Fragmentation of care in the last year of life: Does dementia status matter?

The effect of dementia on patterns of healthcare use in older adults with diabetes

BACKGROUND

For persons with diabetes, incidence of dementia has been associated with increased hospitalization; however, little is known about healthcare use preceding and following incident dementia. We describe healthcare utilization in the 3 years pre- and post-incident dementia among older adults with diabetes.

METHODS

We used the National Health and Aging Trends Study (NHATS) linked to Medicare fee-for-service claims from 2011 to 2018. We included community-dwelling adults ≥65 years who had diabetes without dementia. We matched older adults with dementia (identified with validated NHATS algorithm) at the year of incident dementia to controls using coarsened exact matching. We examined annual outpatient visits, emergency department (ED) visits, hospitalization, and post-acute skilled nursing facility (SNF) use 3 years preceding and 3 years following dementia onset.

RESULTS

We included 195 older adults with diabetes with incident dementia and 1107 controls. Groups had a similar age (81.6 vs 81.7 years) and were 56.4% female. Persons with dementia were more likely to be of minority racial and ethnic groups (26.7% vs 21.3% Black, non-Hispanic, 15.3% vs 6.7% other race or Hispanic). We observed a larger decrease in outpatient visits among persons with dementia, primarily due to decreasing specialty visits (mean outpatient visits: 3 years pre-dementia/matching 6.8 (SD 2.6) dementia vs 6.4 (SD 2.6) controls, p < 0.01 to 3 years post-dementia/matching 4.6 (SD 2.3) dementia vs 5.5 (SD 2.7) controls, p < 0.01). Hospitalization, ED visits, and post-acute SNF use were higher for persons with dementia and rose in both groups (e.g., ED visits 3 years pre-dementia/matching 3.9 (SD 5.4) dementia vs 2.2 (SD 4.8) controls, p < 0.001; 3 years post-dementia/matching 4.5 (SD 4.7) dementia vs 3.5 (SD 6.1) controls, p = 0.04).

CONCLUSIONS

Older adults with diabetes with incident dementia have higher rates of acute and post-acute care use, but decreasing outpatient use over time, primarily due to a decrease in specialty visits.

Is Electronic Information Exchange Associated With Lower 30-Day Readmission Charges Among Medicare Beneficiaries?

OBJECTIVE

Fragmented readmissions, when admission and readmission occur at different hospitals, are associated with increased charges compared with nonfragmented readmissions. We assessed if hospital participation in health information exchange (HIE) was associated with differences in total charges in fragmented readmissions.

DATA SOURCE

Medicare Fee-for-Service Data, 2018.

STUDY DESIGN

We used generalized linear models with hospital referral region and readmission month fixed effects to assess relationships between information sharing (same HIE, different HIEs, and no HIE available) and total charges of 30-day readmissions among fragmented readmissions; analyses were adjusted for patient-level clinical/demographic characteristics and hospital-level characteristics.

DATA EXTRACTION METHODS

We included beneficiaries with a hospitalization for acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, syncope, urinary tract infection, dehydration, or behavioral issues with a 30-day readmission for any reason.

PRINCIPAL FINDINGS

In all, 279,729 admission-readmission pairs were included, 27% of which were fragmented (n=75,438); average charges of fragmented readmissions were $64,897-$71,606. Compared with fragmented readmissions where no HIE was available, the average marginal effects of same-HIE and different-HIE admission-readmission pairs were -$2329.55 (95% CI: -7333.73, 2674.62) and -$3905.20 (95% CI: -7592.85, -307.54), respectively. While the average marginal effects of different-HIE pairs were lower than those for no-HIE fragmented readmissions, the average marginal effects of same-HIE and different-HIE pairs were not significantly different from each other.

CONCLUSIONS

There were no statistical differences in charges between fragmented readmissions to hospitals that share an HIE or that do not share an HIE compared with hospitals with no HIE available.

Exploring End-of-Life Care for Patients with Breast Cancer, Dementia or Heart Failure: A Register-Based Study of Individual and Institutional Factors

OBJECTIVE

To examine variations in end-of-life care for breast cancer, heart failure, and dementia patients.

DATA AND METHODS

Data from four Norwegian health registries were linked using a personal identification number. Longitudinal trends over 365 days and the type of care on the final day of life were analyzed using descriptive techniques and logistic regression analysis.

RESULTS

Patients with dementia were more commonly placed in nursing homes than patients in the two other groups, while patients with heart failure and breast cancer were more frequently hospitalized than the dementia patients. Breast cancer and heart failure patients had a higher likelihood of dying at home than dementia patients. The higher the number of general practitioners, the higher was the probability of home-based end-of-life care for cancer patients, while an increasing non-physician healthcare workers increased the likelihood of home-based care for the other patient groups.

CONCLUSIONS

Diagnoses, individual characteristics, and service availability are all associated with the place of death in end-of-life care. The higher the availability of health care services, the higher also is the probability of ending the life at home.

