Vulnerable populations at risk of potentially avoidable hospitalizations: the case of nursing home residents with Alzheimer's disease

Nurse Practitioner Care, Scope of Practice, and End-of-Life Outcomes for Nursing Home Residents With Dementia

Importance

Nursing home residents with Alzheimer disease and related dementias (ADRD) often receive burdensome care at the end of life. Nurse practitioners (NPs) provide an increasing share of primary care in nursing homes, but how NP care is associated with end-of-life outcomes for this population is unknown.

Objectives

To examine the association of NP care with end-of-life outcomes for nursing home residents with ADRD and assess whether these associations differ according to state-level NP scope of practice regulations.

Design, Setting, and Participants

This cohort study using fee-for-service Medicare claims included 334 618 US nursing home residents with ADRD who died between January 1, 2016, and December 31, 2018. Data were analyzed from April 6, 2015, to December 31, 2018.

Exposures

Share of nursing home primary care visits by NPs, classified as minimal (<10% of visits), moderate (10%-50% of visits), and extensive (>50% of visits). State NP scope of practice regulations were classified as full vs restrictive in 2 domains: practice authority (authorization to practice and prescribe independently) and do-not-resuscitate (DNR) authority (authorization to sign DNR orders).

Main Outcomes and Measures

Hospitalization within the last 30 days of life and death with hospice. Linear probability models with hospital referral region fixed effects controlling for resident characteristics, visit volume, and geographic factors were used to estimate whether the associations between NP care and outcomes varied across states with different scope of practice regulations.

Results

Among 334 618 nursing home decedents (mean [SD] age at death, 86.6 [8.2] years; 69.3% female), 40.5% received minimal NP care, 21.4% received moderate NP care, and 38.0% received extensive NP care. Adjusted hospitalization rates were lower for residents with extensive NP care (31.6% [95% CI, 31.4%-31.9%]) vs minimal NP care (32.3% [95% CI, 32.1%-32.6%]), whereas adjusted hospice rates were higher for residents with extensive (55.6% [95% CI, 55.3%-55.9%]) vs minimal (53.6% [95% CI, 53.3%-53.8%]) NP care. However, there was significant variation by state scope of practice. For example, in full practice authority states, adjusted hospice rates were 2.88 percentage points higher (95% CI, 1.99-3.77; P < .001) for residents with extensive vs minimal NP care, but the difference between these same groups was 1.77 percentage points (95% CI, 1.32-2.23; P < .001) in restricted practice states. Hospitalization rates were 1.76 percentage points lower (95% CI, -2.52 to -1.00; P < .001) for decedents with extensive vs minimal NP care in full practice authority states, but the difference between these same groups in restricted practice states was only 0.43 percentage points (95% CI, -0.84 to -0.01; P < .04). Similar patterns were observed in analyses focused on DNR authority.

Conclusions and Relevance

The findings of this cohort study suggest that NPs appear to be important care providers during the end-of-life period for many nursing home residents with ADRD and that regulations governing NP scope of practice may have implications for end-of-life hospitalizations and hospice use in this population.

Population-level quality indicators of end-of-life-care in an aged care setting: Rapid systematic review

BACKGROUND

As their health declines, many older adults require additional care and move to residential aged care facilities. Despite efforts to reduce it, variation persists in care quality at the end-of-life (EOL) between facilities. Indicators to monitor care variation are therefore required. This rapid systematic review aims to identify population-level indicators of the quality of end-of-life-care (EOLC) for residents of aged care.

METHOD

A rapid systematic review of five databases (MEDLINE, Embase, CINAHL, PsycINFO, Scopus) for studies that reported on the development, assessment or validation of at least one measure of EOLC quality for residents living in an aged care setting from 1 January 2000 to 18 April 2023 was conducted. Abstracts and full-texts were screened by two reviewers and each indicator critically appraised. Key characteristics of each study were extracted.

RESULTS

From seven studies, 106 EOLC quality indicators (75 of which were unique) for aged care residents were identified. Five studies specifically identified EOLC indicators for older residents with cognitive impairment. The EOLC quality indicators were diverse in nature. There were 31 EOLC quality indicators (22 unique indicators) focused on the structure and process of care provided and 51 (38 unique indicators) identified physical and psychological aspects of care. Twenty-three EOLC quality indicators (14 unique indicators) related to care of the imminently dying patient.

CONCLUSION

A common suite of population-level EOLC indicators that are reflective of care quality, are clinically appropriate, and important to residents and their families should be identified to monitor EOLC quality within and across jurisdictions.

Advanced practice clinician care and end-of-life outcomes for community- and nursing home-dwelling Medicare beneficiaries with dementia

INTRODUCTION

Older adults with Alzheimer's disease and related dementias (ADRD) often face burdensome end-of-life care transfers. Advanced practice clinicians (APCs)-which include nurse practitioners and physician assistants-increasingly provide primary care to this population. To fill current gaps in the literature, we measured the association between APC involvement in end-of-life care versus hospice utilization and hospitalization for older adults with ADRD.

METHODS

Using Medicare data, we identified nursing home- (N=517,490) and community-dwelling (N=322,461) beneficiaries with ADRD who died between 2016 and 2018. We employed propensity score-weighted regression methods to examine the association between different levels of APC care during their final 9 months of life versus hospice utilization and hospitalization during their final month.

RESULTS

For both nursing home- and community-dwelling beneficiaries, higher APC care involvement associated with lower hospitalization rates and higher hospice rates.

DISCUSSION

APCs are an important group of providers delivering end-of-life primary care to individuals with ADRD.

HIGHLIGHTS

For both nursing home- and community-dwelling Medicare beneficiaries with ADRD, adjusted hospitalization rates were lower and hospice rates were higher for individuals with higher proportions of APC care involvement during their final 9 months of life. Associations between APC care involvement and both adjusted hospitalization rates and adjusted hospice rates persisted when accounting for primary care visit volume.

[Nursing home-sensitive conditions and approaches to reduce hospitalization of nursing home residents]

BACKGROUND

Interventions to reduce potentially risky hospitalizations among nursing home residents are highly relevant for patient safety and quality improvement. A catalog of nursing home-sensitive conditions (NHSCs) grounds the policy recommendations and interventions.

METHODS

In two previous research phases, an expert panel developed a catalog of 58 NHSCs using an adapted Delphi-procedure (the RAND/UCLA Appropriateness Method). This procedure was developed by the North American non-profit Research and Development Organisation (RAND) and clinicians of the University of California in Los Angeles (UCLA). We present the third phase of the project focused on the development of interventions to reduce NHSCs starting with an expert workshop. The workshop results were then evaluated by six experts from related sectors, supplemented, and systematically used to produce recommendations for action. Possible implementation obstacles were considered and the time horizon of effectiveness was estimated.

RESULTS

The recommendations address communication, cooperation, documentation and care competence as well as facility-related, financial, and legal aspects. Indication bundles demonstrate the relevance for the German healthcare system. To increase effectiveness, the experts advise a meaningful combination of individual recommendations.

DISCUSSION

By optimizing multidisciplinary communication and cooperation, combined with an- also digital - expansion of the infrastructure and the creation of institution-specific and legal prerequisites as well as remuneration structures, an estimated 35% of all hospitalizations, approximately 220,000 hospitalizations for Germany, could be prevented. The implementation expenditure could be refinanced by avoided hospitalization savings amounting to 768 million euros.

Readmissions to hospital following a decision to eat and drink with acknowledged risk

People with a dysphagia may eat and drink with acknowledged risks (EDAR). The FORWARD care bundle (Feeding via the Oral Route With Acknowledged Risk of Deterioration) is used at our hospital to support patients who are EDAR. This two-year retrospective study of patients supported by FORWARD aimed to determine incidence of EDAR-related readmissions and effects of discharge location and documented preferred place of care in advance care plans. Of 316 patients supported by FORWARD, 200 were discharged alive. 63% (n=126) were not readmitted within six months. Of 74 patients readmitted, 49% had an EDAR-related readmission. Significantly fewer patients wishing to remain at home had EDAR-related readmissions (7%, n=4) than those without a documented preferred place of care (23%, n=30, p<0.01), suggesting advance care plans are effective. Significantly more (23%, n=29) patients discharged to private homes had EDAR-related readmissions than those in nursing/care homes (10%, n=6, p<0.05), which could suggest residential care provides more support.

