under the new scheme) were those admitted from April 2016 to March 2018, and control patients were those admitted from April 2014 to March 2016 (before the scheme was implemented). Through propensity score matching, we identified 260 case patients and 260 control patients, and compared using t-tests, and chi-square tests.

RESULTS

The analyses found no significant differences between the case and control groups in medical expenditure (US$26,685 vs US$24,823, P = 0.37), LTC expenditure (US$16,870 vs US$14,374, P = 0.08), daily living independence level changes (26.5% vs 20.4%, P = 0.12), or care needs level changes (36.9% vs 30%, P = 0.11).

CONCLUSIONS

The financial incentive scheme for dementia care did not demonstrate any beneficial effects on patients' healthcare expenditures or health conditions. Further studies are needed to examine the scheme's long-term effects.

Incremental medical cost of delirium in elderly patients with cognitive impairment: analysis of a nationwide administrative database in Japan

OBJECTIVES

Delirium is a neuropsychiatric disorder that commonly occurs in elderly patients with cognitive impairment. The economic burden of delirium in Japan has not been well characterised. In this study, we assessed incremental medical costs of delirium in hospitalised elderly Japanese patients with cognitive impairment.

DESIGN

Retrospective, cross-sectional, observational study.

SETTING

Administrative data collected from acute care hospitals in Japan between April 2012 and September 2020.

PARTICIPANTS

Hospitalised patients ≥65 years old with cognitive impairment were categorised into groups-with and without delirium. Delirium was identified using a delirium identification algorithm based on the International Classification of Diseases 10^th Revision codes or antipsychotic prescriptions.

OUTCOME MEASURES

Total medical costs during hospitalisation were compared between the groups using a generalised linear model.

RESULTS

The study identified 297 600 hospitalised patients ≥65 years of age with cognitive impairment: 39 836 had delirium and 257 764 did not. Patient characteristics such as age, sex, inpatient department and comorbidities were similar between groups. Mean (SD) unadjusted total medical cost during hospitalisation was 979 907.7 (871 366.4) yen for patients with delirium and 816 137.0 (794 745.9) yen for patients without delirium. Adjusted total medical cost was significantly greater for patients with delirium compared with those without delirium (cost ratio=1.09, 95% CI: 1.09 to 1.10; p<0.001). Subgroup analyses revealed significantly higher total medical costs for patients with delirium compared with those without delirium in most subgroups except patients with hemiplegia or paraplegia.

CONCLUSIONS

Medical costs during hospitalisation were significantly higher for patients with delirium compared with those without delirium in elderly Japanese patients with cognitive impairment, regardless of patient subgroups such as age, sex, intensive care unit admission and most comorbidities. These findings suggest that delirium prevention strategies are critical to reducing the economic burden as well as psychological/physiological burden in cognitively impaired elderly patients in Japan.

Association of Diagnosed Dementia with Post-discharge Mortality and Readmission Among Hospitalized Medicare Beneficiaries

BACKGROUND

Patients with dementia are frequently hospitalized and may face barriers in post-discharge care.

OBJECTIVE

To determine whether patients with dementia have an increased risk of adverse outcomes following discharge.

DESIGN

Retrospective cohort study.

SUBJECTS

Medicare beneficiaries hospitalized in 2016.

MAIN MEASURES

Co-primary outcomes were mortality and readmission within 30 days of discharge. Multivariable logistic regression models were estimated to assess the risk of each outcome for patients with and without dementia accounting for demographics, comorbidities, frailty, hospitalization factors, and disposition.

KEY RESULTS

The cohort included 1,089,109 hospitalizations of which 211,698 (19.3%) were of patients with diagnosed dementia (median (IQR) age 83 (76-89); 61.5% female) and 886,411 were of patients without dementia (median (IQR) age 76 (79-83); 55.0% female). At 30 days following discharge, 5.7% of patients with dementia had died compared to 3.1% of patients without dementia (adjusted odds ratio (aOR) 1.21; 95% CI 1.17 to 1.24). At 30 days following discharge, 17.7% of patients with dementia had been readmitted compared to 13.1% of patients without dementia (aOR 1.02; CI 1.002 to 1.04). Dementia was associated with an increased odds of readmission among patients discharged to the community (aOR 1.07, CI 1.05 to 1.09) but a decreased odds of readmission among patients discharge to nursing facilities (aOR 0.93, CI 0.90 to 0.95). Patients with dementia who were discharged to the community were more likely to be readmitted than those discharged to nursing facilities (18.9% vs 16.0%), and, when readmitted, were more likely to die during the readmission (20.7% vs 4.4%).

CONCLUSIONS

Diagnosed dementia was associated with a substantially increased risk of mortality and a modestly increased risk of readmission within 30 days of discharge. Patients with dementia discharged to the community had particularly elevated risk of adverse outcomes indicating possible gaps in post-discharge services and caregiver support.

Automated telephone follow-up programs after hospital discharge: Do older adults engage with these programs?

BACKGROUND

Health systems have developed automated telephone call programs to screen and triage patients' post-hospital discharge issues and concerns. The aims of our study were to determine whether and how older adults engage with automated post-hospital discharge telephone programs and to describe the prevalence of patient-reported post-discharge issues.

