Effect of Obesity on Postacute Outcomes of Skilled Nursing Facility Residents with Hip Fracture

Successful Discharge of Short Stay Veterans from VA Community Living Centers

The Veterans Health Administration (VHA) long-term care rebalancing initiative encouraged VA Community Living Centers (CLCs) to shift from long-stay custodial-focused care to short-stay skilled and rehabilitative care. Using all VA CLC admissions during 2007-2010 categorized as needing short-stay rehabilitation or skilled nursing care, we assessed the patient and facility rates of successful discharge to the community (SDC) of these short-stay Veterans. We found large variation in inter- as well as intra- facility SDC rates across the rehabilitation and skilled nursing short-stay cohorts. We discuss how our results can help guide VHA policy directed at delivering high-quality short-stay CLC care for Veterans.

Prevalence Rates and Characteristics of Malnutrition, Frailty, and Other Nutrition and Muscle Mass-Related Conditions Document Potential Quality of Care Gap for Medicare Patients in US Skilled Nursing Facilities

Changes to the payment structure of the United States (U.S.) healthcare system are leading to an increased acuity level of patients receiving short-term skilled nursing facility care. Most skilled nursing facility patients are older, and many have medical conditions that cannot be changed. However, conditions related to nutrition/muscle mass may be impacted if there is early identification/intervention. To help determine the diagnosis and potential impact of nutrition/muscle mass-related conditions in skilled nursing facilities, this study evaluated 2016–2020 US Medicare claims data. Methods aimed to identify a set of skilled nursing facility claims with one or more specific diagnoses (COVID-19, malnutrition, sarcopenia, frailty, obesity, diabetes, and/or pressure injury) and then to determine length of stay, discharge status, total charges, and total payments for each claim. Mean values per beneficiary were computed and between–group comparisons were performed. Results documented that each year, the total number of Medicare skilled nursing facility claims declined, whereas the percentage of claims for each study diagnosis increased significantly. For most conditions, potentially related to nutrition/muscle mass, Medicare beneficiaries had a shorter length of skilled nursing facility stays compared to those without the condition(s). Furthermore, a lower percentage of these Medicare beneficiaries were discharged home (except for those with claims for sarcopenia and obesity). Total claim charges for those with nutrition/muscle mass-related conditions exceeded those without (except for those with sarcopenia). We conclude that although the acuity level of patients in skilled nursing facilities continues to increase, skilled nursing facility Medicare claims for nutrition/muscle mass-related conditions are reported at lower levels than their likely prevalence. This represents a potential care gap and requires action to help improve patient health outcomes and skilled nursing facility quality metrics.

Sarcopenic obesity and function in women with subacute hip fracture: a short-term prospective study

BACKGROUND

The prognostic role exerted by the concurrent presence of sarcopenia and obesity after hip fracture has not been elucidated.

AIM

To assess the effect of sarcopenic obesity on ability to function in women with subacute hip fracture.

DESIGN

Short-term prospective study.

SETTING

Rehabilitation hospital.

POPULATION

Women with subacute hip fracture.

METHODS

At admission, grip strength, by a Jamar dynamometer, and body composition by dual-energy x-ray absorptiometry were assessed. Sarcopenia was defined according to the criteria released by the European Working Group for Sarcopenia in Older People in 2019, with both grip strength < 16kg and appendicular lean mass (aLM) < 15kg. Alternatively, aLM/(height)2 < 5.5kg/m2 was substituted for aLM < 15kg to confirm sarcopenia in the women with grip strength < 16kg. Obesity was diagnosed with fat mass exceeding 40% of total body mass. Function was assessed by the Barthel index.

RESULTS

We assessed 183 of 200 women. Sarcopenic women had lower Barthel index scores assessed at the end of subacute inpatient rehabilitation (U=300,0; z=-4.3; P<0.001) and lower Batrhel index effectiveness (U=310,0; z=-4.2; P<0.001) than non-sarcopenic women. Conversely, we found no significant differences in function between obese and non-obese women. The concurrent presence of sarcopenia and obesity did not worsen the functional prognosis versus the presence of isolated sarcopenia. After adjustment for Barthel index scores before rehabilitation, age, hip-fracture type and cognitive impairment, sarcopenia was significantly associated with Barthel index scores (P=0.001) and Barthel index effectiveness (P<0.001), whereas obesity was not. The results did not materially change when aLM/(height)2 < 5.5kg/m2 was substituted for aLM <15kg to confirm sarcopenia in the women whose handgrip strength was < 16kg.

CONCLUSIONS

The concurrent presence of obesity did not worsen the negative prognostic role of sarcopenia in the short-term recovery of ability to function after hip fracture in women.

CLINICAL REHABILITATION IMPACT

In women with subacute hip fracture, sarcopenia but not obesity should be assessed to contribute to the prediction of the short-term functional outcome.

Organizational and Geographic Nursing Home Characteristics Associated With Increasing Prevalence of Resident Obesity in the United States

Nursing home resident obesity increases the complexity of nursing care, and nursing homes report avoiding residents with obesity when choosing which prospective residents to accept. The objective of this study was to examine the associations between nursing home obesity prevalence rate and nursing home organizational, staffing, resident, and geographic factors within a profit maximization framework. The study cohort included U.S. Centers for Medicare and Medicaid Services data from U.S. nursing homes in 2013. Study findings supported hypothesized associations between obesity prevalence rate and higher occupancy, higher bed capacity, and multi-facility affiliation, but findings did not support a relationship between obesity prevalence rate and for-profit status.

