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Stanik M, Hass Z, Kong N. Seizure prediction in stroke survivors who experienced an infection at skilled nursing facilities-a machine learning approach. Front Physiol 2024; 15:1399374. [PMID: 38872836 PMCID: PMC11169844 DOI: 10.3389/fphys.2024.1399374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 05/10/2024] [Indexed: 06/15/2024] Open
Abstract
Background Infections and seizures are some of the most common complications in stroke survivors. Infections are the most common risk factor for seizures and stroke survivors that experience an infection are at greater risk of experiencing seizures. A predictive model to determine which stroke survivors are at the greatest risk for a seizure after an infection can be used to help providers focus on prevention of seizures in higher risk residents that experience an infection. Methods A predictive model was generated from a retrospective study of the Long-Term Care Minimum Data Set (MDS) 3.0 (2014-2018, n = 262,301). Techniques included three data balancing methods (SMOTE for up sampling, ENN for down sampling, and SMOTEENN for up and down sampling) and three feature selection methods (LASSO, Recursive Feature Elimination, and Principal Component Analysis). One balancing and one feature selection technique was applied, and the resulting dataset was then trained on four machine learning models (Logistic Regression, Random Forest, XGBoost, and Neural Network). Model performance was evaluated with AUC and accuracy, and interpretation used SHapley Additive exPlanations. Results Using data balancing methods improved the prediction performances of the machine learning models, but feature selection did not remove any features and did not affect performance. With all models having a high accuracy (76.5%-99.9%), interpretation on all four models yielded the most holistic view. SHAP values indicated that therapy (speech, physical, occupational, and respiratory), independence (activities of daily living for walking, mobility, eating, dressing, and toilet use), and mood (severity score, anti-anxiety medications, antidepressants, and antipsychotics) features contributed the most. Meaning, stroke survivors who received fewer therapy hours, were less independent, had a worse overall mood were at a greater risk of having a seizure after an infection. Conclusion The development of a tool to predict seizure following an infection in stroke survivors can be interpreted by providers to guide treatment and prevent complications long term. This promotes individualized treatment plans that can increase the quality of resident care.
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Affiliation(s)
- Madeleine Stanik
- Purdue University, Department of Engineering, Weldon School of Biomedical Engineering, West Lafayette, IN, United States
| | - Zachary Hass
- Purdue University, Schools of Industrial Engineering and Nursing, West Lafayette, IN, United States
| | - Nan Kong
- Purdue University, Department of Engineering, Weldon School of Biomedical Engineering, West Lafayette, IN, United States
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Prusynski RA, Frogner BK, Rundell SD, Pradhan S, Mroz TM. Is More Always Better? Financially Motivated Therapy and Patient Outcomes in Skilled Nursing Facilities. Arch Phys Med Rehabil 2024; 105:287-294. [PMID: 37541357 PMCID: PMC10837324 DOI: 10.1016/j.apmr.2023.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 06/29/2023] [Accepted: 07/11/2023] [Indexed: 08/06/2023]
Abstract
OBJECTIVE To determine if financially motivated therapy in Skilled Nursing Facilities (SNFs) is associated with patient outcomes. DESIGN Cohort study using 2018 Medicare administrative data. SETTING AND PARTICIPANTS 13,949 SNFs in the United States. PARTICIPANTS 934,677 Medicare Part A patients admitted to SNF for post-acute rehabilitation (N=934,677). INTERVENTIONS The primary independent variable was an indicator of financially motivated therapy, separate from intensive therapy, known as thresholding, defined as when SNFs provide 10 or fewer minutes of therapy above weekly reimbursement thresholds. MAIN OUTCOME MEASURES Dichotomous indicators of successful discharge to the community vs institution and functional improvement on measures of transfers, ambulation, or locomotion. Mixed effects models estimated relations between thresholding and community discharge and functional improvement, adjusted for therapy intensity, patient, and facility characteristics. Sensitivity analyses estimated associations between thresholding and outcomes when patients were stratified by therapy volume. RESULTS Thresholding was associated with a small positive effect on functional improvement (odds ratio 1.07; 95% CI 1.06-1.09) and community discharge (odds ratio 1.03, 95% CI 1.02-1.05). Effect sizes for functional improvement were consistent across patients receiving different volumes of therapy. However, effect sizes for community discharge were largest for patients in low-volume therapy groups (odds ratio 1.27, 95% CI 1.18-1.35). CONCLUSIONS Patients who experienced thresholding during post-acute SNF stays were slightly more likely to improve in function and successfully discharge to the community, especially for patients receiving lower volumes of therapy. While thresholding is an inefficient and financially motivated practice, results suggest that even small amounts of extra therapy time may have contributed positively to outcomes for patients receiving lower-volume therapy. As therapy volumes decline in SNFs, these results emphasize the importance of Medicare payment policy designed to promote, not disincentivize, potentially beneficial rehabilitation services for patients.
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Affiliation(s)
- Rachel A Prusynski
- Department of Rehabilitation Medicine, University of Washington, Seattle WA; Center for Health Workforce Studies, Department of Family Medicine, University of Washington, Seattle WA.