METHODS

We identified all telephone calls made by an urban academic medical center as part of a post-hospital discharge program between May 1, 2018 and April 30, 2019. The program used automated telephone outreach to patients or their caregivers that included 11 distinct steps 3 days post-discharge. All adults discharged home from the hospital, were included, and we categorized patients into ≤64 years, 65-84 years, and ≥85 years age groups. We then compared call reach rate, completeness of 11-step calls and patient-reported issues between age groups.

RESULTS

Eighteen thousand and seventy six patients were included. More patients 65-84 years old were reached compared to patients ≤64 years old (84.3% vs. 78.9%, AME 5.52%; 95%CI: 3.58%-7.45%). Completion rates of automated calls for those ≥85 years old were also high. Patients ≥85 years old were more likely to have questions about their follow-up plans and need assistance scheduling appointments compared to those ≤64 years old (19.0% vs. 11.9%, AME 7.0% (95%CI: 2.7%-11.3%).

CONCLUSION

Post-hospital automated telephone calls are feasible and effective at reaching older adults. Future work should focus on improving discharge communication to ensure older adults are aware of their follow-up plan and appointments.

Quality of End-of-Life in Cancer Patients With Dementia: Using A Nationwide Inpatient Database

CONTEXT

The growing number of older people significantly affects end-of-life care. However, few studies have assessed the quality of end-of-life care among cancer patients with dementia.

OBJECTIVES

To assess the quality of end-of-life care among non-small cell lung cancer patients with or without dementia using a nationwide inpatient database from Japan.

METHODS

This was a retrospective observational study that used a nationwide inpatient database of 366 acute care hospitals from April 2014 to November 2018. Poisson regression models were used where the quality indicator was the dependent variable, dementia status was the independent variable, and the age group and Charlson comorbidity index were covariates. Incidence proportion ratios (IPRs) and confidence intervals (CIs) were obtained from the model.

RESULTS

The study population included 16,758 patients, of whom 4507 (26.9%) had dementia. The incidence proportion of opioid use (61.8% vs. 70.8%; IPR: 0.87, 95% CI: 0.83-0.91), palliative care consultation (2.7% vs. 3.8%; IPR: 0.71, 95% CI: 0.58-0.88), mechanical ventilation (4.0% vs. 5.4%; IPR: 0.74, 95% CI: 0.62-0.87), and cardiopulmonary resuscitation (2.2% vs. 2.8%; IPR: 0.79, 95% CI: 0.63-0.99) was significantly lower in patients with dementia than in those without dementia.

CONCLUSION

Patients with dementia are less likely to receive end-of-life care. This study demonstrates the importance of providing high-quality end-of-life care regardless the cognitive status of patients with cancer.

Correlation of Inpatients Suffering from Acute Acalculous Cholecystitis during ICU Treatment with Acute Physiology and Chronic Health Evaluation II Score, Duration of Ventilator Use, and Time on Total Parenteral Nutrition

Objective

To explore the correlation of inpatients suffering from acute acalculous cholecystitis (AAC) during ICU treatment with Acute Physiology and Chronic Health Evaluation II (APACHE-II) score, duration of ventilator use, and time on total parenteral nutrition (TPN).

Methods

From March 2016 to March 2022, the clinical data of 47 patients with AAC who received ICU treatment in our hospital were retrospectively reviewed, and these patients were included in the AAC group. Another 36 patients treated in the ICU in the same period with age and gender matching with those in the AAC group were selected as the non-AAC group. Patients' various clinical data were recorded to analyze the correlation of AAC with APACHE-II score, duration of ventilator use, and time on TPN.

Results

The shock time, duration of ventilator usage, and duration of sedative medicine use were all substantially longer in the AAC group than in the non-AAC group, according to the univariate analysis (P < 0.05); the amount of norepinephrine used, white blood cell count, C-reactive protein (CRP) amount, and APACHE-II score were significantly higher in the AAC group than in the non-AAC group (P < 0.05); between the two groups, the time on TPN and fasting time were different, but with no statistical significance (P > 0.05); after performing Spearman's correlation with the significantly between-group different indicators, the result showed that the amount of norepinephrine used, duration of ventilator use, white blood cell count, and CRP amount were significantly correlated with the occurrence of AAC, and the correlation was positive (P all <0.001).

Conclusion

The APACHE-II score and time on TPN are not significantly correlated with the occurrence of AAC; and the amount of norepinephrine used, duration of ventilator use, white blood cell count, and serum CRP are positively correlated with the occurrence of AAC. Measuring the variations in the levels of various markers can signal the onset of AAC or reflect the state and prognosis, suggesting a possible application in clinic-based targeted prevention and treatment of AAC.

The Performance Assessment of Self-Care Skills to Predict Adverse Events Post-Discharge

Background. The Performance Assessment of Self-Care Skills (PASS) is a standardized assessment of the ability to perform daily activities. Purposes. This preliminary exploratory study aimed to 1) explore the ability of four PASS tasks to predict adverse events (readmissions and injuries) in older adults following hospitalization; 2) compare PASS's predictive validity to that of a generic tool (SMAF) and OT clinical judgement. Method.Twenty-two older patients were assessed in hospital at discharge and at home one week later. Adverse events were documented for six months post-discharge. Sensitivity and specificity analyses (ROC curves, Fisher's exact tests) were performed. Findings. Two PASS tasks (telephone, medication), the SMAF-Social and OT clinical judgement could identify individuals at risk of readmission (AUC > 0.7; p < 0.05). Implications. Using the PASS to assess more cognitively demanding tasks could be a promising way to predict adverse events after discharge, as a complement to clinical judgment.