Staffing Levels and COVID-19 Infections and Deaths in Korean Nursing Homes

The novel coronavirus disease 2019 (COVID-19) spread rapidly worldwide. Nursing home (NH) residents are the most vulnerable high-risk population to infection. Professional registered nurses' (RNs') infection control is irreplaceable. We used a secondary data analysis method using the government's senior citizen welfare department large data set about all NHs (N = 3,389) across Korea between January 20 and October 20, 2020. Bed size positively associated with the mortality rate (No. of COVID-19 resident deaths / No. of total residents) (p = .048). When the proportion of RNs to total nursing staff was higher, the infection rate was 0.626% lower (p = .049), the mortality rate was 0.088% lower (p = .076), the proportion of confirmed COVID-19 cases per resident out of the total number of NHs was 44.472% lower (p = .041), and the proportion of confirmed COVID-19 deaths per resident out of the total number of NHs was 6.456% lower (p = .055). This study highlighted nurse staffing criteria and suggests that increasing RNs in NHs will reduce infection and mortality rates during the COVID-19 pandemic. We strongly suggest NHs hire at least one RN per day to properly function, and a minimum of four RNs to provide a fully competent RN workforce in long-term care settings in Korean NHs.

A Call to Address RN, Social Work, and Advanced Practice Registered Nurses in Nursing Homes: Solutions From the Missouri Quality Initiative

BACKGROUND

US nursing homes (NHs) have struggled to overcome a historic pandemic that laid bare limitations in the number and clinical expertise of NH staff.

PROBLEM

For nurse staffing, current regulations require only one registered nurse (RN) on duty 8 consecutive hours per day, 7 days per week, and one RN on call when a licensed practical/vocational nurse is on duty. There is no requirement for a degreed or licensed social worker, and advanced practice registered nurses (APRNs) in NHs cannot bill for services.

APPROACH

It is time to establish regulation that mandates a 24-hour, 7-day-a-week, on-site RN presence at a minimum requirement of 1 hour per resident-day that is adjusted upward for greater resident acuity and complexity. Skilled social workers are needed to improve the quality of care, and barriers for APRN billing for services in NHs need to be removed.

CONCLUSIONS

Coupling enhanced RN and social work requirements with access to APRNs can support staff and residents in NHs.

Admissions and Mortality Related to Urinary Tract Infections in Male Veterans with Dementia

Objective To examine mortality and hospital readmission rates in male veterans with dementia diagnosed with urinary tract infection (UTI) compared with patients without dementia. Design Retrospective cohort study. Setting Veterans Healthcare Systems (VA). Participants Male inpatients with a diagnosis of UTI who were treated at any VA Healthcare Center from January 1, 2009, to December 31, 2018. Interventions None. Main Outcome Measures Mortality and hospital readmission for patients with and without dementia at 30, 60, and 90 days from UTI diagnosis. Results 262,515 veterans admitted with UTI were analyzed, and 58,940 (22.5%) had dementia. The mean age for veterans with dementia was 80.0 +/- 9.7 years. Veterans with dementia experienced less mortality than patients without dementia at 30 days (8.3% vs 8.5%; P < 0.001), but more mortality at 60-day (4.9% vs 4.7%; P < 0.001) and 90-day (3.6% vs 3.3%; P < 0.001) intervals. Death was 20% less likely at 30 days in patients with dementia. Veterans with dementia were readmitted more than those without dementia at 30-day (18.4% vs 16.0%), 60-day (4.5% vs 2.8%), and 90-day (3.4% vs 2.5%) intervals; P < 0.0001. Conclusion Though patients with dementia are at an increased risk for death long-term, risk of death is less than those without dementia shortly following UTI diagnosis. This highlights the possibility that veterans with dementia may be hospitalized and diagnosed with UTIs when in actuality they have asymptomatic bacteriuria. Patients with dementia and UTI therefore represent an important group of geriatric patients that could benefit from the oversight of a senior care pharmacist to help prevent unnecessary treatment of asymptomatic bacteriuria.

A complex intervention to reduce avoidable hospital admissions in nursing homes: a research programme including the BHiRCH-NH pilot cluster RCT

Background

An unplanned hospital admission of a nursing home resident distresses the person, their family and nursing home staff, and is costly to the NHS. Improving health care in care homes, including early detection of residents’ health changes, may reduce hospital admissions. Previously, we identified four conditions associated with avoidable hospital admissions. We noted promising ‘within-home’ complex interventions including care pathways, knowledge and skills enhancement, and implementation support.

Objectives

Develop a complex intervention with implementation support [the Better Health in Residents in Care Homes with Nursing (BHiRCH-NH)] to improve early detection, assessment and treatment for the four conditions. Determine its impact on hospital admissions, test study procedures and acceptability of the intervention and implementation support, and indicate if a definitive trial was warranted.

Design

A Carer Reference Panel advised on the intervention, implementation support and study documentation, and engaged in data analysis and interpretation. In workstream 1, we developed a complex intervention to reduce rates of hospitalisation from nursing homes using mixed methods, including a rapid research review, semistructured interviews and consensus workshops. The complex intervention comprised care pathways, approaches to enhance staff knowledge and skills, implementation support and clarity regarding the role of family carers. In workstream 2, we tested the complex intervention and implementation support via two work packages. In work package 1, we conducted a feasibility study of the intervention, implementation support and study procedures in two nursing homes and refined the complex intervention to comprise the Stop and Watch Early Warning Tool (S&W), condition-specific care pathways and a structured framework for nurses to communicate with primary care. The final implementation support included identifying two Practice Development Champions (PDCs) in each intervention home, and supporting them with a training workshop, practice development support group, monthly coaching calls, handbooks and web-based resources. In work package 2, we undertook a cluster randomised controlled trial to pilot test the complex intervention for acceptability and a preliminary estimate of effect.

Setting

Fourteen nursing homes allocated to intervention and implementation support (n = 7) or treatment as usual (n = 7).

Participants

We recruited sufficient numbers of nursing homes (n = 14), staff (n = 148), family carers (n = 95) and residents (n = 245). Two nursing homes withdrew prior to the intervention starting.

Intervention

This ran from February to July 2018.

Data sources

Individual-level data on nursing home residents, their family carers and staff; system-level data using nursing home records; and process-level data comprising how the intervention was implemented. Data were collected on recruitment rates, consent and the numbers of family carers who wished to be involved in the residents’ care. Completeness of outcome measures and data collection and the return rate of questionnaires were assessed.

Results

The pilot trial showed no effects on hospitalisations or secondary outcomes. No home implemented the intervention tools as expected. Most staff endorsed the importance of early detection, assessment and treatment. Many reported that they ‘were already doing it’, using an early-warning tool; a detailed nursing assessment; or the situation, background, assessment, recommendation communication protocol. Three homes never used the S&W and four never used care pathways. Only 16 S&W forms and eight care pathways were completed. Care records revealed little use of the intervention principles. PDCs from five of six intervention homes attended the training workshop, following which they had variable engagement with implementation support. Progression criteria regarding recruitment and data collection were met: 70% of homes were retained, the proportion of missing data was < 20% and 80% of individual-level data were collected. Necessary rates of data collection, documentation completion and return over the 6-month study period were achieved. However, intervention tools were not fully adopted, suggesting they would not be sustainable outside the trial. Few hospitalisations for the four conditions suggest it an unsuitable primary outcome measure. Key cost components were estimated.

Limitations

The study homes may already have had effective approaches to early detection, assessment and treatment for acute health changes; consistent with government policy emphasising the need for enhanced health care in homes. Alternatively, the implementation support may not have been sufficiently potent.

Conclusion

A definitive trial is feasible, but the intervention is unlikely to be effective. Participant recruitment, retention, data collection and engagement with family carers can guide subsequent studies, including service evaluation and quality improvement methodologies.