| | - Bianca K Frogner
- Center for Health Workforce Studies, Department of Family Medicine, University of Washington, Seattle WA
| | - Sean D Rundell
- Department of Rehabilitation Medicine, University of Washington, Seattle WA
| | - Sujata Pradhan
- Department of Rehabilitation Medicine, University of Washington, Seattle WA
| | - Tracy M Mroz
- Department of Rehabilitation Medicine, University of Washington, Seattle WA; Center for Health Workforce Studies, Department of Family Medicine, University of Washington, Seattle WA
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Prusynski RA, Rundell SD, Pradhan S, Mroz TM. Some But Not Too Much: Multiparticipant Therapy and Positive Patient Outcomes in Skilled Nursing Facilities. J Geriatr Phys Ther 2023; 46:185-195. [PMID: 36103147 PMCID: PMC10008750 DOI: 10.1519/jpt.0000000000000363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND AND PURPOSE Physical and occupational therapy practices in skilled nursing facilities (SNFs) were greatly impacted by the 2019 Medicare Patient-Driven Payment Model (PDPM). Under the PDPM, the practice of multiparticipant therapy-treating more than one patient per therapy provider per session-increased in SNFs, but it is unknown how substituting multiparticipant therapy for individualized therapy may impact patient outcomes. This cross-sectional study establishes baseline relationships between multiparticipant therapy and patient outcomes using pre-PDPM data. METHODS We used Minimum Data Set assessments from all short-term Medicare fee-for-service SNF stays in 2018. Using generalized mixed-effects logistic regression adjusted for therapy volume and patient factors, we examined associations between the proportion of minutes of physical and occupational therapy that were received as multiparticipant sessions during the SNF stay and 2 outcomes: community discharge and functional improvement. Multiparticipant therapy minutes as a proportion of total therapy time were categorized as none, low (below the median of 5%), medium (median to <25%), and high (≥25%) to reflect the 25% multiparticipant therapy limit required by the PDPM. RESULTS AND DISCUSSION We included 901 544 patients with complete data for functional improvement and 912 996 for the discharge outcome. Compared with patients receiving no multiparticipant therapy, adjusted models found small positive associations between low and medium multiparticipant therapy levels and outcomes. Patients receiving low levels of multiparticipant therapy had 14% higher odds of improving in function (95% CI 1.09-1.19) and 10% higher odds of community discharge (95% CI 1.05-1.15). Patients receiving medium levels of multiparticipant therapy had 18% higher odds of functional improvement (95% CI 1.13-1.24) and 44% higher odds of community discharge (95% CI 1.34-1.55). However, associations disappeared with high levels of multiparticipant therapy. CONCLUSIONS Prior to the PDPM, providing up to 25% multiparticipant therapy was an efficient strategy for SNFs that may have also benefitted patients. As positive associations disappeared with high levels (≥25%) of multiparticipant therapy, it may be best to continue delivering the majority of therapy in SNFs as individualized treatment.
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Affiliation(s)
- Rachel A Prusynski
- Department of Rehabilitation Medicine, University of Washington, Seattle
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Prusynski RA, Pradhan S, Mroz TM. Skilled Nursing Facility Organizational Characteristics Are More Strongly Associated With Multiparticipant Therapy Provision Than Patient Characteristics. Phys Ther 2022; 102:pzab292. [PMID: 34972865 PMCID: PMC9097255 DOI: 10.1093/ptj/pzab292] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 08/25/2021] [Accepted: 11/19/2021] [Indexed: 01/29/2023]
Abstract
OBJECTIVES Multiparticipant physical and occupational therapy provision has fluctuated significantly in skilled nursing facilities (SNFs) under shifts in Medicare reimbursement policy. Multiparticipant therapy includes group (2-6 individuals per therapist) and concurrent therapy (2 individuals per therapist). This study uses recent patient-level data to characterize multiparticipant therapy provision in SNFs to help anticipate shifts under new Medicare policy and the COVID-19 pandemic. METHODS This secondary analysis used data on 1,016,984 post-acute rehabilitation stays in SNFs in 2018. This analysis identified patient predictors (eg, demographic, clinical) and organizational predictors (eg, ownership, quality, staffing) of receiving multiparticipant therapy using mixed-effects logistic regression. Among individuals who received any multiparticipant therapy, those patient or facility factors associated with high rates of multiparticipant therapy provision were also determined. RESULTS Less than 3% of individuals received multiparticipant therapy in 2018. Patient functional and cognitive impairment and indicators of market regulation were associated with lower odds of multiparticipant therapy. Effect sizes for organizational factors associated with multiparticipant therapy provision were generally larger compared with patient factors. High multiparticipant therapy provision was concentrated in <2% of SNFs and was positively associated with for-profit ownership, contract staffing, and low 5-star quality ratings. CONCLUSION SNF organizational characteristics tended to have stronger associations with multiparticipant therapy provision than patient factors, suggesting that changes in patient case-mix, as expected during the COVID-19 pandemic, may have less of an impact on multiparticipant therapy provision than organizational factors. Results suggest that for-profit SNFs in states with higher market regulation, SNFs providing high volumes of therapy, and SNFs utilizing high proportions of assistants and contract staff may be more responsive to Medicare policy by increasing multiparticipant therapy provision. IMPACT This study may help identify SNFs that are more likely to increase multiparticipant therapy provision under new Medicare payment policy.
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Affiliation(s)
- Rachel A Prusynski
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Sujata Pradhan
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Tracy M Mroz
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
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Do Skilled Nursing Facilities That Provide More Rehabilitation Therapy Have Lower Rehospitalization Rates? Am J Med Qual 2021; 36:304-310. [PMID: 34050054 DOI: 10.1097/01.jmq.0000735444.48095.74] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This study examines whether skilled nursing facilities (SNFs) that consistently provided more rehabilitation therapy than other SNFs had lower 30-day rehospitalization rates. A cross-sectional analysis of 11 866 SNFs in the United States compared 30-day rehospitalization rates of SNFs that consistently provided more rehabilitation therapy to other SNFs using linear regression models. High-billing SNFs were defined as the 10% of SNFs with the highest proportions of Medicare fee-for-service claims that just surpassed the therapy minute threshold for the highest payment category. After controlling for patient and facility characteristics, high-billing SNFs had higher 30-day rehospitalization rates as well as longer median length of stay and greater mean cost per stay. Small reductions in the amount of therapy provided are unlikely to increase 30-day rehospitalization rates in SNFs. This has important consequences for the recently implemented patient-driven payment model, which incentivizes SNFs to provide less rehabilitation therapy.