Existing Data Sources for Clinical Epidemiology: Database of the National Hospital Organization in Japan

This review introduces the National Hospital Organization (NHO) database in Japan. The NHO has maintained two databases through a system of data collection from 140 hospitals in the NHO. National Hospital Organization Clinical Data Archives (NCDA) is collecting clinical information in real time from the electronic medical records since January 2016, and Medical Information Analysis (MIA) databank is collecting daily insurance claims data since April 2010. The NHO database covers more than 8 million patients in 140 hospitals throughout Japan. The database consists of the information of patient profiles, hospital admission and discharge, diagnosis with ICD-10 codes, text data from medical chart, daily health insurance claims such as medical procedures, medications or surgeries, vital signs and laboratory data, and so on. The NHO database includes a wide variety of diseases and settings, including acute, chronic and intractable diseases, emergency medical services, disaster medicine, response to emerging infectious disease outbreaks, medical care according to health policies such as psychiatry, tuberculosis, or muscular dystrophy, and health systems in sparsely populated non-urban areas. Among several common diseases, the database has representativeness in terms of age distribution compared with the Patient Survey 2017 by the Ministry of Health, Labour and Welfare. Interested researchers can contact (700-dbproject@mail.hosp.go.jp) the NHO database division to obtain more information about the NHO database for utilization.

“Staying at Home”: A pivotal trial of telemedicine-based internal medicine hospitalization at a nursing home

Background

In-hospital stay of acutely ill elderlies could be reduced by increasing the availability of community-based hospitalizations. The feasibility of remotely managing these patients by specialized internists, without leaving their nursing homes should be sought. In the current pivotal study, we aimed to evaluate the aforementioned model.

Methods

This was a prospective, open-label study at a tertiary medical center and a nursing home. The study aimed at comparing clinical outcomes of patients hospitalized in each location.

Results

Over a period of 5.5 months, we recruited 18 patients designated for hospitalization, meeting our inclusion criteria to either in-hospital stay or staying in their nursing home and treated by means of telemedicine from our tertiary medical center. The mean age was 85.3 years. Out of 114 hospitalization days, 44 days (48%) were at the nursing home. No significant difference was noted in terms of age, gender, and length of stay between the patients who were hospitalized in either location. In almost all cases, diagnosis changed during hospitalization. Three patients died during the study, all included in the in-hospital group. No safety breaching events happened in the nursing home-hospitalization group.

Conclusions

Remote, telemedicine-based hospitalization of nursing home-dwelling elderlies is safe and feasible, potentially reducing the length of in-hospital stay by almost 50%. Larger studies in this realm are warranted.

Discharge Communication of Dementia-Related Neuropsychiatric Symptoms and Care Management Strategies During Hospital to Skilled Nursing Facility Transitions

Provided the complexity of managing dementia-related neuropsychiatric symptoms (NPS), accurate communication about these symptoms at hospital discharge is critical to facilitating safe and effective transitions, particularly transitions from hospitals to skilled nursing facilities (SNF), which are often poorly managed. Skilled nursing facilities providers have cited undercommunication regarding NPS as a major challenge that contributes to poor outcomes including rehospitalization. This multisite retrospective cohort study identified omission rates for NPS and associated management strategies in discharge communication as compared to medical record documentation in the 72 hours preceding discharge among hospitalized patients with dementia. High rates of omission were found across NPS and management strategies: anxiety (94%), agitation/aggression (77%), hallucinations (85%), 1:1 supervision (90%), high fall risk (89%), use of restraints (91%). Omission rate for new or modified antipsychotic medication was 12.9%. Findings underscore the need for additional research on cross-setting communication regarding care needs of patients with dementia-who often cannot communicate these needs on their own-in facilitating high-quality transitions.

Outcomes of a financial incentive scheme for dementia care by dementia specialist teams in acute-care hospitals: A difference-in-differences analysis of a nationwide retrospective cohort study in Japan

OBJECTIVES

The quality of care for dementia in acute-care settings has been criticised. In 2016, the Japanese universal health insurance system introduced a financial incentive scheme for dementia care by dementia specialist teams in acute-care hospitals. This study aimed to investigate the effectiveness of this financial incentive scheme on short-term outcomes (in-hospital mortality and 30-day readmission).

DESIGN AND METHODS

Using a Japanese nationwide inpatient database, we identified older adult patients with moderate-to-severe dementia admitted for pneumonia, heart failure, cerebral infarction, urinary tract infection, intracranial injury or hip fracture from April 2014 to March 2018. We selected 180 propensity score-matched pairs of hospitals that adopted (n = 180 of 185) and that did not adopt (n = 180 of 744) the financial incentive scheme. We then conducted a patient-level difference-in-differences analysis. In a sensitivity analysis, we restricted the postintervention group to patients who actually received dementia care.

RESULTS

There was no association between a hospital's adoption of the incentive scheme and in-hospital mortality (adjusted odds ratio [aOR]: 0.97; 95% confidence interval [CI]: 0.88-1.06; p = 0.48) or 30-day readmission (aOR: 1.04; 95% CI: 0.95-1.14; p = 0.37). Only 29% of patients in hospitals adopting the scheme actually received dementia care. The sensitivity analysis showed that receiving dementia care was associated with decreased in-hospital mortality.