Future work

Intervention research should be conducted in homes which need to enhance early detection, assessment and treatment. Interventions to reduce avoidable hospital admissions may be beneficial in residential care homes, as they are not required to employ nurses.

Trial registration

Current Controlled Trials ISRCTN74109734 and ISRCTN86811077.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 2. See the NIHR Journals Library website for further project information.

Pilot cluster randomised trial of an evidence-based intervention to reduce avoidable hospital admissions in nursing home residents (Better Health in Residents of Care Homes with Nursing-BHiRCH-NH Study)

OBJECTIVES

To pilot a complex intervention to support healthcare and improve early detection and treatment for common health conditions experienced by nursing home (NH) residents.

DESIGN

Pilot cluster randomised controlled trial.

SETTING

14 NHs (7 intervention, 7 control) in London and West Yorkshire.

PARTICIPANTS

NH residents, their family carers and staff.

INTERVENTION

Complex intervention to support healthcare and improve early detection and treatment of urinary tract and respiratory infections, chronic heart failure and dehydration, comprising: (1) 'Stop and Watch (S&W)' early warning tool for changes in physical health, (2) condition-specific care pathway and (3) Situation, Background, Assessment and Recommendation tool to enhance communication with primary care. Implementation was supported by Practice Development Champions, a Practice Development Support Group and regular telephone coaching with external facilitators.

OUTCOME MEASURES

Data on NH (quality ratings, size, ownership), residents, family carers and staff demographics during the month prior to intervention and subsequently, numbers of admissions, accident and emergency visits, and unscheduled general practitioner visits monthly for 6 months during intervention. We collected data on how the intervention was used, healthcare resource use and quality of life data for economic evaluation. We assessed recruitment and retention, and whether a full trial was warranted.

RESULTS

We recruited 14 NHs, 148 staff, 95 family carers and 245 residents. We retained the majority of participants recruited (95%). 15% of residents had an unplanned hospital admission for one of the four study conditions. We were able to collect sufficient questionnaire data (all over 96% complete). No NH implemented intervention tools as planned. Only 16 S&W forms and 8 care pathways were completed. There was no evidence of harm.

CONCLUSIONS

Recruitment, retention and data collection processes were effective but the intervention not implemented. A full trial is not warranted.

TRIAL REGISTRATION NUMBER

ISRCTN74109734 (https://doi.org/10.1186/ISRCTN74109734). ORIGINAL PROTOCOL: BMJ Open. 2019;9(5):e026510. doi:10.1136/bmjopen-2018-026510.

Urgent care for patients with dementia: a scoping review of associated factors and stakeholder experiences

OBJECTIVES

People with dementia are more vulnerable to complications in urgent health situations due to older age, increased comorbidity, higher dependency on others and cognitive impairment. This review explored the factors associated with urgent care use in dementia and the experiences of people with dementia, informal carers and professionals.

DESIGN

Scoping review. The search strategy and data synthesis were informed by people with dementia and carers.

DATA SOURCES

Searches of CINAHL, Embase, Medline, PsycINFO, PubMed were conducted alongside handsearches of relevant journals and the grey literature through 15 January 2019.

ELIGIBILITY CRITERIA

Empirical studies including all research designs, and other published literature exploring factors associated with urgent care use in prehospital and emergency room settings for people with dementia were included. Two authors independently screened studies for inclusion.

DATA EXTRACTION AND SYNTHESIS

Data were extracted using charting techniques and findings were synthesised according to content and themes.

RESULTS

Of 2967 records identified, 54 studies were included in the review. Specific factors that influenced use of urgent care included: (1) common age-related conditions occurring alongside dementia, (2) dementia as a diagnosis increasing or decreasing urgent care use, (3) informal and professional carers, (4) patient characteristics such as older age or behavioural symptoms and (5) the presence or absence of community support services. Included studies reported three crucial components of urgent care situations: (1) knowledge of the patient and dementia as a condition, (2) inadequate non-emergency health and social care support and (3) informal carer education and stress.

CONCLUSIONS

The scoping review highlighted a wider variety of sometimes competing factors that were associated with urgent care situations. Improved and increased community support for non-urgent situations, such as integrated care, caregiver education and dementia specialists, will both mitigate avoidable urgent care use and improve the experience of those in crisis.

Drug related problems in older adults living with dementia

BACKGROUND

Compared with those without dementia, older patients with dementia admitted to acute care settings are at higher risk for triad combination of polypharmacy (PP), potentially inappropriate medication (PIM), and drug-drug interaction (DDI), which may consequently result in detrimental health. The aims of this research were to assess risk factors associated with triad combination of PP, PIM and DDI among hospitalized older patients with dementia, and to assess prevalence and characteristics of PP, PIM and DDI in this population.

METHODS

In this retrospective cross-sectional study, 416 older inpatients diagnosed with dementia and referred for specialist geriatric consultation at a tertiary hospital in Brisbane, Australia during 2006-2016 were enrolled. Patients were categorized into two groups according to their exposure to the combination of PP, PIM and DDI: 'triad combination' and 'non-triad combination'. Data were collected using the interRAI Acute Care (AC) assessment instrument. Independent risk factors of exposure to the triad combination were evaluated using bivariate and multivariate logistic regression analyses.

RESULTS

Overall, 181 (43.5%) were classified as triad combination group. The majority of the population took at least 1 PIM (56%) or experienced at least one potential DDI (76%). Over 75% of the participants were exposed to polypharmacy. The most common prescribed PIMs were antipsychotics, followed by benzodiazepines. The independent risk factors of the triad combination were the presence of atrial fibrillation diagnosis and higher medications use in cardiac therapy, psycholeptics and psychoanaleptics.

CONCLUSIONS

The exposure to triad combination of PP, PIM and DDI are common among people with dementia as a result of their vulnerable conditions and the greater risks of adverse events from medications use. This study identified the use of cardiac therapy, psycholeptics and psychoanaleptics as predictors of exposure to PP, PIM and DDI. Therefore, use of these medications should be carefully considered and closely monitored. Furthermore, comprehensive medication reviews to optimize medication prescribing should be initiated and continually implemented for this vulnerable population.

Comparing quality of care in medical specialties between nurse practitioners and physicians

BACKGROUND

The American health care system is facing a growing health care provider shortage in primary and specialty care settings. Research has established that nurse practitioners (NPs) match or exceed their physician colleagues in providing quality care in primary care settings.

OBJECTIVE

This systematic review aimed to compare the quality of NP versus physician-led care in outpatient specialty care setting for clinical outcomes patient satisfaction.

DATA SOURCES

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guided the literature search (CINAHL, PubMed, and Cochrane Library) and interpretation of findings. Of the 228 articles that met the inclusion/exclusion criteria, 11 were selected for further review.

CONCLUSIONS

Studies were conducted from 1995 to 2016 across four countries and spanned 10 distinct medical specialties. As a whole, these studies demonstrated that NPs in specialty settings perform as well as physicians terms of clinical safety and positive patient outcomes. Nurse practitioners matched or exceeded their physician counterparts in patient education and satisfaction.

IMPLICATIONS FOR PRACTICE

Nurse practitioners are a feasible option for addressing specialty care shortages. Further research should investigate whether NPs and physicians are equally prepared to provide equivalent care immediately following their respective postbaccalaureate programs. If not, studies should explore specific training duration and elements NPs require to provide equivalent care.

Does older adults' use of social care influence their healthcare utilisation? A systematic review of international evidence

Improving our understanding of the complex relationship between health and social care utilisation is vital as populations age. This systematic review aimed to synthesise evidence on the relationship between older adults' use of social care and their healthcare utilisation. Ten databases were searched for international literature on social care (exposure), healthcare use (outcome) and older adults (population). Searches were carried out in October 2016, and updated May 2018. Studies were eligible if they were published after 2000 in a high income country, examined the relationship between use of social care and healthcare utilisation by older adults (aged ≥60 years), and controlled for an indicator of need. Study quality and bias were rated using the National Institute of Health (NIH) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Study data were extracted and a narrative synthesis was conducted. Data were not suitable for quantitative synthesis. Thirteen studies were identified from 12,065 citations. Overall, the quality and volume of evidence was low. There was limited evidence to suggest that longer lengths of stay in care homes were associated with a lower risk of inpatient admissions. Residents of care homes with onsite nursing had fewer than expected admissions to hospital, compared to people in care homes without nursing, and adjusting for need. Evidence for other healthcare use outcomes was even more limited and heterogeneous, with notable gaps in primary care. We conclude that older adults' use of care homes may moderate inpatient admissions. In particular, the presence of registered nurses in care homes may reduce the need to transfer residents to hospital. However, further evidence is needed to add weight to this conclusion. Future research should build on this evidence and address gaps regarding the influence of community based social care on older adults' healthcare use. A greater focus on primary care outcomes is imperative.