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Hang JA, Naseri C, Francis-Coad J, Jacques A, Waldron N, Knuckey R, Hill AM. Effectiveness of facility-based transition care on health-related outcomes for older adults: A systematic review and meta-analysis. Int J Older People Nurs 2021; 16:e12408. [PMID: 34323006 DOI: 10.1111/opn.12408] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 06/22/2021] [Accepted: 06/24/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Although Transition Care Programmes (TCP) are designed to assist older adults to regain functional ability after hospitalisation, it is unclear whether TCP improve older adults' health-related outcomes. OBJECTIVES The objective of the review was to synthesise the best available evidence for the effectiveness of TCP on health-related outcomes for older adults admitted to a transition care facility after hospitalisation. METHODS Searches were conducted using the databases PubMed, AMED (Ovid), Embase (Ovid), PscyINFO (Ovid) and CINAHL (Full text) and grey literature from January 2000 to May 2020 in English only. Studies that reported health-related outcomes of older adults (aged 65 and above) who received TCP in a facility setting were deemed eligible for inclusion following critical appraisal by two reviewers. Data were pooled in meta-analysis where possible, or reported narratively. RESULTS A total of 21 studies from seven countries [(n = 5 RCT, n = 16 observational cohort studies) participants' mean age 80.2 (±8.3)] were included. Pooled analysis (2069 participants, 7 studies) demonstrated that 80% of older adults undertaking TCP were discharged home [95% CI (0.78-0.82, p < 0.001), I2 = 21.99%, very low GRADE evidence]. Proportions of older adults discharged home varied widely between countries (33.3%-86.4%). There was a significant improvement in ability to perform activities of daily living (2001 participants, 7 studies) as measured by the Modified Barthel Index [17.65 points (95% CI 5.68-29.62, p = 0.004), I2 = 0.00%, very low GRADE evidence]. CONCLUSIONS The proportion of older adults discharged home from TCP compared to other discharge destinations differs between countries. This could be due to the intensity of the rehabilitation delivered and the maximum length of stay allowed prior to discharge. IMPLICATIONS FOR PRACTICE Future studies that comprehensively evaluate the efficacy of TCP on health-related outcomes including quality of life are required. Further investigation is required to identify which aspects of TCP affect successful discharge home.
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Affiliation(s)
- Jo-Aine Hang
- School of Physiotherapy and Exercise Science, Curtin University, Perth, WA, Australia
| | - Chiara Naseri
- School of Physiotherapy and Exercise Science, Curtin University, Perth, WA, Australia
| | | | - Angela Jacques
- School of Physiotherapy and Exercise Science, Curtin University, Perth, WA, Australia
| | - Nicholas Waldron
- School of Physiotherapy and Exercise Science, Curtin University, Perth, WA, Australia.,Department of Aged Care and Rehabilitation, Armadale Kelmscott Memorial Hospital, East Metropolitan Health Service, Armadale, WA, Australia
| | | | - Anne-Marie Hill
- School of Physiotherapy and Exercise Science, Curtin University, Perth, WA, Australia
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Prusynski RA, Frogner BK, Skillman SM, Dahal A, Mroz TM. Therapy Assistant Staffing and Patient Quality Outcomes in Skilled Nursing Facilities. J Appl Gerontol 2021; 41:352-362. [PMID: 34291695 DOI: 10.1177/07334648211033417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Therapy staffing declined in response to Medicare payment policy that removes incentives for intensive physical and occupational therapy in skilled nursing facilities, with therapy assistant staffing more impacted than therapist staffing. However, it is unknown whether therapy assistant staffing is associated with patient outcomes. Using 2017 national data, we examined associations between therapy assistant staffing and three outcomes: patient functional improvement, community discharge, and hospital readmissions, controlling for therapy intensity and facility characteristics. Assistant staffing was not associated with functional improvement. Compared with employing no assistants, staffing 25% to 75% occupational therapy assistants and 25% to 50% physical therapist assistants were associated with more community discharges. Higher occupational therapy assistant staffing was associated with higher readmissions. Higher intensity physical therapy was associated with better quality across outcomes. Skilled nursing facilities seeking to maximize profit while maintaining quality may be successful by choosing to employ more physical therapy assistants rather than sacrificing physical therapy intensity.
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8
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Prusynski RA, Gustavson AM, Shrivastav SR, Mroz TM. Rehabilitation Intensity and Patient Outcomes in Skilled Nursing Facilities in the United States: A Systematic Review. Phys Ther 2021; 101:6059293. [PMID: 33388761 DOI: 10.1093/ptj/pzaa230] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 12/02/2020] [Indexed: 02/09/2023]
Abstract
OBJECTIVE Exponential increases in rehabilitation intensity in skilled nursing facilities (SNFs) motivated recent changes in Medicare reimbursement policies, which remove financial incentives for providing more minutes of physical therapy, occupational therapy, and speech therapy. Yet, there is concern that SNFs will reduce therapy provision and patients will experience worse outcomes. The purpose of this systematic review was to synthesize current evidence on the relationship between therapy intensity and patient outcomes in SNFs. METHODS PubMed, Medline, Scopus, Embase, CINAHL, PEDro, and COCHRANE databases were searched. English-language studies published in the United States between 1998 and February 14, 2020, examining the relationship between therapy intensity and community discharge, hospital readmission, length of stay (LOS), and functional improvement for short-stay SNF patients were considered. Data extraction and risk of bias were performed using the American Academy of Neurology Classification of Evidence scale for causation questions. American Academy of Neurology criteria were used to assess confidence in the evidence for each outcome. RESULTS Eight observational studies met inclusion criteria. There was moderate evidence that higher intensity therapy was associated with higher rates of community discharge and shorter LOS. One study provided very low-level evidence of associations between higher intensity therapy and lower hospital readmissions after total hip and knee replacement. There was low-level evidence indicating higher intensity therapy is associated with improvements in function. CONCLUSIONS This systematic review concludes with moderate confidence that higher intensity therapy in SNFs leads to higher community discharge rates and shorter LOS. Future research should improve quality of evidence on functional improvement and hospital readmissions. IMPACT This systematic review demonstrates that patients in SNFs may benefit from higher intensity therapy. Because new policies no longer incentivize intensive therapy, patient outcomes should be closely monitored to ensure patients in SNFs receive high-quality care.