CONCLUSIONS

The financial incentive scheme to enhance dementia care by dementia specialist teams in Japan may not be working effectively, but the results do suggest that individual dementia care was associated with decreased in-hospital mortality.

Hospital readmissions following infections in dementia: a nationwide and registry-based cohort study

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.

Skin Ulcers are Predictors of 30-Day Hospital Readmission, But are Under-represented in the DRG Coding: A Retrospective Case-Control Study From an Italian Internal Medicine Unit

This study retrospectively analyzes all consecutive patients who underwent during a year hospital readmissions, defined as an admission to a hospital within 30 days of discharge, to an Italian Internal Medicine ward. All these data were compared with those from patients who underwent only 1 hospital admission in the same period. The aim of this study was to identify potential novel risk factors for hospital readmissions. In 2018, a total of 3012 patients were hospitalized. Among these, 14.1% (n = 426; mean age, 79.7 ± 11.9; range, 23-100) were defined as readmissions; data were compared with controls (n = 420; 13.9%; mean age, 75.9 ± 14.7; range, 22-99) who had only 1 hospitalization. Cases showed a significantly higher prevalence than controls regarding cerebrovascular disease (77.2% vs 48.1%), cognitive impairment (51.8% vs 26.9%), congestive heart failure (47.6% vs 20.2%), chronic kidney disease (31.7% vs 13.1%), and chronic obstructive pulmonary disease (23.0% vs 14.5%). Skin ulcers were significantly more prevalent among cases (45.1% vs 17.6%). Diagnosis-related group (DRG) analysis showed a higher proportion of "infectious disease" (24.4% vs 15.0%) among the cases than in controls. Despite skin ulcers were very frequent among cases and controls (45.1% vs 17.6%), they were codified as "skin wound" DRG only in 1.4% and 0.2%, respectively. At the DRGs analysis, sepsis (31.6% vs 19.1%), pneumonia (17.1% vs 7.6%), and kidney failure (9.6% vs 3.8%) represented the main significant cause of death in cases compared to controls. Our study confirms that readmissions to Internal Medicine departments are related to the severity of chronic diseases affecting patients. Skin ulcers are present in about half of patients who will be early readmitted within 30 days, but they are almost never reported in DRGs, so more accurate coding is needed. Key challenges for the future are sepsis prevention measures and investing resources in chronic disease assistance, including skin ulcer chronic management.

Dementia and patient outcomes after hip surgery in older patients: A retrospective observational study using nationwide administrative data in Japan

OBJECTIVE

To investigate whether dementia is associated with incidence of adverse events and longer hospital stays in older adults who underwent hip surgery, after adjusting for individual social and nursing care environment.

DESIGN AND SETTING

Retrospective observational study using the linked data between the Japanese Diagnosis Procedure Combination database and the reports of the medical functions of hospital beds database in Japan (April 2016-March 2017).

PARTICIPANTS

A total of 48,797 individuals aged 65 and older who underwent hip surgery and were discharged during the study period.

METHODS

Outcomes included in-hospital death, in-hospital pneumonia, in-hospital fracture, and longer hospital stay. We performed two-level, multilevel models adjusting for individual and hospital characteristics.

RESULTS

Among all participants, 20,638 individuals (42.3%) had dementia. The incidence of adverse events for those with and without dementia included in-hospital death: 2.11% and 1.11%, in-hospital pneumonia: 0.15% and 0.07%, and in-hospital fracture: 3.76% and 3.05%, respectively. The median (inter quartile range) length of hospital stay for those with and without dementia were 26 (19-39) and 25 (19-37) days, respectively. Overall, the odds ratios (95% confidence interval (CI)) of dementia for in-hospital death, in-hospital pneumonia, and in-hospital fracture were 1.12 (0.95-1.33), 0.95 (0.51-1.80), and 1.08 (0.92-1.25), respectively. Dementia was not associated with the length of hospital stay (% change) (-0.7%, 95% CI -1.6-0.3%). Admission from home, discharge to home, and lower nurse staffing were associated with prolonged hospital stays.

CONCLUSIONS

Although adverse events are more likely to occur in older adults with dementia than in those without dementia after hip surgery, we found no evidence of an association between dementia and adverse events or the length of hospital stay after adjusting for individual social and nursing care environment.

Malnutrition and depression as predictors for 30-day unplanned readmission in older patient: a prospective cohort study to develop 7-point scoring system

BACKGROUND

Readmission is related to high cost, high burden, and high risk for mortality in geriatric patients. A scoring system can be developed to predict the readmission of older inpatients to perform earlier interventions and prevent readmission.

METHODS

We followed prospectively inpatients aged 60 years and older for 30 days, with initial comprehensive geriatric assessment (CGA) on admission in a tertiary referral centre. Patients were assessed with CGA tools consisting of FRAIL scale (fatigue, resistance, ambulation, illness, loss of weight), the 15-item Geriatric Depression Scale, Mini Nutritional Assessment short-form (MNA-SF), the Barthel index for activities of daily living (ADL), Charlson Comorbidity Index (CCI), caregiver burden based on 4-item Zarit Burden Index (ZBI), and cognitive problem with Abbreviated Mental Test (AMT). Demographic data, malignancy diagnosis, and number of drugs were also recorded. We excluded data of deceased patients and patients transferred to other hospitals. We conducted stepwise multivariate regression analysis to develop the scoring system.