Obesity among Nursing Home Residents: Association with Potentially Avoidable Hospitalizations

BACKGROUND/OBJECTIVES

Studies show that in nursing homes (NHs), the prevalence of moderate-to-severe obesity has doubled in the last decade and continues to increase. Obese residents are often complex and costly, and this increase in prevalence has come at a time when NHs struggle to decrease hospitalizations, particularly those that are potentially avoidable. This study examined the association between obesity and hospitalizations.

DESIGN

We linked 2011-2014 national data using Medicare NH assessments, hospital claims, and the NH Compare.

SETTING AND PARTICIPANTS

Individuals aged ≥65 years, newly admitted to NHs, who became long-term residents between July 1, 2011 and March 26, 2014. The analytical sample included 490,086 residents.

METHODS

NH-originating hospitalization was the outcome; a categorical variable defined as no hospitalization, potentially avoidable hospitalization (PAH), and other hospitalization (non-PAH). The main independent variable was body mass index (BMI) defined as normal weight (30 >BMI ≥18.5 kg/m2), mildly obese (35 >BMI ≥30 kg/m2), or moderately-to-severely obese (BMI ≥35 kg/m2). Covariates included individual and NH characteristics. Multinomial models with NH random effects and state dummies were estimated.

RESULTS

After adjusting for individual level covariates, the risk of non-PAH for the mildly and moderate/severely obese was not different from normal weight residents. But the risk of PAH remained significantly higher for the moderate/severely obese (relative risk ratio = 1.055; 95% confidence interval 1.018, 1.094). Several NH-level factors also influenced hospitalization risk.

CONCLUSIONS AND IMPLICATIONS

Obese residents are more likely to experience PAH but not non-PAH. Efforts to improve care for these residents may need to broadly consider the ability of NHs to commit additional resources to fully integrate care for this growing segment of the population.

Hospital Readmissions Among Post-acute Nursing Home Residents: Does Obesity Matter?

OBJECTIVES

To explore profiles of obese residents who receive post-acute care in nursing homes (NHs) and to assess the relationship between obesity and hospital readmissions and how it is modified by individual comorbidities, age, and type of index hospitalizations.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Medicare fee-for-service beneficiaries who were newly admitted to free-standing US NHs after an acute inpatient episode between 2011 and 2014 (N = 2,323,019).

MEASURES

The Minimum Data Set 3.0 were linked with Medicare data. The outcome variable was 30-day hospital readmission from an NH. Residents were categorized into 3 groups based on their body mass index (BMI): nonobese, mildly obese, moderate-to-severely obese. We tested the relationship between obesity and 30-day readmissions by fixed-effects logit models and stratified analyses by the type of index hospitalization and residents' age.

RESULTS

Forty percent of the identified residents were admitted after a surgical episode, and the rest were admitted after a medical episode. The overall relationship between obesity and readmissions suggested that obesity was associated with higher risks of readmission among the oldest old (≥85 years) residents but with lower risks of readmission among the youngest group (65-74 years). After accounting for individual co-covariates, the association between obesity and readmissions among the oldest old residents became weaker; the adjusted odds ratio was 1.061 (P = .049) and 1.004 (P = .829) for moderate-to-severely obese patients with surgical and medical index hospitalizations, respectively. The protective effect of obesity among younger residents reduced after adjusting for covariates.

CONCLUSIONS/RELEVANCE

The relationship between obesity and hospital readmission among post-acute residents could be affected by comorbidities, age, and the type of index hospitalization. Further studies are also warranted to understand how to effectively measure NH quality outcomes, including hospital readmissions, so that policies targeting at quality improvement can successfully achieve their goals without unintended consequences.

Higher Level of Obesity Is Associated with Intensive Personal Care Assistance in the Nursing Home

OBJECTIVES

To examine whether higher obesity level was associated with extensive staffing assistance (from 2 or more persons) for completing activities of daily living (ADL) among older nursing home residents.

DESIGN

Retrospective cross-sectional study.

SETTING

US government-certified nursing homes.

PARTICIPANTS

Medicare beneficiaries residing in a nursing home on April 1, 2015. Exclusion criteria were age less than 65 years and body mass index (BMI) below 18.5 (underweight).

MEASURES

Residents were divided by obesity level according to established BMI cutoffs, as follows: nonobese (BMI = 18.5-29.9) or mild (BMI = 30.0-34.9), moderate (BMI = 35.0-39.9), or severe (BMI ≥40) obesity. Level of staffing assistance for completing each of 10 ADL (bed mobility, transfer, walking in room, walking in corridor, on- and off-unit locomotion, dressing, eating, toileting, and personal hygiene) was dichotomized as below 2 and 2 or more. Robust Poisson regression was used to test whether obesity conferred excess risk for needing 2 or more staff to complete each ADL. Adjusted models included individual-level covariates and nursing home fixed effects.

RESULTS

A total of 1,063,383 nursing home residents were identified, including 309,263 (29.0%) with obesity. Adjusted relative risks (95% confidence intervals) for 2-person assistance with bed mobility associated with mild, moderate, and severe obesity were 1.17 (1.15, 1.18), 1.28 (1.25, 1.31), and 1.40 (1.36, 1.43), respectively. Adjusted relative risks for 2-person assistance with transferring associated with mild, moderate, and severe obesity were 1.15 (1.13, 1.17), 1.24 (1.22, 1.27), and 1.36 (1.33, 1.39), respectively. Obesity was associated with 2-person assistance for all other ADL except for eating.

CONCLUSIONS

Higher obesity level was significantly associated with assistance from 2 or more staff for completing 9 of 10 ADL. Given increasing obesity rates in nursing homes, payment mechanisms that do not adjust for obesity or comprehensively account for excess ADL assistance may need revision to prevent adverse impacts on the long-term care system.