Role of family medicine physicians in providing nutrition support to older patients admitted to orthopedics departments: a grounded theory approach

BACKGROUND

Care of older adults requires comprehensive management and control of systemic diseases, which can be effectively managed by family physicians. Complicated medical conditions in older patients admitted to orthopedic departments (orthopedic patients) necessitate interprofessional collaboration. Nutrition is one of the essential components of management involved in improving the systemic condition of older patients. Nutrition support teams play an important role in nutrition management and can be supported by family physicians. However, the role of family physicians in nutrition support teams is not well documented. This study aimed to investigate the role of family physicians in supporting nutrition management in orthopedic patients.

METHODS

This qualitative study was conducted between January and June 2023 using constructivist grounded theory methodology. Eight family medicine physicians, three orthopedic surgeons, two nurses, two pharmacists, four rehabilitation therapists, four nutritionists, and one laboratory technician working in Japanese rural hospitals participated in the research. Data collection was performed through ethnography and semi-structured interviews. The analysis was performed iteratively during the study.

RESULTS

Using a grounded theory approach, four theories were developed regarding family physicians' role in providing nutrition support to orthopedic patients: hierarchical and relational limitation, delay of onset and detection of the need for geriatric care in orthopedic patients, providing effective family medicine in hospitals, and comprehensive management through the nutrition support team.

CONCLUSIONS

The inclusion of family physicians in nutrition support teams can help with early detection of the rapid deterioration of orthopedic patients' conditions, and comprehensive management can be provided by nutrition support teams. In rural primary care settings, family physicians play a vital role in providing geriatric care in community hospitals in collaboration with specialists. Family medicine in hospitals should be investigated in other settings for better geriatric care and to drive mutual learning among healthcare professionals.

Electronic Health Record Usability and Postsurgical Outcomes Among Older Adults With Dementia

INTRODUCTION

Electronic health record (EHR) usability, defined as the extent to which the system can be used to complete tasks, can influence patient outcomes. The aim of this study is to assess the relationship between EHR usability and postsurgical outcomes of older adults with dementia including 30-day readmission, 30-day mortality, and length of stay (LOS).

METHODS

A cross-sectional analysis of linked American Hospital Association, Medicare claims data, and nurse survey data was conducted using logistic regression and negative binominal models.

RESULTS

The dementia population who received care in hospitals with better EHR usability were less likely to die within 30 days of their admission following surgery compared to hospitals with poorer EHR usability (OR: 0.79, 95% CI: 0.68-0.91, p = 0.001). EHR usability was not associated with readmission or LOS.

DISCUSSION

Better nurse reported EHR usability has the potential to reduce mortality rates among older adults with dementia in hospitals.

Frequency and implications of coexistent manifestations of serious illness in older adults with dementia

BACKGROUND

In older adults, serious illness comprises three manifestations: dementia, activity of daily living (ADL) impairment, and other advanced medical conditions (AMC; e.g., end-stage renal disease). Little is known about how dementia and other manifestations of serious illness co-occur. We aim to describe the prevalence of persons with dementia (PWD) who are living with additional manifestations of serious illness, and the implications on healthcare utilization, Medicare costs, caregiving hours and out-of-pocket expenses.

METHODS

In this cross-sectional study, we use data from the 2016 Health and Retirement Study (HRS) linked to Medicare fee-for-service claims. We limited inclusion to adults >65 years. Dementia was determined using validated methodology that incorporates functional and cognitive test scores from HRS. We classified PWD as having dementia alone, dementia and an AMC (irrespective of ADL impairment) or dementia and ADL impairment (without an AMC). Healthcare utilization and Medicare costs were measured in claims, caregiving hours and out-of-pocket expenses were self-reported.

RESULTS

Most PWD (67%) met criteria for another manifestation of serious illness (24% advanced medical condition, 44% ADL impairment). PWD and an AMC had the highest proportion of hospital use and the highest median total Medicare costs ($17,900 vs. $8962 dementia + ADL impairment vs. $4376 dementia alone). Mean total hours of caregiving per month were similar for PWD and an AMC and PWD and ADL impairment (142.9 and 141.9 h, respectively), while mean hours were much lower for PWD alone (47.7 h). Median out-of-pocket costs were highest for PWD and ADL impairment ($13,261) followed by PWD and an AMC ($10,837) and PWD alone ($7017).

CONCLUSIONS

PWD commonly face another manifestation of serious illness. Dementia and ADL impairment was associated with the highest costs for PWD and families while dementia and an AMC was associated with the highest costs for Medicare.

Ambulance use and subsequent fragmented hospital readmission among older adults

BACKGROUND

Interhospital care fragmentation, when a patient is readmitted to a different hospital than they were originally discharged from, occurs in 20%-25% of readmissions. Mode of transport to the hospital, specifically ambulance use, may be a risk factor for fragmented readmissions. Our study seeks to further understand the relationship between ambulance transport and fragmented readmissions in older adults, a population that is at increased risk for poor outcomes following fragmented readmissions.