RESULTS

Thirty-day unplanned readmission rate was 37.6 %. Among 266 patients, 64.7 % of them were malnourished, and 46.5 % of them were readmitted. About 24 % were at risk for depression or having depressed mood, and 53.1 % of them were readmitted. In multivariate analysis, nutritional status (OR 2.152, 95 %CI 1.151-4.024), depression status (OR 1.884, 95 %CI 1.071-3.314), malignancy (OR 1.863 95 %CI 1.005-3.451), and functional status (OR 1.584, 95 %CI 0.885-2.835) were included in derivation of 7 score system. The scoring system had maximum score of 7 and incorporated malnutrition (2 points), depression (2 points), malignancy (2 points), and dependent functional status (1 point). A score of 3 or higher suggested 82 % probability of readmission within 30 days following discharge. Area under the curve (AUC) was 0.694 (p = 0.001).

CONCLUSIONS

Malnutrition, depression, malignancy and functional problem are predictors for 30-day readmission. A practical CGA-based 7 scoring system had moderate accuracy and strong calibration in predicting 30-day unplanned readmission for older patients.

Physical performance measures and hospital outcomes among Italian older adults: results from the CRIME project

BACKGROUND

Older adults are a complex population, at risk of adverse events during and after hospital stay.

AIM

To investigate the association of walking speed (WS) and grip strength (GS) with adverse outcomes, during and after hospitalization, among older individuals admitted to acute care wards.

METHODS

Multicentre observational study including 1123 adults aged ≥ 65 years admitted to acute wards in Italy. WS and GS were measured at admission and discharge. Outcomes were length-of-stay, in-hospital mortality, 1-year mortality and rehospitalisation. Length-of-stay was defined as a number of days from admission to discharge/death.

RESULTS

Mean age was 81 ± 7 years, 56% were women. Compared to patients with WS ≥ 0.8 m/sec, those unable to perform or with WS < 0.8 m/sec had a higher likelihood of longer length-of-stay (OR 2.57; 95% CI 1.63-4.03 and 2.42; 95% CI 1.55-3.79) and 1-year mortality and rehospitalization (OR 1.47, 95% CI 1.07-2.01; OR 1.57, 95% CI 1.04-2.37); those unable to perform WS had a higher likelihood of in-hospital mortality (OR 9.59; 95% CI 1.23-14.57) and 1-year mortality (OR 2.60; 95% CI 1.37-4.93). Compared to good GS performers, those unable to perform had a higher likelihood of in-hospital mortality (OR 17.43; 95% CI 3.87-28.46), 1-year mortality ( OR 3.14; 95% CI 1.37-4.93) and combination of 1-year mortality and rehospitalisation (OR 1.46; 95% CI 1.01-2.12); poor GS performers had a higher likelihood of 1-year mortality (OR 1.39; 95% CI 1.03-2.35); participants unable to perform GS had a lower likelihood of rehospitalisation (OR 0.59; 95% CI 0.39-0.89).

CONCLUSION

Walking speed (WS) and grip strength (GS) are easy-to-assess predictors of length-of-stay, in-hospital and post-discharge death and should be incorporated in the standard assessment of hospitalized patients.

Propofol shows less negative effects on cognitive performances than dexmedetomidine in elderly intensive care unit patients

BACKGROUND

Due to the improved clinical management of aging population and the consequently declined mortality among patients with critical illnesses, the number of survivors from intensive care units (ICUs) keeps rising. Studies to examine the association of cognitive impairment analgesic and sedation strategies would be beneficial to improve the quality of life of ICU survivors.

METHODS

A prospective clinical trial was designed to compare the effects of two drugs, propofol, and dexmedetomidine, on short-term cognitive impairment after sedation in elderly ICU survivors by evaluating the extent of independence limited by the dementia-related activities of daily livings (ADLs). The plasma concentrations of brain injury biomarkers including S100β and neuron-specific enolase (NSE) were determined using an enzyme immunoassay. There were 136 patients allocated into both the dexmedetomidine group and the propofol group, respectively, with matched demographic characteristics.

RESULTS

The dementia scale of the patients in the dexmedetomidine group was significantly higher than the propofol group at weeks 1-4. Moreover, the changes in S100β and NSE concentrations in the dexmedetomidine group were significantly more pronounced than the propofol group. ICU patients who received dexmedetomidine intervention showed higher cognitive impairment than patients who received propofol, and this protective effect of propofol was not associated with the levels of brain injury markers S100β and NSE.

CONCLUSION

Our study compared the effects of commonly used medications on short-term cognitive impairment in elderly ICU patients, which would aid the selection of sedation plan for the benefit of ICU patients.

An analysis of equity in treatment of hip fractures for older patients with dementia in acute care hospitals: observational study using nationwide hospital claims data in Japan

Background

Globally, and particularly in countries with rapidly ageing populations like Japan, there are growing concerns over the heavy burden of ill health borne by older people, and the capacity of the health system to ensure their access to quality care. Older people with dementia may face even greater barriers to appropriate care in acute care settings. Yet, studies about the care quality for older patients with dementia in acute care settings are still few. The objective of this study is to assess whether dementia status is associated with poorer treatment by examining the association of a patient’s dementia status with the probability of receiving surgery and the waiting time until surgery for a hip fracture in acute care hospitals in Japan.