Evidence-based intervention to reduce avoidable hospital admissions in care home residents (the Better Health in Residents in Care Homes (BHiRCH) study): protocol for a pilot cluster randomised trial

INTRODUCTION

Acute hospital admission is distressing for care home residents. Ambulatory care sensitive conditions, such as respiratory and urinary tract infections, are conditions that can cause unplanned hospital admission but may have been avoidable with timely detection and intervention in the community. The Better Health in Residents in Care Homes (BHiRCH) programme has feasibility tested and will pilot a multicomponent intervention to reduce these avoidable hospital admissions. The BHiRCH intervention comprises an early warning tool for noting changes in resident health, a care pathway (clinical guidance and decision support system) and a structured method for communicating with primary care, adapted for use in the care home. We use practice development champions to support implementation and embed changes in care.

METHODS AND ANALYSIS

Cluster randomised pilot trial to test study procedures and indicate whether a further definitive trial is warranted. Fourteen care homes with nursing (nursing homes) will be randomly allocated to intervention (delivered at nursing home level) or control groups. Two nurses from each home become Practice Development Champions trained to implement the intervention, supported by a practice development support group. Data will be collected for 3 months preintervention, monthly during the 12-month intervention and 1 month after. Individual-level data includes resident, care partner and staff demographics, resident functional status, service use and quality of life (for health economic analysis) and the extent to which staff perceive the organisation supports person centred care. System-level data includes primary and secondary health services contacts (ie, general practitioner and hospital admissions). Process evaluation assesses intervention acceptability, feasibility, fidelity, ease of implementation in practice and study procedures (ie, consent and recruitment rates).

ETHICS AND DISSEMINATION

Approved by Research Ethics Committee and the UK Health Research Authority. Findings will be disseminated via academic and policy conferences, peer-reviewed publications and social media (eg, Twitter).

TRIAL REGISTRATION NUMBER

ISRCTN74109734; Pre-results.

Preventable Hospitalizations Among Nursing Home Residents With Dementia and Behavioral Health Disorders

OBJECTIVE

Nursing home (NH) residents with Alzheimer's disease/related dementias (ADRD) and/or behavioral health disorders (BHD) are at high risk of hospitalizations, many of which are potentially avoidable. Empirical evidence regarding potentially avoidable hospitalizations (PAHs) among these residents is quite sparse and mixed. The objectives of this study were to (1) examine the risk of PAH among residents with ADRD only, BHD only, ADRD and BHD compared to residents with neither and (2) identify associations between individual- and facility-level factors and PAH in these subgroups.

DESIGN

Retrospective, CY2014-2015.

SETTING AND PARTICIPANTS

Long-term residents age 65+ (N = 807,630) residing in 15,234 NHs.

METHODS

We employed the Minimum Data Set, MedPAR, Medicare beneficiary summary, and Nursing Home Compare. Hospitalization risk was the outcome of interest. Individual-level covariates were used to adjust for health conditions. Facility-level covariates and state dummies were included. Multinomial logistic regression models were fit to estimate the risk of PAH and non-potentially avoidable hospitalizations (N-PAH).

RESULTS

Compared to residents without ADRD or BHD, those with ADRD had at least a 10% lower relative risk ratio (RRR) of N-PAH and a significantly lower risk of PAH, at 16% (P < .0001). Residents with BHD only had a statistically higher, but clinically very modest (RRR = 1.03) risk of N-PAH, with no difference in the risk of PAH. Focusing on specific BHD conditions, we found no difference in N-PAH or PAH among residents with depression, lower PAH risk among those with schizophrenia/psychosis (RRR = 0.92), and an increased risk of both N-PAH (RRR = 1.15) and PAH (RRR = 1.09) among residents with bipolar disorders.

CONCLUSIONS AND RELEVANCE

We observed a lower risk of PAH and N-PAH among residents with ADRD, with the risk for residents with BHD varying by condition. Substantial variations in PAH and N-PAH were evident across states. Future research is needed to identify state-level modifiable factors that explain these variations.

Preventing Burdensome Transitions of Nursing Home Residents with Advanced Dementia: It's More than Advance Directives

BACKGROUND

Although a palliative approach to care is recommended for people with advanced dementia, many nursing home (NH) residents with dementia experience burdensome interventions such as hospital transfers at the end of life.

OBJECTIVE

The goal of this study was to examine how decisions to transfer NH residents with advanced dementia are made, from the perspective of NH nurses and physicians.

METHODS

A qualitative, descriptive method was used. Purposive sampling was used to recruit 20 healthcare providers from 9 NHs. Data collection included semistructured, open-ended interviews.

RESULTS

Decision making regarding hospital transfer comprised two phases. Phase one, laying the groundwork, was influenced by the ability of the providers to effectively establish trust, foreshadow, and illuminate hazards of hospitalization. Phase two, responding to an acute event, began at the start of an acute event and ended when a decision was made to either treat the resident in the NH or transfer to the hospital. Responding to the acute event was influenced by the ability to care for residents in the NH, the providers' comfort with end-of-life conversations, and surrogates' preferences.

CONCLUSIONS

Advance care planning before an acute event is only the first step in a process of decision making. Attention to and support for decision making is needed at the time of each acute event to ensure that goals of care are maintained.

Variation in ambulance call rates for care homes in Torbay, UK

Emergency ambulance calls represent one of the routes of emergency hospital admissions from care homes. We aimed to describe the pattern of ambulance call rates from care homes and identify factors predicting those homes calling for an ambulance most frequently. We obtained data from South Western Ambulance Service NHS Foundation Trust on 3138 ambulance calls relating to people aged 65 and over from care homes in the Torbay region between 1 April 2012 and 31 July 2013. We supplemented this with data from the Care Quality Commission (CQC) website on home characteristics and outcomes of CQC inspections. We used descriptive statistics to identify variation in ambulance call rates for residential and nursing homes and fitted negative binomial regression models to determine if call rates were predicted by home type (nursing versus residential), the five standards in the CQC reports, dementia care status or travel time to hospital. One hundred and forty-six homes (119 residential and 27 nursing) were included in the analysis. The number of calls made ranged from 1 to 99. The median number (IQR; range) of calls per resident per year was 0.51 (0.21-0.89; 0.03-2.45). Nursing homes had a lower call rate than residential homes [adjusted rate ratio (ARR) 0.29; 95% CI: 0.22-0.40; P < 0.001]; care homes failing the quality and suitability of management standard had a lower call rate compared to those who passed (ARR 0.67; 95% CI: 0.50-0.90; P = 0.006); and homes specialising in dementia had a higher call rate compared to those not specialising (ARR 1.56; 95% CI: 1.23-1.96; P < 0.001). These findings require replication in other regions to establish their generalisability and further investigation is required to determine the extent to which call rate variability reflects the different needs of resident populations or differences in care home policies and practice.

Evaluating the Effectiveness of a Nurse Practitioner-Led Outreach Program for Long-Term-Care Homes

An observational prospective cohort study was conducted on 1,353 observations from a convenience sample of 311 long-term-care (LTC) residents to evaluate the effectiveness of a nurse practitioner-led outreach program on the health outcomes, emergency department (ED) transfers, and hospital admissions of LTC residents. The results show that ED transfers by the NPs were 27% less likely to be non-urgent than transfers made by MDs (OR = .73; 95% CI .54-.97) and that ED transfers by the NPs were 3.23 times more likely to be admitted to hospital than transfers by MDs (OR = 3.23; 95% CI 1.17-8.90). These findings highlight the potential benefits of the NP-led outreach program for LTC residents and for the health-care system.