METHODS

We analyzed inpatient claims from Medicare beneficiaries in 2018 who had a hospital admission for select Hospital Readmission Reduction Program Conditions (acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, pneumonia) as well as dehydration, syncope, urinary tract infection, or behavioral issues. We evaluated the associations between ambulance transport and a fragmented readmission using logistic regression models adjusted for demographic, clinical, and hospital characteristics.

RESULTS

The study included 1,186,600 30-day readmissions. Of these, 46.8% (n = 555,847) required ambulance transport. In fully adjusted models, taking an ambulance to the readmission hospital increased the odds of a fragmented readmission by 38% (95% CI 1.32, 1.44). When this association was examined by readmission major diagnostic category (MDC), the strongest associations were seen for Factors Influencing Health Status and Other Contacts with Health Services (i.e., rehabilitation, aftercare) (AOR 3.66, 95% CI 3.11, 4.32), Mental Diseases and Disorders (AOR 2.69, 95% CI 2.44, 2.97), and Multiple Significant Trauma (AOR 2.61, 95% CI 1.56, 4.35). When the model was stratified by patient origin, ambulance use remained associated with fragmented readmissions across all locations.

CONCLUSIONS

Ambulance use is associated with increased odds of a fragmented readmission, though the strength of the association varies by readmission diagnosis and origin. Patient-, hospital-, and system-level interventions should be developed, implemented, and evaluated to address this modifiable risk factor.

Patterns of Healthcare Utilization and Spending Among Homebound Older Adults in the USA: an Observational Study

BACKGROUND

Homebound older adults have complex social, medical, and financial needs, but little is known about their healthcare utilization and spending.

OBJECTIVE

To characterize healthcare utilization and spending among homebound older adults.

DESIGN

Cohort study using National Health and Aging Trends Study data linked to Medicare Fee-for-Service (FFS) claims data.

PARTICIPANTS

Adults aged 70 years and older with Medicare FFS coverage (n = 6468).

MAIN MEASURES

In a person-year analysis, survey-weighted rates and adjusted marginal differences in inpatient, outpatient, and emergency department utilization and spending 12 months post-interview were calculated by homebound status, defined as reporting never or rarely (no more than 1 day/week) leaving home in the last month.

KEY RESULTS

Compared to the non-homebound, homebound observations had lower annual unadjusted rates of accessing primary care (60.9% vs 71.9%, p < 0.001) and specialist care (61.0% vs 74.9%, p < 0.001) and higher annual rates of emergency department use (54.0% vs 32.6%, p < 0.001) and hospitalization (39.8% vs 19.8%, p < 0.001). Total annual Medicare spending was $11,346 higher among the homebound compared to the non-homebound (p < 0.001). In a single year analysis (2015), homebound older adults accounted for 11.0% of Medicare spending among those over 70 despite making up only 5.7% of this population. 13.6% of the homebound were in the 95th percentile or above of Medicare spending in 2015. In models adjusting for demographic, clinical, and geographic characteristics, homebound status was associated with a decreased likelihood of having an annual primary care or specialist visit and $2226 additional total annual Medicare spending.

CONCLUSIONS

Homebound older adults use more hospital-based care and less outpatient care than the non-homebound, contributing to higher levels of overall Medicare spending.

Fragmented care and chronic illness patient outcomes: A systematic review

AIM

This systematic review examined recent studies on fragmented care of patients with chronic illnesses in the United States to examine the association between fragmented care and patient outcomes.

DESIGN

Systematic review.

METHODS

Studies published from January 1, 2012, to June 1, 2022, were selected from four electronic databases (PubMed, CINAHL, PsycINFO, and Web of Science), following the Cochrane protocols and PRISMA statements. Based on inclusion and exclusion criteria, ten studies that examined associations published between 2015 and 2021 were selected. A methodological assessment was conducted with the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. The studies selected for this systematic review were rated as having fair methodological rigor. The protocol of this review was registered in the International Prospective Register of Systematic Reviews (PROSPERO registration number: CRD42021285379). Because of the heterogeneity of the selected studies' data, a systematic narrative synthesis of the extracted data was conducted.

RESULTS

Three common measures for fragmented care and outcomes were synthesized. A synthesis of the studies found significant association between fragmented care and adverse outcomes of chronic illnesses (emergency department visits, utilization of diagnostic tests, and healthcare costs). Despite the heterogeneity of significant findings between fragmented care and patient outcomes, the relationship between these outcomes and fragmented care was significant. This systematic review provides clear evidence of the association between care fragmentation and its adverse effects on individuals with chronic illnesses. However, mixed relationship findings were also reported.

CONCLUSION

Given the demands of overcoming fragmented care in healthcare settings in the United States, nurse managers, healthcare leaders, and policymakers should utilize this evidence to reduce fragmented care strategies. It is recommended that nurse researchers and other healthcare practitioners conduct further studies to understand the contexts and mechanisms of fragmented care and develop theoretical frameworks for care fragmentation and chronic illness outcomes.