Methods

All patients with closed hip fracture were extracted from the Diagnosis Procedure Combination (DPC) database between April 2014 and March 2018. After excluding complicated cases, we conducted regressions with multilevel models. We used two outcome measures: (i) whether the patient received a surgery or was treated by watchful waiting; and (ii) number of waiting days until surgery after admission.

Results

Two hundred fourteen thousand six hundred one patients discharged from 1328 hospitals were identified. Among them, 159,173 patients received surgery. Both 80–89 year-olds (OR 0.87; 95% CI, 0.84, 0.90) and those 90 years old and above (OR 0.67; 95% CI, 0.65, 0.70) had significantly lower odds ratios for receiving surgery compared to 65–79 year-olds. Those with severe dementia had a significantly greater likelihood of receiving surgery compared to those without dementia (OR 1.21; 95% CI, 1.16, 1.25). Patients aged 90 years old and above had shorter waiting time for surgery (Coef. -0.06; 95% CI, − 0.11, − 0.01). Mild dementia did not have a statistically significant impact on the number of waiting days until surgery (P = 0.34), whereas severe dementia was associated with shorter waiting days (Coef. -0.08; 95% CI, − 0.12, − 0.03).

Conclusions

These findings suggest physicians may be taking proactive measures to preserve physical function for those with severe dementia and to avoid prolonged hospitalization although there are no formal guidelines on prioritization for the aged and dementia patients.

Hospitalization and discharge routes of elderly hip fracture patients with and without dementia: a nationwide cross-sectional exploratory study using the Japanese Diagnostic Procedure Combination database

PURPOSE

The characteristics of elderly hip fracture patients in acute care hospitals were analyzed based on hospitalization and discharge route and the presence or absence of a dementia diagnosis.

METHODS

The study was conducted as a cross-sectional exploratory study using data from the Diagnosis Procedure Combination database in Japan from April 2014 to March 2016. Patients aged 65 years or older who had surgery for a hip fracture were identified. We subsequently extracted patients whose home, medical institution (including convalescent rehabilitation wards), or elderly care facility was both the admission and discharge route. A total of 105 122 patients were included.

RESULTS

19% of patients were diagnosed with dementia. Patients with dementia had a shorter length of acute care hospital stay than those without dementia. The hospitalization route for dementia patients was 51% at home and 40% at a care facility. Dementia patients were discharged to hospital and care facilities at 41% each. Nearly all patients received hospital-based postoperative rehabilitation regardless of dementia but patients with dementia had lower gains in activities of daily living.

CONCLUSION

Hip fracture patients with dementia have less opportunity for continuous hospital-based rehabilitation and need an environment that allows for continuous elderly care facility-based and community-based rehabilitation.IMPLICATIONS FOR REHABILITATIONIn Japan, an aging society, one in five elderly patients undergoing hip fracture surgery was diagnosed with dementia.Many hip fracture patients with dementia have a shorter length of hospital stay and may have fewer opportunities to change hospitals to receive rehabilitation.It is necessary to establish an ongoing and proactive community- and elderly care facility-based rehabilitation system for patients with hip fracture with dementia after acute care hospital discharge.

Association between nursing care delivery models and patients' health outcomes in a university hospital: A retrospective cohort study based on the Diagnostic Procedure Combination database

AIM

This study aims to examine the association between nursing delivery models (fixed-team nursing model and Partnership Nursing System® [PNS®]) and patients' health outcomes (30-day in-hospital mortality and functional decline, indicated by a decline in Barthel Index or in-hospital mortality).

METHODS

This study used a retrospective cohort design based on the data from the Diagnostic Procedure Combination database, which included routinely collected health data for Japanese administrative claims. Participants were inpatients aged 20-99 years admitted between July 2010 and August 2012 (fixed-team nursing period) and July 2014 and August 2017 (PNS® period) to an academic teaching hospital in Japan. Odds ratios and 95% confidence intervals were estimated using multivariable logistic models.

RESULTS

We included 24,108 and 23,872 patients for the analyses of 30-day in-hospital mortality and functional decline, respectively (median age: 62 years; 52% women). The 30-day mortalities in both fixed-team nursing and PNS® groups were 0.5%. There was no significant association between the nursing delivery models and 30-day in-hospital mortality (adjusted odds ratio = 1.15, 95% confidence interval = 0.78-1.70). However, the PNS® group was found to have a higher proportion of patients with functional decline (2.7%) than the fixed-team nursing group (2.2%; p = .030). The adjusted odds ratio of declined function in the PNS® group, compared to the fixed-team nursing group, was 1.40 (95% confidence interval = 1.17-1.68, p < .001).

CONCLUSIONS

Further studies are needed to examine how the PNS® model influences patient outcomes, especially nurse-sensitive patient outcomes.

Associations of Hospital Discharge Services With Potentially Avoidable Readmissions Within 30 Days Among Older Adults After Rehabilitation in Acute Care Hospitals in Tokyo, Japan

OBJECTIVE

To examine the associations of 3 major hospital discharge services covered under health insurance (discharge planning, rehabilitation discharge instruction, and coordination with community care) with potentially avoidable readmissions (PARs) within 30 days in older adults after rehabilitation in acute care hospitals in Tokyo, Japan.

DESIGN

Retrospective cohort study using a large-scale medical claims database of all Tokyo residents aged ≥75 years.