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Affiliation(s)
- Rachel A Prusynski
- Department of Rehabilitation Medicine, University of Washington, 1959 NE Pacific St., Seattle, WA 98195-6490, USA
| | - Allison M Gustavson
- Veterans Affairs Health Services Research and Development Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota, USA
| | - Siddhi R Shrivastav
- Department of Rehabilitation Medicine, University of Washington, 1959 NE Pacific St., Seattle, WA 98195-6490, USA
| | - Tracy M Mroz
- Department of Rehabilitation Medicine, University of Washington, 1959 NE Pacific St., Seattle, WA 98195-6490, USA
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Prusynski RA, Frogner BK, Dahal AD, Skillman SM, Mroz TM. Skilled Nursing Facility Characteristics Associated With Financially Motivated Therapy and Relation to Quality. J Am Med Dir Assoc 2020; 21:1944-1950.e3. [DOI: 10.1016/j.jamda.2020.04.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 03/31/2020] [Accepted: 04/09/2020] [Indexed: 10/24/2022]
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Gustavson AM, Malone DJ, Boxer RS, Forster JE, Stevens-Lapsley JE. Application of High-Intensity Functional Resistance Training in a Skilled Nursing Facility: An Implementation Study. Phys Ther 2020; 100:1746-1758. [PMID: 32750132 PMCID: PMC7530575 DOI: 10.1093/ptj/pzaa126] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 08/20/2019] [Accepted: 04/24/2020] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Rehabilitation in skilled nursing facilities (SNFs) is under scrutiny to deliver high-quality care and superior outcomes in less time. High-intensity resistance training demonstrates functional improvements in community-dwelling and long-term care populations but has not been generalized to the SNF population. The purpose of this study was to evaluate implementation issues including safety and feasibility and to provide preliminary information on effectiveness of rehabilitation focused on high-intensity functional resistance training in an SNF. METHODS The implementation study design consisted of 2 nonrandomized independent groups (usual care and high intensity) that were staged within a single SNF. The i-STRONGER program (IntenSive Therapeutic Rehabilitation for Older Skilled NursinG HomE Residents) integrates principles of physiologic tissue overload into rehabilitation. Physical therapists administered the Short Physical Performance Battery and gait speed at evaluation and discharge. Reach, Effectiveness, Adoption, Implementation, and Maintenance was used to evaluate the implementation process. An observational checklist and documentation audits were used to assess treatment fidelity. Regression analyses evaluated the response of functional change by group. RESULTS No treatment-specific adverse events were reported. Treatment fidelity was high at >99%, whereas documentation varied from 21% to 50%. Patient satisfaction was greater in i-STRONGER, and patient refusals to participate in therapy sessions trended downward in i-STRONGER. Patients in i-STRONGER exhibited a 0.13 m/s greater change in gait speed than in the usual care group. Although not significant, i-STRONGER resulted in a 0.64-point greater change in the Short Physical Performance Battery than usual care, and average SNF length of stay was 3.5 days shorter for i-STRONGER patients. CONCLUSION The findings from this study indicate that implementation of a high-intensity resistance training framework in SNFs is safe and feasible. Furthermore, results support a signal effectiveness of improving function and satisfaction, although the heterogeneity of the population necessitates a larger implementation study to confirm. IMPACT STATEMENT This pragmatic study demonstrates that high-intensity resistance training in medically complex older adults is safe and favorable in SNFs. This work supports the need to fundamentally change the intensity of rehabilitation provided to this population to promote greater value within post-acute care. Furthermore, this study supports the application of implementation science to rehabilitation for rapid and effective translation of evidence into practice.
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Affiliation(s)
- Allison M Gustavson
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, Colorado
| | - Daniel J Malone
- CCS, Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado
| | - Rebecca S Boxer
- Division of Geriatric Medicine, Department of Medicine, University of Colorado, and Eastern Colorado Geriatric Research Education and Clinical Center, Aurora, Colorado
| | - Jeri E Forster
- Rocky Mountain Regional Veterans Affairs Medical Center, Rocky Mountain Mental Illness Research, Education and Clinical Center, Aurora; Department of Physical Medicine and Rehabilitation, University of Colorado; and Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado
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Tijsen LM, Derksen EW, Achterberg WP, Buijck BI. Challenging rehabilitation environment for older patients. Clin Interv Aging 2019; 14:1451-1460. [PMID: 31496672 PMCID: PMC6697645 DOI: 10.2147/cia.s207863] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 07/07/2019] [Indexed: 01/19/2023] Open
Abstract
Introduction After hospitalization, 11% of the older patients are referred to rehabilitation facilities. Nowadays, there is a trend to formalize the rehabilitation process for these patients in a Challenging Rehabilitation Environment (CRE). This concept involves the comprehensive organization of care, support and the environment on a rehabilitation ward. However, since literature on the principles of CRE is scarce, this review aimed to explore and describe the principles of CRE. Methods A search was made in PubMed for relevant literature concerning CRE. Then, articles were hand searched for relevant keywords (ie, task-oriented training, therapy intensity, patient-led therapy, group training), references were identified, and topics categorized. Results After evaluating 51 articles, 7 main topics of CRE were identified: 1) Therapy time; ie, the level of (physical) activity; the intensity of therapy and activity is related to rehabilitation outcomes, 2) group training; used to increase practice time and can be used to achieve multiple goals (eg, activities of daily living, mobility), 3) patient-regulated exercise; increases the level of self-management and practice time, 4) family participation; may lead to increased practice time and have a positive effect on rehabilitation outcomes, 5) task-oriented training; in addition to therapy, nurses can stimulate rehabilitants to perform meaningful tasks that improve functional outcomes, 6) enriched environment; this challenges rehabilitants to be active in social and physical activities, and 7) team dynamics; shared goals during rehabilitation and good communication in a transdisciplinary team improve the quality of rehabilitation. Discussion This is the first description of CRE based on literature; however, the included studies discussed rehabilitation mainly after stroke and for few other diagnostic groups. Conclusion Seven main topics related to CRE were identified that may help patients to improve their rehabilitation outcomes. Further research on the concept and effectivity of CRE is necessary.