Enhanced susceptibility of triple transgenic Alzheimer's disease (3xTg-AD) mice to acute infection

BACKGROUND

Infection is a recognised risk factor for Alzheimer's disease (AD) and can worsen symptoms in established disease. AD patients have higher rates of infection and are more likely to require hospital admissions due to infections than individuals without dementia. Infections have also been found to increase the risk of those over 84 years of age being diagnosed with dementia. However, few studies have investigated immune responses to infection in AD.

METHODS

Here, we investigated the immune responses of the triple transgenic Alzheimer's disease (3xTg-AD) mouse model of AD to infection with the parasites Toxoplasma gondii and Trichuris muris. Cytometric bead array, histology, immunohistochemistry and immunofluorescence were used to evaluate immune responses and the effects on the brain of acute infection.

RESULTS

3xTg-AD mice, despite having comparable parasite loads, were more susceptible to infection with more severe morbidity. A worsened outcome to infection can be linked to an exaggerated immune response. 3xTg-AD mice had an increased pro-inflammatory response characterised by the production of pro-inflammatory mediators such as tumour necrosis TNF-α, IL-6, CCL5 and CXCL-1, as well as an increase in immune cell infiltration to the sites of infection. T cell responses to parasite antigen also showed elevated production of the pro-inflammatory cytokines TNF-α (10 fold) and IL-6 (twofold). We investigated whether 3xTg-AD mice had a propensity for a more Th1-dominated response using the T. muris worm infection and showed that akin to T. gondii, there was an enhanced pro-inflammatory response which was associated with retention of worms in the gut and associated pathology. Irrespective of whether the infection was one that could infect the brain or cause a local gut inflammation, 3xTg-AD mice had increased numbers of activated microglia during infection in both the cortex and the hippocampus.

CONCLUSIONS

Our findings suggest that in AD, responses to infection are exaggerated outside of the CNS. Additionally, the results presented here indicate that both systemic and localised inflammation caused by an infection exacerbate neuroinflammation in AD.

Support at Home: Interventions to Enhance Life in Dementia (SHIELD) – evidence, development and evaluation of complex interventions

Background

Dementia is a national priority and this research addresses the Prime Minister’s commitment to dementia research as demonstrated by his 2020 challenge and the new UK Dementia Research Institute. In the UK > 800,000 older people have dementia. It has a major impact on the lives of people with dementia themselves, on the lives of their family carers and on services, and costs the nation £26B per year. Pharmacological cures for dementias such as Alzheimer’s disease are not expected before 2025. If no cure can be found, the ageing demographic will result in 2 million people living with dementia by 2050. People with dementia lose much more than just their memory and their daily living skills; they can also lose their independence, their dignity and status, their confidence and morale, and their roles both within the family and beyond. They can be seen as a burden by society, by their families and even by themselves, and may feel unable to contribute to society. This programme of research aims to find useful interventions to improve the quality of life of people with dementia and their carers, and to better understand how people with dementia can be supported at home and avoid being admitted to hospital.

Objectives

(1) To develop and evaluate the maintenance cognitive stimulation therapy (MCST) for people with dementia; (2) to develop the Carer Supporter Programme (CSP), and to evaluate the CSP and Remembering Yesterday, Caring Today (RYCT) for people with dementia both separately and together in comparison with usual care; and (3) to develop a home treatment package (HTP) for dementia, to field test the HTP in practice and to conduct an exploratory trial.

Methods

(1) The MCST programme was developed for people with dementia based on evidence and qualitative work. A randomised controlled trial (RCT) [with a pilot study of MCST plus acetylcholinesterase inhibitors (AChEIs)] compared MCST with cognitive stimulation therapy (CST) only. The MCST implementation study conducted a trial of outreach compared with usual care, and assessed implementation in practice. (2) The CSP was developed based on existing evidence and the engagement of carers of people with dementia. The RCT (with internal pilot) compared the CSP and reminiscence (RYCT), both separately and in combination, with usual care. (3) A HTP for dementia, including the most promising interventions and components, was developed by systematically reviewing the literature and qualitative studies including consensus approaches. The HTP for dementia was evaluated in practice by conducting in-depth field testing.

Results

(1) Continuing MCST improved quality of life and improved cognition for those taking AChEIs. It was also cost-effective. The CST implementation studies indicated that many staff will run CST groups following a 1-day training course, but that outreach support helps staff go on to run maintenance groups and may also improve staff sense of competence in dementia care. The study of CST in practice found no change in cognition or quality of life at 8-month follow-up. (2) The CSP/RYCT study found no benefits for family carers but improved quality of life for people with dementia. RYCT appeared beneficial for the quality of life of people with dementia but at an excessively high cost. (3) Case management for people with dementia reduces admissions to long-term care and reduces behavioural problems. In terms of managing crises, staff suggested more costly interventions, carers liked education and support, and people with dementia wanted family support, home adaptations and technology. The easy-to-use home treatment manual was feasible in practice to help staff working in crisis teams to prevent hospital admissions for people with dementia.

Limitations

Given constraints on time and funding, we were unable to compete the exploratory trial of the HTP package or to conduct an economic evaluation.

Future research

To improve the care of people with dementia experiencing crises, a large-scale clinical trial of the home treatment manual is needed.

Conclusion

There is an urgent need for effective psychosocial interventions for dementia. MCST improved quality of life and was cost-effective, with benefits to cognition for those on AChEIs. MCST was feasible in practice. Both CSP and RYCT improved the quality of life of people with dementia, but the overall costs may be too high. The HTP was useful in practice but requires evaluation in a full trial. Dementia care research may improve the lives of millions of people across the world.

Trial registrations

Current Controlled Trials ISRCTN26286067 (MCST), ISRCTN28793457 (MCST implementation) and ISRCTN37956201 (CSP/RYCT).

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 5, No. 5. See the NIHR Journals Library website for further project information.

Transfer of nursing home residents to emergency departments: organizational differences between nursing homes with high vs. low transfer rates

AIM

To explore possible factors in the organization of nursing homes that could be related to differences in the rate of transfer of residents from nursing homes to emergency department.

DESIGN

Explorative.

METHOD

In a single municipality, qualitative and quantitative data were collected from documents and through semi-structured interviews with 11 RNs from five nursing homes identified as having the highest vs. six identified as having the lowest transfer rates to emergency department. Data were analysed by non-parametric tests and basic content analysis.

RESULTS

All nursing homes in the highest transfer rate group and one in the lowest transfer rate group were run by private for-profit providers. Compared with the low group, the high group had fewer updated advance care plans and the RNs interviewed had less work experience in care of older people and less training in care of persons with dementia. There was no difference in nursing home size or staff/resident ratio. The RNs described similar possibilities to provide palliative care, medical equipment and perceived medical support from GPs.

24/7 Registered Nurse Staffing Coverage in Saskatchewan Nursing Homes and Acute Hospital Use

La législation, dans de nombreuses juridictions, nécessite les établissements des soins de longue durée (SLD) d'avoir une infirmière en service 24 heures par jour, 7 jours par semaine. Bien que la recherche considérable existe sur l'intensité SLD de la dotation en personnel infirmier, il n'existe pas de la recherche empirique relative à cette exigence. Notre étude rétrospectif d'observation a comparé des installations en Saskatchewan avec 24/7 RN couverture aux établissements offrant moins de couverture, complétées par divers modèles de dotation des postes de nuit. Les ratios de risque associés à moins de 24/7 couverture RN complété de la dotation infirmière autorisé de nuit, ajusté pour l'intensité de dotation en personnel infirmier et d'autres facteurs de confusion potentiels, étaient de 1,17, IC 95% [0,91, 1,50] et 1.00, IC à 95% [0,72, 1,39], et avec moins de couverture 24/7 RN complété avec soin par aides personnels de nuit, les ratios de risque étaient de 1,46, IC 95% [1,11, 1,91] et 1,11, IC 95% [0,78, 1,58], pour les patients hospitalisés et de visites aux services d'urgence, respectivement. Ces résultats suggèrent que l'utilisation des soins de courte durée peut être influencée négativement par l'absence de la couverture 24/7 RN.