SETTING

Acute care hospitals.

PARTICIPANTS

Patients who underwent rehabilitation and were discharged to home (N=31,247; mean age in years ± SD, 84.1±5.7) between October 2013 and July 2014.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

30-day PAR.

RESULTS

Among the patients, 883 (2.9%) experienced 30-day PAR. A multivariable logistic generalized estimating equation model (with a logit link function and binominal sampling distribution) that adjusted for patient characteristics and clustering within hospitals showed that the discharge services were not significantly associated with 30-day PAR. The odds ratios were 0.962 (95% confidence interval [CI], 0.805-1.151) for discharge planning, 1.060 (95% CI, 0.916-1.227) for rehabilitation discharge instruction, and 1.118 (95% CI, 0.817-1.529) for coordination with community care. In contrast, the odds of 30-day PAR among patients with home medical care services were 1.431 times higher than those of patients without these services (P<.001), and the odds of 30-day PAR among patients with a higher number (median or higher) of rehabilitation units were 2.031 times higher than those of patients with a lower number (below median) (P<.001). Also, the odds of 30-day PAR among patients with a higher Hospital Frailty Risk Score (median or higher) were 1.252 times higher than those of patients with a lower score (below median) (P=.001).

CONCLUSIONS

The insurance-covered discharge services were not associated with 30-day PAR, and the development of comprehensive transitional care programs through the integration of existing discharge services may help to reduce such readmissions.

What are we asking for when requesting "Specialling" for the confused hospitalised older person? A concept analysis

BACKGROUND AND/OR RATIONALE: "Specialling" is a common nursing practice in hospitals which entails the allocation of extra staff to be with an older person who is confused to maintain safety. Despite ongoing use, this practice has little evidence of effectiveness. To facilitate further investigation, a concept analysis of "specialling" was undertaken.

AIMS

The aim of this paper was to report on a concept analysis on the practice of "specialling" pertaining to older people who have cognitive impairment when in hospital.

METHODS

This study used Rodgers evolutionary approach to concept analysis to clarify the attributes, antecedents and consequences of the concept to determine a definition of "specialling." Web of Science (Core Collection and Web of Science Medline), CINAHL and SCOPUS databases were searched to identify relevant literature. Due to the scarcity of papers, the search was broadened to include all sources that could add understanding.

FINDINGS

A total of (n = 43) sources were identified. The attributes were themed to 5 categories: Labels and descriptions; the "Special" role; Patient safety; Patient care; and Communication. The antecedents to 2 themes: Patient characteristics; and Organisational risk. The consequences of "specialling" were diverse with 6 themes: the "Special" role; the Older persons experience; Costly; "Special" use and nursing beliefs; Safety outcomes; and Opportunities.

DISCUSSION

The process of concept analysis provided a means to identify knowledge gaps and practice challenges. The definition determined from this analysis has provided a reflective opportunity for clinicians and researchers to consider when implementing care initiatives to support older people in hospital. Important is the lack of person-centred approaches and the opportunities in developing nurse leadership through empowerment. The findings from this analysis will inform a PhD study.

IMPLICATIONS FOR PRACTICE

Nurses have an opportunity to lead care improvements by ensuring person-centred approaches in the care of older people with cognitive impairment.

Establishing a hospital transfusion management system promotes appropriate clinical use of human albumin in Japan: a nationwide retrospective study

BACKGROUND

Despite international recommendations to establish hospital transfusion management systems to promote appropriate use of blood products, the general efficacy of establishing such systems has not been proven. This study aimed to validate the effect of establishing such systems for promoting the appropriate use of human albumin.

METHODS

In this retrospective observational study, we used a Japanese Diagnosis Procedure Combination (DPC) database from fiscal year 2012 to 2016, which included inpatient records from approximately 1200 hospitals for payment processes in the national medical insurance system. From this existing database, containing approximately 8 million inpatient records per year, we selected patients with emergency due to "bleeding," "sepsis," and "burn injury," by using the International Classification of Diseases and Injuries 10th revision (ICD-10) codes, and hospitals that had one or more patients for each disease group in each fiscal year. We conducted multivariable logistic regression analysis to estimate the relationship between human albumin administration and the state of the hospital transfusion management system. We evaluated temporal trends of mortality rate and length of stay as an indicator of care quality.

RESULTS

Overall, 139,853 eligible patients admitted to 682 hospitals were selected. The results of the multivariable logistic regression analysis show that patients who were admitted to hospitals with an established hospital transfusion department introducing good practice criteria of blood products were less likely to be administered human albumin compared with those who were admitted to hospitals not introducing it, by approximately 30% for each of the three disease groups; adjusted odds ratios (95% confidential intervals) were 0.70 (0.59-0.83), 0.75 (0.69-0.81), and 0.71 (0.58-0.87) in the "bleeding," "sepsis," and "burn injury" groups, respectively. The temporal trends evaluation shows that there were no increasing trends of mortality rate and average length of stay against decreasing trends of human albumin administration in any disease groups.

CONCLUSIONS

Establishing a hospital transfusion department responsible for promoting appropriate clinical use of blood products could reduce human albumin administration for critically ill patients without loss of care quality. These findings provide support for policy makers and hospital managers to consider establishing such systems.

Structure and process of dementia care and patient outcomes after hip surgery in elderly people with dementia: A retrospective observational study in Japan

BACKGROUND

Japan introduced the financial incentives for dementia special care at hospitals in the fee schedule in April 2016.