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Affiliation(s)
- Lian Mj Tijsen
- Department Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands.,Oktober , Bladel, The Netherlands.,De Zorgboog , Bakel, The Netherlands
| | - Els Wc Derksen
- Department Primary and Community Care, Center for Family Medicine, Geriatric Care and Public Health, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Wilco P Achterberg
- Department Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Bianca I Buijck
- Oktober , Bladel, The Netherlands.,De Zorgboog , Bakel, The Netherlands
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Beaupre L, Sobolev B, Guy P, Kim JD, Kuramoto L, Sheehan KJ, Sutherland JM, Harvey E, Morin SN. Discharge destination following hip fracture in Canada among previously community-dwelling older adults, 2004-2012: database study. Osteoporos Int 2019; 30:1383-1394. [PMID: 30937483 DOI: 10.1007/s00198-019-04943-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 03/15/2019] [Indexed: 10/27/2022]
Abstract
UNLABELLED Little is known about post-acute care following hip fracture surgery. We investigated discharge destinations from surgical hospitals for nine Canadian provinces. We identified significant heterogeneity in discharge patterns across provinces suggesting different post-acute recovery pathways. Further work is required to determine the impact on patient outcomes and health system costs. INTRODUCTION To examine discharge destinations by provinces in Canada, adjusting for patient, injury, and care characteristics. METHODS We analyzed population-based hospital discharge abstracts from a national administrative database for community-dwelling patients who underwent hip fracture surgery between 2004 and 2012 in Canada. Discharge destination was categorized as rehabilitation, home, acute care, and continuing care. Multinomial logistic regression modeling compared proportions of discharge to rehabilitation, acute care, and continuing care versus home between each province and Ontario. Adjusted risk differences and risk ratios were estimated. RESULTS Of 111,952 previously community-dwelling patients aged 65 years or older, 22.5% were discharged to rehabilitation, 31.6% to home, 27.0% to acute care, and 18.2% to continuing care, with significant variation across provinces (p < 0.001). The proportion of discharge to rehabilitation ranged from 2.4% in British Columbia to 41.0% in Ontario while the proportion discharged home ranged from 20.3% in Prince Edward Island to 52.2% in British Columbia. The proportion of discharge to acute care ranged from 15.2% in Ontario to 58.8% in Saskatchewan while the proportion discharged to continuing care ranged from 9.3% in Manitoba and Prince Edward Island to 22.9% in New Brunswick. Adjusting for hospital type changed the direction of the provincial effect on discharge to continuing care in two provinces, but statistical significance remained consistent with the primary analysis. CONCLUSIONS Discharge destination from the surgical hospital after hip fracture is highly variable across nine Canadian provinces. Further work is required to determine the impact of this heterogeneity on patient outcomes and health system costs.
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Affiliation(s)
- L Beaupre
- University of Alberta, 2-50 Corbett Hall, Edmonton, AB, T6G 2G4, Canada.
| | - B Sobolev
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - P Guy
- Centre for Hip Health and Mobility, University of British Columbia, Vancouver, Canada
| | - J D Kim
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - L Kuramoto
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, Canada
| | - K J Sheehan
- Academic Department of Physiotherapy, Division of Health and Social Care Research, King's College London, London, UK
| | - J M Sutherland
- Centre for Hip Health and Mobility, University of British Columbia, Vancouver, Canada
| | - E Harvey
- McGill University, Montreal, Canada
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Higashikawa T, Shigemoto K, Goshima K, Usuda D, Okuro M, Moriyama M, Inujima H, Hangyou M, Usuda K, Morimoto S, Matsumoto T, Takashima S, Kanda T, Sawaguchi T. Urinary retention as a postoperative complication associated with functional decline in elderly female patients with femoral neck and trochanteric fractures: A retrospective study of a patient cohort. Medicine (Baltimore) 2019; 98:e16023. [PMID: 31192952 PMCID: PMC6587656 DOI: 10.1097/md.0000000000016023] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Urinary retention (UR) has been recognized as one of the most common postoperative complications after hip surgery in elderly. The objective of the present study was to evaluate risk for postoperative complications of UR in elderly female patients with femoral neck fractures.We recruited 221 female patients (age 85.3 ± 7.0 years) with a history of hip surgery carried out at Toyama Municipal Hospital. UR occurred in 34 out of 221 cases (15.4%). Multiple logistic regression analysis was conducted to investigate the risk factors for UR, including age, body mass index (BMI), serum albumin, cognitive impairment, and activities of daily living (ADL).The results showed significant association of UR with cognitive impairment (P = .005, odds ratio [OR] 4.11, 95% confidence interval [CI] 1.53-11.03), and ADL (P = .029, OR 2.61, 95% CI 1.11-6.18), under adjustment with age and BMI.This study demonstrated that cognitive function and ADL were the important risk factors for UR, suggested that the postoperative management of UR is important with taking account of neurofunctional assistance and nursing care in daily living, especially in elderly female patients receiving surgery of femoral neck and trochanteric fractures.