Elevated Hospitalization Risk of Assisted Living Residents With Dementia in Alberta, Canada

OBJECTIVES

Assisted living (AL) is an increasingly used residential option for older adults with dementia; however, lower staffing rates and service availability raise concerns that such residents may be at increased risk for adverse outcomes. Our objectives were to determine the incidence of hospitalization over 1 year for dementia residents of designated AL (DAL) facilities, compared with long-term care (LTC) facilities, and identify resident- and facility-level predictors of hospitalization among DAL residents.

METHODS

Participants were 609 DAL (mean age 85.7 ± 6.6 years) and 691 LTC (86.4 ± 6.9 years) residents with dementia enrolled in the Alberta Continuing Care Epidemiological Studies. Research nurses completed a standardized comprehensive assessment of residents and interviewed family caregivers at baseline (2006-2008) and 1 year later. Standardized administrator interviews provided facility level data. Hospitalization was determined via linkage with the provincial Inpatient Discharge Abstract Database. Multivariable Cox proportional hazards models were used to identify predictors of hospitalization.

RESULTS

The cumulative annual incidence of hospitalization was 38.6% (34.5%-42.7%) for DAL and 10.3% (8.0%-12.6%) for LTC residents with dementia. A significantly increased risk for hospitalization was observed for DAL residents aged 90+ years, with poor social relationships, less severe cognitive impairment, greater health instability, fatigue, high medication use (11+ medications), and 2+ hospitalizations in the preceding year. Residents from DAL facilities with a smaller number of spaces, no chain affiliation, and from specific health regions showed a higher risk of hospitalization.

CONCLUSIONS

DAL residents with dementia had a hospitalization rate almost 4-fold higher than LTC residents with dementia. Our findings raise questions about the ability of some AL facilities to adequately address the needs of cognitively impaired residents and highlight potential clinical, social, and policy areas for targeted interventions to reduce hospitalization risk.

Hospitalizations of nursing home residents with dementia in the last month of life: results from a nationwide survey

BACKGROUND

Hospitalizations of nursing home residents with dementia may not be uncommon. However, evidence from epidemiological studies outside the United States and knowledge about the circumstances of hospitalizations are lacking.

AIM

To examine the proportion of nursing home residents with dementia hospitalized in the last month of life and factors associated with hospitalization.

DESIGN

The design is stratified cluster sampling survey. Nurses retrospectively registered demographic and dementia-related information about deceased residents with dementia. This included information about hospitalizations, persons involved in hospitalization decisions and type and content of information transferred when hospitalized.

SETTING/PARTICIPANTS

Nursing home residents dying with dementia in Belgium (Flanders) in 2010.

RESULTS

In the final month of life, 19.5% of nursing home residents dying with dementia (N = 198) were hospitalized, including 4.6% admitted to an intensive care unit. For 12.2% of residents dying with dementia, a do-not-hospitalize advance directive was present, for 57.0%, a do-not-hospitalize general physician-order. Residents without a do-not-hospitalize general physician-order were more likely of being hospitalized (adjusted odds ratio: 3.4; 95% confidence interval: 1.3-8.7). None of the hospitalizations occurred at the request of the resident; 37% were at the request of relatives; curative or life-prolonging treatments were the most frequent reasons given. Information about the resident's nursing care or medical treatment was transferred in almost all hospitalizations, information about wishes and preferences for future care in 19%.

CONCLUSION

Hospitalization in Belgian nursing home residents with dementia in the last month of life was common. Documentation of do-not-hospitalize physician-orders in the resident's medical files may prevent hospitalizations.

From nursing home to acute care: signs, symptoms, and strategies used to prevent transfer

Older adults are vulnerable to experiencing physiologic changes that may permanently decrease functional abilities when transferring from the nursing home (NH) to the acute care setting. Making the right decision about who and when to transfer from the nursing home (NH) to acute care is critical for optimizing quality care. The specific aims of this study were to identify the common signs and symptoms exhibited by NH residents at the time of transfer to acute care and to identify strategies used to prevent transfer of NH residents. Using survey methodology, this descriptive study found change in level of consciousness, chest pressure/tightness, shortness of breath, decreased oxygenation, and muscle or bone pain were the highest ranked signs/symptoms requiring action. Actions to prevent transfer focused on stabilizing resident conditions and included hydration, oxygen, antibiotics, medications, symptom management, and providing additional physical assistance. When transfer was warranted, actions concentrated on the practical tasks of getting the residents transferred.

The effects of cognitive impairment on nursing home residents' emergency department visits and hospitalizations

BACKGROUND

Little is known about the relationship of cognitive impairment (CI) in nursing home (NH) residents and their use of emergency department (ED) and subsequent hospital services.

METHODS

We analyzed 2006 Medicare claims and resident assessment data for 112,412 Medicare beneficiaries aged >65 years residing in US nursing facilities. We estimated the effect of resident characteristics and severity of CI on rates of total ED visits per year, then estimated the odds of hospitalization after ED evaluation.

RESULTS

Mild CI predicted higher rates of ED visits relative to no CI, and ED visit rates decreased as severity of CI increased. In unadjusted models, mild CI and very severe CI predicted higher odds of hospitalization after ED evaluation; however, after adjusting for other factors, severity of CI was not significant.

CONCLUSIONS

Higher rates of ED visits among those with mild CI may represent a unique marker in the presentation of acute illness and warrant further investigation.

Assessment tools for determining appropriateness of admission to acute care of persons transferred from long-term care facilities: a systematic review

Background

Residents of long-term care facilities have a high risk of acute care admission. Estimates of the frequency of inappropriate transfers vary substantially throughout the studies and various assessment tools have been used. The purpose of this study is to systematically review and describe the internationally existing assessment tools used for determining appropriateness of hospital admissions among long-term care residents.

Method

Systematic review of the literature of two databases (PubMed and CINAHL®). The search covered seven languages and the period between January 2000 and December 2012. All quantitative studies were included if any assessment tool for appropriateness of hospital and/or emergency department admission of long-term care residents was used. Two pairs of independent researchers extracted the data.

Results

Twenty-nine articles were included, covering study periods between 1991 and 2009. The proportion of admissions considered as inappropriate ranged from 2% to 77%. Throughout the studies, 16 different assessment tools were used; all were based on expert opinion to some extent; six also took into account published literature or interpretation of patient data. Variation between tools depended on the concepts studied, format and application, and aspects evaluated. Overall, the assessment tools covered six aspects: specific medical diagnoses (assessed by n = 8 tools), acuteness/severity of symptoms (n = 7), residents’ characteristics prior to admission (n = 6), residents’ or families’ wishes (n = 3), existence of a care plan (n = 1), and availability or requirement of resources (n = 10). Most tools judged appropriateness based on one fulfilled item; five tools judged appropriateness based on a balance of aspects. Five tools covered only one of these aspects and only six considered four or more aspects. Little information was available on the psychometric properties of the tools.

Conclusions

Most assessment tools are not comprehensive and do not take into account residents’ individual aspects, such as characteristics of residents prior to admission and wishes of residents or families. The generalizability of the existing tools is unknown. Further research is needed to develop a tool that is evidence-based, comprehensive and generalizable to different regions or countries in order to assess the appropriateness of hospital admissions among long-term care residents.

Emergency department visits and hospitalizations by tube-fed nursing home residents with varying degrees of cognitive impairment: a national study

Background

Numerous studies indicate that the use of feeding tubes (FT) in persons with advanced cognitive impairment (CI) does not improve clinical outcomes or survival, and results in higher rates of hospitalization and emergency department (ED) visits. It is not clear, however, whether such risk varies by resident level of CI and whether these ED visits and hospitalizations are potentially preventable. The objective of this study was to determine the rates of ED visits, hospitalizations and potentially preventable ambulatory care sensitive (ACS) ED visits and ACS hospitalizations for long-stay NH residents with FTs at differing levels of CI.