OBJECTIVE

To investigate whether the financial incentives for dementia special care contributed to better patient outcomes after hip surgery for older adults with dementia.

DESIGN

Retrospective observational study using the Diagnosis Procedure Combination database and the Reporting on medical functions of hospital beds data.

SETTING

Acute care hospitals adopting the Diagnosis Procedure Combination system in Japan.

PARTICIPANTS

A total of 20,393 eligible patients aged 65 years or older with dementia who underwent hip surgeries and discharged from 405 hospitals from April 2016 to March 2017.

METHODS

There are two levels of dementia care quality categories in the financial incentives for dementia special care as follows: Type 1 requires a multidisciplinary team with geriatric and dementia care expertise and Type 2 requires to assign trained nurses who underwent dementia training at every general ward. The outcomes were in-hospital mortality, readmission within 30 days, and length of hospital stay. We performed generalized estimating equation model or logistic generalized estimating equation models adjusting for individual and hospital characteristics.

RESULTS

Among the 405 hospitals, the numbers of hospitals without dementia care incentive, those with Type 1, and those with Type 2 were 207, 99, and, 99, respectively. Overall, the prevalence of in-hospital death and readmission within 30 days was 2.01% and 2.70%, respectively. Overall, the mean (standard deviation, SD) length of hospital stay was 32.0 (20.0) days. There were no significant associations between dementia special care and in-hospital mortality in Type 1 (adjusted OR [odds ratio] =0.87, 95% confidence interval [CI] = 0.66-1.16) and Type 2 (adjusted OR = 1.18, 95% CI = 0.92-1.52), and readmission within 30 days in Type 1 (adjusted OR = 1.11, 95% CI = 0.89-1.38) and Type 2 (adjusted OR = 1.03, 95% CI = 0.83-1.29). Length of hospital stay was not significantly different among hospitals with and without incentive, Type 1 (coefficient -0.23, 95% CI = -2.64-2.18.), and Type 2 (coefficient 0.87, 95% CI = -1.54-3.28). An increase in patient-to-nurse ratio was significantly associated with 2.25 days longer length of hospital stay (95% CI 1.00-3.51).

CONCLUSION

Dementia care incentive was not associated with better outcomes in elderly with dementia who underwent hip surgery in Japan, but the worse nurse workload was associated with longer length of hospital stay. Further long-term assessment is necessary.

The association of cognitive impairment as screened by the Mini-Cog with long term post-hospitalization outcomes

BACKGROUND

Prior studies have suggested that patients with cognitive impairment are at increased risk for adverse post-hospitalization outcomes. We aimed to determine if cognitive status assessed by the Mini-Cog, a quick bedside screening test, is associated with long-term outcomes.

METHODS

In this secondary analysis of data from a prospective cohort study, 668 patients >65 years of age admitted to a tertiary care academic hospital over a two-year period were screened for cognitive impairment with the Mini-Cog within 24 h of admission. We performed multivariable regression adjusting for demographics, comorbidities, principal diagnoses and functional status to determine association between cognitive impairment and discharge to post-acute care, 90-day readmission and one-year mortality.

RESULTS

Overall 35% screened positive for cognitive impairment. Those with impairment were older (median age 83 versus 78), less likely to be admitted from home and had lower functional independence and self-reported performance scores (p < 0.001 for all). Patients with cognitive impairment were more likely to be discharged to post-acute care facilities (54% versus 39%, p < 0.001). 90-day readmission rate of patients with and without cognitive impairment was 35% versus 27%; one-year survival 77% versus 84% and median length-of-stay was 4 days for both groups. Differences in readmission and mortality were not statistically significant after adjusting for covariates.

CONCLUSION

Cognitive impairment as screened for by the Mini-Cog was not associated with readmission, length-of-stay, or 1-year mortality but was associated with discharge to post-acute care. Other tools such as frailty assessment may be more useful in predicting these outcomes in hospitalized older adults.

[The associations between readmission within 30 days and the medical institute factors among older patients receiving home medical care]

AIM

To improve preventive strategies for readmission within 30 days after discharge among older patients receiving home medical care services, we examined the associations between readmission within 30 days and the medical institute factors among patients over 75 years of age.

METHODS

All patients over 75 years of age receiving home medical care services and who had been admitted to hospital or clinic and discharged between September 2013 and July 2014 in Tokyo, Japan, were participants of this study (n=7,213). The primary outcome was readmission within 30 days after discharge. We performed generalized estimating equations (GEEs) using a model with logit link and binominal sampling distribution to examine the associations of sociodemographic variables, the prevalence of chronic diseases and medical institute factors with readmission within 30 days.

RESULTS

Approximately 11.2% of the patients receiving home medical care services who had been discharged were readmitted within 30 days after discharge. Men, cancer patients, and emergency admission were positively associated with readmission within 30 days according to the GEEs. The rate of readmission within 30 days was lower in patients receiving home medical care services at home care support clinics/hospitals after discharge (adjusted odds ratio [aOR] = 0.205, p value < 0.001) and in patients discharged from hospitals with over 200 beds (aOR = 0.447, p value < 0.001, vs. clinics) than in others.

CONCLUSION

Home care support clinics/hospitals, which can provide home medical care services around the clock, may help reduce the rate of readmission within 30 days.