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Affiliation(s)
- Toshihiro Higashikawa
- Department of Geriatric Medicine, Kanazawa Medical University Himi Municipal Hospital, Kurakawa, Himi
| | - Kenji Shigemoto
- Department of Orthopedics and Joint Reconstructive Surgery, Toyama Municipal Hospital, Hokubumachi, Imaizumi, Toyama
| | - Kenichi Goshima
- Department of Orthopedics and Joint Reconstructive Surgery, Toyama Municipal Hospital, Hokubumachi, Imaizumi, Toyama
| | | | - Masashi Okuro
- Department of Geriatric Medicine, Kanazawa Medical University, Uchinada, Kahoku-gun, Ishikawa
| | - Manabu Moriyama
- Department of Urology, Kanazawa Medical University Himi Municipal Hospital, Kurakawa, Himi
| | - Hiromi Inujima
- Toyama Municipal Hospital, Hokubumachi, Imaizumi, Toyama
| | | | - Kimiko Usuda
- Toyama Municipal Hospital, Hokubumachi, Imaizumi, Toyama
| | - Shigeto Morimoto
- Department of Geriatric Medicine, Kanazawa Medical University, Uchinada, Kahoku-gun, Ishikawa
| | - Tadami Matsumoto
- Department of Orthopedic Medicine, Kanazawa Medical University, Uchinada, Kahoku-gun, Ishikawa, Japan
| | | | | | - Takeshi Sawaguchi
- Department of Orthopedics and Joint Reconstructive Surgery, Toyama Municipal Hospital, Hokubumachi, Imaizumi, Toyama
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Zhang T, Jambhekar B, Kumar A, Rizvi SA, Resnik L, Shireman TI. Assessing the effects of post-acute rehabilitation services on health care outcomes for people with multiple sclerosis. Mult Scler Relat Disord 2019; 30:277-283. [DOI: 10.1016/j.msard.2019.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 03/01/2019] [Accepted: 03/03/2019] [Indexed: 12/12/2022]
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Abrahamson K, Mueller C, Duan Y, Cooke V. Heightening Person-Centered Care Processes in the Delivery of Nursing Restorative Care. J Gerontol Nurs 2019; 45:5-10. [PMID: 31026326 DOI: 10.3928/00989134-20190328-03] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The objective of the current study was to investigate the perspectives of nursing home (NH) providers regarding the requirements to achieve reimbursement for nursing restorative care (NRC) services and propose recommendations to state agencies to assist NH providers to conduct NRC programs that are person-centered and able to achieve full reimbursement. Methods included a survey of NH providers in one state and a stakeholder focus group to discuss survey findings and develop recommendations. Key findings are that NH providers perceive value to residents from the provision of NRC; providers do not associate these benefits with the stringent reimbursement requirements; and NHs often provide NRC that is individualized, based on resident goals and activity tolerance, as well as realistic given competing demands on staff, even when doing so means giving up reimbursement for NRC services. Recommendations include basing reimbursement for NRC on outcomes rather than the process; reconsideration of the frequency and intensity requirements for NRC components; and increased availability of NRC training/education and resources for providers and case-mix reviewers. [Journal of Gerontological Nursing, 45(5), 5-10.].
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The Relationship Between Quality of Care, Physical Therapy, and Occupational Therapy Staffing Levels in Nursing Homes in 4 Years' Follow-up. J Am Med Dir Assoc 2019; 20:462-469. [DOI: 10.1016/j.jamda.2019.02.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 02/01/2019] [Accepted: 02/03/2019] [Indexed: 11/15/2022]
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Vest JR, Jung HY, Wiley K, Kooreman H, Pettit L, Unruh MA. Adoption of Health Information Technology Among US Nursing Facilities. J Am Med Dir Assoc 2018; 20:995-1000.e4. [PMID: 30579920 DOI: 10.1016/j.jamda.2018.11.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 10/30/2018] [Accepted: 11/02/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVES Nursing facilities have lagged behind in the adoption of interoperable health information technology (ie technologies that allow the sharing and use of electronic patient information between different information systems). The objective of this study was to estimate the nationwide prevalence of electronic health record (EHR) adoption among nursing facilities and to identify the factors associated with adoption. DESIGN Cross-sectional survey. SETTING & PARTICIPANTS We surveyed members of the Society for Post-Acute & Long-Term Care Medicine (AMDA) about their organizations' health information technology usage and characteristics. MEASUREMENTS Using questions adopted from existing instruments, the survey measured nursing home's EHR adoption, the ability to send, receive, search and integrate electronic information, as well as barriers to usage. Additionally, we linked survey responses to public use secondary data sources to construct measurements for 8 determinants known to be associated with organizational adoption: innovativeness, functional differentiation, role specialization, administrative intensity, professionalism, complexity, technical knowledge resources, and slack resources. A series of regression models estimated the association between potential determinants and technology adoption. RESULTS 84% of nursing facilities reported using an EHR. After controlling for all other factors, respondents who characterized their organization as more innovative had more than 6 times the odds (adjusted odds ratio = 6.39, 95% confidence interval = 2.69, 15.21) of adopting an EHR. Organization innovativeness was also associated with an increased odds of being able to send, integrate, and search for electronic information. The most commonly identified barrier to sharing clinical information among nursing facilities with an EHR was a reported absence of interoperability (57%). CONCLUSIONS/IMPLICATIONS An organizational culture that fosters innovation and awareness campaigns by professional societies may facilitate further adoption and effective use of technology. This will be increasingly important as policy makers continue to emphasize the use of EHRs and interoperability to improve the quality of care in nursing facilities.
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Affiliation(s)
- Joshua R Vest
- Department of Health Policy & Management, Indiana University Richard M. Fairbanks School of Public Health at IUPUI, Indianapolis, IN.
| | - Hye-Young Jung
- Division of Health Policy and Economics, Weill Cornell Medical College, New York, NY
| | - Kevin Wiley
- Department of Health Policy & Management, Indiana University Richard M. Fairbanks School of Public Health at IUPUI, Indianapolis, IN
| | - Harold Kooreman
- Department of Health Policy & Management, Indiana University Richard M. Fairbanks School of Public Health at IUPUI, Indianapolis, IN
| | - Lorren Pettit
- Healthcare Information and Management Systems Society (HIMSS), Chicago, IL
| | - Mark A Unruh
- Division of Health Policy and Economics, Weill Cornell Medical College, New York, NY
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Abraham DS, Barr E, Ostir GV, Hebel JR, Golden J, Gruber-Baldini AL, Guralnik JM, Hochberg MC, Orwig DL, Resnick B, Magaziner JS. Residual Disability, Mortality, and Nursing Home Placement After Hip Fracture Over 2 Decades. Arch Phys Med Rehabil 2018; 100:874-882. [PMID: 30391413 DOI: 10.1016/j.apmr.2018.10.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 09/26/2018] [Accepted: 10/10/2018] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To examine trends in 12-month postfracture residual disability, nursing home placement, and mortality among patients with a hip fracture between 1990 and 2011. DESIGN Secondary analysis of 12-month outcomes from 3 cohort studies and control arms of 2 randomized controlled trials. SETTING Original studies were conducted as part of the Baltimore Hip Studies (BHS). PARTICIPANTS Community-dwelling patients ≥65 years of age hospitalized for surgical repair of a nonpathologic hip fracture (N=988). MAIN OUTCOME MEASURES Twelve-month residual disability, mortality, and nursing home residency were examined in case-mix adjusted models by sex and study. Residual disability was calculated by subtracting prefracture scores of Lower Extremity Physical Activities of Daily Living from scores at 12 months postfracture. We also examined the proportion of individuals with a 12-month score higher than their prefracture score (residual disability>0). RESULTS Only small improvements were seen in residual disability between 1990 and 2011. No significant differences were seen for men between BHS2 (enrollment 1990-1991; mean residual disability=3.1 activities; 95% confidence interval [CI], 2.16-4.10) and BHS7 (enrollment 2006-2011; mean=3.1 activities; 95% CI, 2.41-3.82). In women, residual disability significantly improved from BHS2 (mean=3.5 activities; 95% CI, 2.95-3.99) to BHS3 (enrollment 1992-1995; mean=2.7 activities; 95% CI, 2.01-3.30) with no significant improvements in later studies. After adjustment, a substantial proportion (91% of men and 79% of women) had a negative outcome (residual disability, died, or nursing home residence at 12 months) in the most recently completed study (BHS7). CONCLUSIONS Over 2 decades, patients undergoing usual care post-hip fracture still had substantial residual disability. Additional clinical and research efforts are needed to determine how to improve hip fracture treatment, rehabilitation, and subsequent outcomes.