Methods

We linked Centers for Medicare and Medicaid Services inpatient & outpatient administrative claims and beneficiary eligibility data with Minimum Data Set (MDS) resident assessment data for nursing home residents with feeding tubes in a 5% random sample of Medicare beneficiaries residing in US nursing facilities in 2006 (n = 3479). Severity of CI was measured using the Cognitive Performance Scale (CPS) and categorized into 4 groups: None/Mild (CPS = 0-1, MMSE = 22-25), Moderate (CPS = 2-3, MMSE = 15-19), Severe (CPS = 4-5, MMSE = 5-7) and Very Severe (CPS = 6, MMSE = 0-4). ED visits, hospitalizations, ACS ED visits and ACS hospitalizations were ascertained from inpatient and outpatient administrative claims. We estimated the risk ratio of each outcome by CI level using over-dispersed Poisson models accounting for potential confounding factors.

Results

Twenty-nine percent of our cohort was considered “comatose” and “without any discernible consciousness”, suggesting that over 20,000 NH residents in the US with feeding tubes are non-interactive. Approximately 25% of NH residents with FTs required an ED visit or hospitalization, with 44% of hospitalizations and 24% of ED visits being potentially preventable or for an ACS condition. Severity of CI had a significant effect on rates of ACS ED visits, but little effect on ACS hospitalizations.

Conclusions

ED visits and hospitalizations are common in cognitively impaired tube-fed nursing home residents and a substantial proportion of ED visits and hospitalizations are potentially preventable due to ACS conditions.

The association between long-term care setting and potentially preventable hospitalizations among older dual eligibles

OBJECTIVE

To compare the probability of experiencing a potentially preventable hospitalization (PPH) between older dual eligible Medicaid home and community-based service (HCBS) users and nursing home residents.

DATA SOURCES

Three years of Medicaid and Medicare claims data (2003-2005) from seven states, linked to area characteristics from the Area Resource File.

STUDY DESIGN

A primary diagnosis of an ambulatory care sensitive condition on the inpatient hospital claim was used to identify PPHs. We used inverse probability of treatment weighting to mitigate the potential selection of HCBS versus nursing home use.

PRINCIPAL FINDINGS

The most frequent conditions accounting for PPHs were the same among the HCBS users and nursing home residents and included congestive heart failure, pneumonia, chronic obstructive pulmonary disease, urinary tract infection, and dehydration. Compared to nursing home residents, elderly HCBS users had an increased probability of experiencing both a PPH and a non-PPH.

CONCLUSIONS

HCBS users' increased probability for potentially and non-PPHs suggests a need for more proactive integration of medical and long-term care.

Nursing home characteristics associated with resident transfers to emergency departments

This study examined how nursing home facility ownership and organizational characteristics relate to emergency department (ED) transfer rates. The sample included a retrospective cohort of nursing home residents in the Vancouver Coastal Health region (n = 13,140). Rates of ED transfers were compared between nursing home ownership types. Administrative data were further linked to survey-derived data of facility organizational characteristics for exploratory analysis. Crude ED transfer rates (transfers/100 resident years) were 69, 70, and 51, respectively, in for-profit, non-profit, and publicly owned facilities. Controlling for sex and age, public ownership was associated with lower ED transfer rates compared to for-profit and non-profit ownership. Results showed that higher total direct-care nursing hours per resident day, and presence of allied health staff--disproportionately present in publicly owned facilities--were associated with lower transfer rates. A number of other facility organizational characteristics--unrelated to ownership--were also associated with transfer rates.

Hospitalizations of nursing home residents in the last year of life: nursing home characteristics and variation in potentially avoidable hospitalizations

OBJECTIVES

To examine the incidence of, variations in, and costs of potentially avoidable hospitalizations (PAHs) of nursing home (NH) residents at the end of life and to identify the association between NH characteristics and a facility-level quality measure (QM) for PAH.

DESIGN

Retrospective.

SETTING

Hospitalizations originating from NHs.

PARTICIPANTS

Long-term care NH residents who died in 2007.

MEASUREMENTS

A risk-adjusted QM was constructed for PAH. A Poisson regression model was used to predict the count of PAH given residents' risk factors. For each facility, the QM was defined as the difference between the observed facility-specific rate (per 1,000 person-years) of PAH (O) and the expected risk-adjusted rate (E). A logistic regression model with state fixed-effects was then fit to examine the association between facility characteristics and the likelihood of having higher-than-expected rates of PAH (O-E > 0). QM values greater than 0 indicate worse-than-average quality.

RESULTS

Almost 50% of hospital admissions for NH residents in their last year of life were for potentially avoidable conditions, costing Medicare $1 billion. Five conditions were responsible for more than 80% of PAHs. PAH QM across facilities showed significant variation (mean 12.0 ± 142.3 per 1,000 person-years, range -399.48 to 398.09 per 1,000 person-years). Chain and hospital-based facilities were more likely to exhibit better performance (O-E < 0). Facilities with higher nursing staffing were more likely to have better performance, as were facilities with higher skilled staff ratio, those with nurse practitioners or physician assistants, and those with on-site X-ray services.

CONCLUSION

Variations in facility-level PAHs suggest that a potential for reducing hospital admissions for these conditions may exist. Presence of modifiable facility characteristics associated with PAH performance could help us formulate interventions and policies for reducing PAHs at the end of life.

Causes of crises and appropriate interventions: the views of people with dementia, carers and healthcare professionals

The aims of this study were to identify which factors may lead to crisis for people with dementia and their carers and identify interventions these individuals believe could help in crisis. Qualitative study using focus groups to compare the perspectives of people with dementia, family carers and healthcare professionals on causes of crises and crisis interventions. To help in a crisis, people with dementia were favourable towards support from family and friends, access to mobile phones and home adaptations to reduce risks. Carers were keen on assistive technology and home adaptation. Both carers and staff valued carer training and education, care plans and well-coordinated care. Staff were the only group emphasizing more intensive interventions such as emergency home respite and extended hours services. In terms of causes of crises, people with dementia focused on risks and hazards in their home, whereas family carers emphasized carer stress and their own mental health problems. Staff, in contrast were concerned about problems with service organization and coordination leading to crises. Physical problems were less commonly identified as causes of crises but when they did occur they had a major impact. Practical interventions such as home adaptations, assistive technology, education and training for family carers, and flexible home care services were highly valued by service users and their families during times of crisis and may help prevent hospital admissions. Specialist home care was highly valued by all groups.

Potentially avoidable hospitalizations among Medicare beneficiaries with Alzheimer's disease and related disorders

BACKGROUND

Individuals with Alzheimer's disease and related disorders (ADRD) have more frequent hospitalizations than individuals without ADRD, and some of these admissions may be preventable with proactive outpatient care.

METHODS

This study was a cross-sectional analysis of Medicare claims data from 195,024 fee-for-service ADRD beneficiaries aged ≥65 years and an equal number of matched non-ADRD controls drawn from the 5% random sample of Medicare beneficiaries in 2007-2008. We analyzed the proportion of patients with potentially avoidable hospitalizations (PAHs, as defined by the Medicare Ambulatory Care Indicators for the Elderly) and used logistic regression to examine patient characteristics associated with PAHs. We used paired t tests to compare Medicare expenditures by ADRD status, stratified by whether there were PAHs related to a particular condition.

RESULTS

Compared with matched non-ADRD subjects, Medicare beneficiaries with ADRD were significantly more likely to have PAHs for diabetes short-term complications (OR = 1.43; 95% CI 1.31-1.57), diabetes long-term complications (OR = 1.08; 95% CI = 1.02-1.14), and hypertension (OR = 1.22; 95% CI 1.08-1.38), but less likely to have PAHs for chronic obstructive pulmonary disease (COPD)/asthma (OR = 0.85; 95% CI 0.82-0.87) and heart failure (OR = 0.89; 95% CI 0.86-0.92). Risks of PAHs increased significantly with comorbidity burden. Among beneficiaries with a PAH, total Medicare expenditures were significantly higher for those subjects who also had ADRD.

CONCLUSION

Medicare beneficiaries with ADRD were at a higher risk of PAHs for certain uncontrolled comorbidities and incurred higher Medicare expenditures compared with matched controls without dementia. ADRD appears to make the management of some comorbidities more difficult and expensive. Ideally, ADRD programs should involve care management targeting high-risk patients with multiple chronic conditions.

Can infections cause Alzheimer's disease?

Late-onset Alzheimer's disease (AD) is the most prevalent cause of dementia among older adults, yet more than a century of research has not determined why this disease develops. One prevailing hypothesis is that late-onset AD is caused by infectious pathogens, an idea widely studied in both humans and experimental animal models. This review examines the infectious AD etiology hypothesis and summarizes existing evidence associating infectious agents with AD in humans. The various mechanisms through which different clinical and subclinical infections could cause or promote the progression of AD are considered, as is the concordance between putative infectious agents and the epidemiology of AD. We searched the PubMed, Web of Science, and EBSCO databases for research articles pertaining to infections and AD and systematically reviewed the evidence linking specific infectious pathogens to AD. The evidence compiled from the literature linking AD to an infectious cause is inconclusive, but the amount of evidence suggestive of an association is too substantial to ignore. Epidemiologic, clinical, and basic science studies that could improve on current understanding of the associations between AD and infections and possibly uncover ways to control this highly prevalent and debilitating disease are suggested.

Emergency Department Visits and Resulting Hospitalizations by Elderly Nursing Home Residents, 2001–2008

This study examines emergency department (ED) visits by nursing home (NH) residents aged 65 and over, and factors associated with hospital admission from the ED visit using data from the 2001–2008 National Hospital Ambulatory Medical Care Survey. Cross-sectional analyses were conducted on patient characteristics, diagnosis, procedures received, and triage status. On average, elderly NH residents visited EDs at a rate of 123 visits per 100 institutionalized persons. Nearly 15% of all ED visits had ambulatory care sensitive condition diagnoses. Nearly half of these visits resulted in hospital admission; chronic obstructive pulmonary disease, congestive heart failure, kidney/urinary tract infection, and dehydration were associated with higher odds of admission. Previous studies suggested that adequate medical staffing and appropriate care in the NH could reduce ED visits and hospital admissions. Recent initiatives seek to reduce ED visits and hospitalizations by providing financial incentives to spur better coordination between NH and hospital.

The relationships among licensed nurse turnover, retention, and rehospitalization of nursing home residents

PURPOSE

Individuals receiving postacute care in skilled nursing facilities often require complex, skilled care provided by licensed nurses. It is believed that a stable set of nursing personnel is more likely to deliver better care. The purpose of this study was to determine the relationships among licensed nurse retention, turnover, and a 30-day rehospitalization rate in nursing homes (NHs).

DESIGN AND METHODS

We combined two data sources: NH facility-level data (including characteristics of the facility, the market, and residents) and the Florida Nursing Home Staffing Reports (which provide staffing information for each NH) for 681 Florida NHs from 2002 to 2009. Using a two-way fixed effects model, we examined the relationships among licensed nurse turnover rates, retention rates, and 30-day rehospitalization rates.

RESULTS

Results indicate that an NH's licensed nurse retention rate is significantly associated with the 30-day rehospitalization rate (est. = -.02, p = .04) controlling for demographic characteristics of the patient population, residents' preferences for hospitalization, and the ownership characteristics of the NH. The NHs experiencing a 10% increase in their licensed nurse retention had a 0.2% lower rehospitalization rate, which equates to 2 fewer hospitalizations per NH annually. Licensed nurse turnover is not significantly related to the 30-day rehospitalization rate.

IMPLICATIONS

These findings highlight the need for NH administrators and policy makers to focus on licensed nurse retention, and future research should focus on the measures of staff retention for understanding the staffing/quality relationship.

A Survey of Nursing Home Organizational Characteristics Associated with Potentially Avoidable Hospital Transfers and Care Quality in One Large British Columbia Health Region

L’hospitalisation des résidents en maisons de soins infirmiers peut être futile aussi bien que coûteux, et il y a maintenant des preuves qui indiquent que le traitement des résidents des maisons de soins infirmiers en place donne de meilleurs résultats pour certaines conditions. Nous avons examiné les caractéristiques organisationnelles des installations que des récherches précédentes ont montré sont associées à des transferts de l’hôpital potentiellement évitables et avec une meilleure qualité de soins. En conséquence, nous avons mené une enquête transversale de l’administration des maisons de soins infirmiers dans Vancouver Coastal Health, une grande région sanitaire en la Colombie-Britannique. Le sondage portait sur les niveaux de dotation de personnel et l’organisation, l’accès aux médecins, les soins au fin de vie, et les facteurs influençant transferts de l’installation à l’hôpital. Un bon nombre des caractéristiques organisationnels modifiables, associés dans la littérature avec les transferts hospitaliers potentiellement évitables, et de meilleure qualité de soins, sont présents dans les maisons de soins infirmiers en la Colombie-Britannique. Cependant, leur présence n’est pas universelle, et certaines fonctionnalités sont particulièrement en défaut, en particulier l’organisation des soins médicaux et le planification et les services pour la fin de vie.

Alzheimer's disease and co-morbidity: increased prevalence and possible risk factors of excess mortality in a naturalistic 7-year follow-up

BACKGROUND

Subjects with late-onset Alzheimer's disease (AD) have to be sufficiently healthy to live long enough to experience and to be diagnosed with dementia in later life. In contrast, neurodegeneration and cognitive deficits in AD may increase the frequency of co-morbid disorders and their possible influence on mortality. Consequently, we investigated whether the pattern of co-morbidity and its relevance for later death differed between hospitalized AD and age-matched controls subjects.

METHODS

Co-morbid diseases with a prevalence of more than 1% at hospital admission were compared between 634 hospitalized AD and 72,244 control subjects aged above 70 years admitted to the University of Birmingham NHS Trust between 1 January 2000 to 31 December 2007. Risk factors, i.e. co-morbid diseases that were predictors of mortality within the 7-year follow-up, were identified and compared.

RESULTS

Subjects with AD suffer more eating disorders, infections, brain diseases and neck of femur fractures than other hospitalized elderly patients. In contrast, some cardiovascular diseases and diabetes mellitus were less prevalent in AD subjects in comparison with hospitalized controls. Diseases that might have contributed to later mortality in AD were pneumonia, ischemic heart disease and gastroenteritis, but there were no significant differences in their impact on mortality compared to other hospitalized elderly subjects with the same co-morbidities in multivariate logistic regression analyses.

CONCLUSION

Patients with AD have a different pattern of co-morbidity, but die from the same diseases as other hospitalized patients. Infections including pneumonia and diseases that may occur secondary to neurodegeneration and cognitive decline may need special attention in patients with AD who may not be able to identify or report the early symptoms. Preventive measures may be helpful to reduce the high risk and fatal consequences of undetected disease in AD.

The interplay of infections, function and length of stay (LOS) in newly admitted geriatric psychiatry patients

The purpose of this study was to determine the impact of identifying and treating infections on functional outcomes and length of stay (LOS). Our retrospective naturalistic study reviewed all new admissions to a tertiary geriatric psychiatry teaching hospital from 2003 to 2007. Over this four-year period, 390 patients were admitted and discharged with 21% (85) of patients identified as having infections on admission. Those with infections were compared to the group without to determine and compare clinical characteristics. Factors included in analysis were: age, gender, diagnoses, medical comorbidity, neuropsychiatric symptoms, functional outcomes, medications and LOS. Both groups were similar in gender, psychiatric diagnoses and severity of dementia. Those requiring antibiotics for treatment of infections on admission, were older (p=0.003), had poorer baseline function (p=0.005) and higher medical comorbidity (p<0.001). At discharge, the group with infections showed greater functional improvement (p<0.001), particularly in mobility (p=0.005) and cognition (p=0.046), and had a shorter LOS (p=0.02). We conclude that a significant number of patients in tertiary geriatric services continue to have infections on admission. Early identification and treatment of infections can result in improved function and decreased LOS.