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Affiliation(s)
- Danielle S Abraham
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - Erik Barr
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - Glenn V Ostir
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD; Institute of Gerontology, University of Georgia College of Public Health, Athens, GA
| | - J Richard Hebel
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - Justine Golden
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - Ann L Gruber-Baldini
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - Jack M Guralnik
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - Marc C Hochberg
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD; Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Denise L Orwig
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| | | | - Jay S Magaziner
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD.
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Kimball CC, Nichols CI, Nunley RM, Vose JG, Stambough JB. Skilled Nursing Facility Star Rating, Patient Outcomes, and Readmission Risk After Total Joint Arthroplasty. J Arthroplasty 2018; 33:3130-3137. [PMID: 30001882 DOI: 10.1016/j.arth.2018.06.020] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 06/07/2018] [Accepted: 06/15/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND This study examined the correlation between publicly reported indicators of skilled nursing facility (SNF) quality and clinical outcomes after primary total knee arthroplasty (TKA) and total hip arthroplasty (THA). METHODS This retrospective analysis used Medicare claims from the Centers for Medicare and Medicaid Services 100% Standard Analytic File (2014-2015) that were linked to SNF quality star ratings from the Centers for Medicare and Medicaid Services Nursing Home Compare database. Overall SNF rating and subcomponents of the rating were evaluated for correlation to 30-day and 90-day risk of readmission. Ratings were based upon a 5-star rating system (1 representing the lowest quality). Cox proportional hazards regressions controlled for age, race, census division, hospital location, comorbidities, and SNF length of stay. RESULTS A total of 9418 SNFs, 58,064 TKA patients, and 26,837 THA patients met criteria. As SNF overall star rating increased from 1 to 5, incidence of all-cause 30-day readmission decreased from 6.4% to 5.0% for TKA (relative reduction [RR] 22%; P < .001) and from 9.1% to 6.2% for THA (RR 32%; P < .001). As nurse staffing rating increased, incidence of all-cause readmission decreased from 6.8% to 4.7% for the TKA cohort (30.9% RR; P < .001), and from 7.7% to 6.0% for the THA cohort (22.1% RR; P = .003). Regression analysis demonstrated that a higher star rating was associated with decreased risk of readmission (both cohorts P < .05). CONCLUSIONS For patients undergoing TKA or THA, the overall SNF star rating, nurse staffing ratios, and physical therapy intensity were significantly correlated with risk of readmission within 30 days of SNF admission.
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Affiliation(s)
| | | | - Ryan M Nunley
- Department of Orthopedics, Washington University in St. Louis, Barnes Jewish Hospital, St. Louis, MI
| | | | - Jeffrey B Stambough
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
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Kumar A, Rahman M, Trivedi AN, Resnik L, Gozalo P, Mor V. Comparing post-acute rehabilitation use, length of stay, and outcomes experienced by Medicare fee-for-service and Medicare Advantage beneficiaries with hip fracture in the United States: A secondary analysis of administrative data. PLoS Med 2018; 15:e1002592. [PMID: 29944655 PMCID: PMC6019094 DOI: 10.1371/journal.pmed.1002592] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 05/21/2018] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Medicare Advantage (MA) and Medicare fee-for-service (FFS) plans have different financial incentives. Medicare pays predetermined rates per beneficiary to MA plans for providing care throughout the year, while providers serving FFS patients are reimbursed per utilization event. It is unknown how these incentives affect post-acute care in skilled nursing facilities (SNFs). The objective of this study was to examine differences in rehabilitation service use, length of stay, and outcomes for patients following hip fracture between FFS and MA enrollees. METHODS AND FINDINGS This was a retrospective cohort study to examine differences in health service utilization and outcomes between FFS and MA patients in SNFs following hip fracture hospitalization during the period January 1, 2011, to June 30, 2015, and followed up until December 31, 2015. We linked the Master Beneficiary Summary File, Medicare Provider and Analysis Review data, Healthcare Effectiveness Data and Information Set data, the Minimum Data Set, and the American Community Survey. The 6 primary outcomes of interest in this study included 2 process measures and 4 patient-centered outcomes. Process measures included length of stay in the SNF and average rehabilitation therapy minutes (physical and occupational therapy) received per day. Patient-centered outcomes included 30-day hospital readmission, changes in functional status as measured by the 28-point late loss MDS-ADL scale, likelihood of becoming a long-term resident, and successful discharge to the community. Successful discharge from a SNF was defined as being discharged to the community within 100 days of SNF admission and remaining alive in the community without being institutionalized in any acute or post-acute setting for at least 30 days. We analyzed 211,296 FFS and 75,554 MA patients with hip fracture admitted directly to a SNF following an index hospitalization who had not been in a nursing facility or hospital in the preceding year. We used inverse probability of treatment weighting (IPTW) and nursing facility fixed effects regression models to compare treatments and outcomes between MA and FFS patients. MA patients were younger and less cognitively impaired upon SNF admission than FFS patients. After applying IPTW, demographic and clinical characteristics of MA patients were comparable with those of FFS patients. After adjusting for risk factors using IPTW-weighted fixed effects regression models, MA patients spent 5.1 (95% CI -5.4 to -4.8) fewer days in the SNF and received 463 (95% CI to -483.2 to -442.4) fewer minutes of total rehabilitation therapy during the first 40 days following SNF admission, i.e., 12.1 (95% CI -12.7 to -11.4) fewer minutes of rehabilitation therapy per day compared to FFS patients. In addition, MA patients had a 1.2 percentage point (95% CI -1.5 to -1.1) lower 30-day readmission rate, 0.6 percentage point (95% CI -0.8 to -0.3) lower rate of becoming a long-stay resident, and a 3.2 percentage point (95% CI 2.7 to 3.7) higher rate of successful discharge to the community compared to FFS patients. The major limitation of this study was that we only adjusted for observed differences to address selection bias between FFS and MA patients with hip fracture. Therefore, results may not be generalizable to other conditions requiring extensive rehabilitation. CONCLUSIONS Compared to FFS patients, MA patients had a shorter course of rehabilitation but were more likely to be discharged to the community successfully and were less likely to experience a 30-day hospital readmission. Longer lengths of stay may not translate into better outcomes in the case of hip fracture patients in SNFs.
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Affiliation(s)
- Amit Kumar
- Center for Gerontology and Health Care Research, Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island, United States of America
| | - Momotazur Rahman
- Center for Gerontology and Health Care Research, Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island, United States of America
| | - Amal N. Trivedi
- Center for Gerontology and Health Care Research, Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island, United States of America
- Providence Veterans Affairs Medical Center, Providence, Rhode Island, United States of America
| | - Linda Resnik
- Center for Gerontology and Health Care Research, Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island, United States of America
- Providence Veterans Affairs Medical Center, Providence, Rhode Island, United States of America
| | - Pedro Gozalo
- Center for Gerontology and Health Care Research, Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island, United States of America
- Providence Veterans Affairs Medical Center, Providence, Rhode Island, United States of America
| | - Vincent Mor
- Center for Gerontology and Health Care Research, Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island, United States of America
- Providence Veterans Affairs Medical Center, Providence, Rhode Island, United States of America
- * E-mail:
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Graham JE, Middleton A, Roberts P, Mallinson T, Prvu-Bettger J. Health Services Research in Rehabilitation and Disability-The Time is Now. Arch Phys Med Rehabil 2018; 99:198-203. [PMID: 28782540 PMCID: PMC5748255 DOI: 10.1016/j.apmr.2017.06.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 06/23/2017] [Accepted: 06/28/2017] [Indexed: 01/17/2023]
Abstract
Policy drives practice, and health services research (HSR) is at the intersection of policy, practice, and patient outcomes. HSR specific to rehabilitation and disability is particularly needed. As rehabilitation researchers and providers, we are uniquely positioned to provide the evidence that guides reforms targeting rehabilitative care. We have the expertise to define the value of rehabilitation in a policy-relevant context. HSR is a powerful tool for providing this evidence. We need to continue building capacity for conducting rigorous, timely rehabilitation-related HSR. Fostering stakeholder engagement in these research efforts will ensure we maintain a patient-centered focus as we address the "Triple Aim" of better care, better health, and better value. In this Special Communication we discuss the role of rehabilitation researchers in HSR. We also provide information on current resources available in our field for conducting HSR and identify gaps for capacity building and future research. Health care reforms are a reality, and through HSR we can give rehabilitation a strong voice during these transformative times.
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Affiliation(s)
- James E Graham
- Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX.
| | - Addie Middleton
- Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX
| | | | - Trudy Mallinson
- School of Medicine & Health Sciences, George Washington University, Washington, DC
| | - Janet Prvu-Bettger
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
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Lage DE, Jernigan MC, Chang Y, Grabowski DC, Hsu J, Metlay JP, Shah SJ. Living Alone and Discharge to Skilled Nursing Facility Care after Hospitalization in Older Adults. J Am Geriatr Soc 2018; 66:100-105. [PMID: 29072783 DOI: 10.1111/jgs.15150] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND/OBJECTIVES Community-based older adults are increasingly living alone. When they become ill, they might need greater support from the healthcare system than would those who live with others. There also has been a growing concern about the high use of postacute care such as skilled nursing facility (SNF) care and the level of variation in this use between hospitals and regions. Our objective was to examine whether living alone contributed to the risk of being discharged to a SNF. DESIGN Retrospective cohort study. SETTING Massachusetts General Hospital. PARTICIPANTS Community-dwelling individuals aged 50 and older admitted to the medical service and discharged alive between July 2014 and August 2015 (N = 7,029). MEASUREMENTS We extracted demographic, clinical, and functional data from the electronic medical record and used multivariable logistic regression to determine whether living alone at the time of hospitalization was associated with subsequent discharge to a SNF. RESULTS Of eligible individuals, 24.8% reported living alone before admission. Those living alone were more likely to be female, older, and more independent before admission than those living with others. Of all participants, 10.9% were discharged to a SNF. After adjustment, participants living alone had more than twice the odds of being discharged to a SNF (odds ratio = 2.23, 95% confidence interval = 1.85-2.69, P < .001). DISCUSSION People living alone are more likely to be discharged to SNFs, even when compared to other individuals with similar levels of clinical complexity and functional status. To the extent that this variation is due to a lack of home support, it could be possible to reduce SNF use through additional home services after hospital discharge.
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Affiliation(s)
- Daniel E Lage
- Massachusetts General Hospital, Department of Medicine, Boston, Massachusetts
- Harvard Medical School, Department of Health Care Policy, Boston, Massachusetts
| | - Michael C Jernigan
- Massachusetts General Hospital, Department of Medicine, Boston, Massachusetts
- Harvard Medical School, Department of Health Care Policy, Boston, Massachusetts
| | - Yuchiao Chang
- Massachusetts General Hospital, Department of Medicine, Boston, Massachusetts
- Harvard Medical School, Department of Health Care Policy, Boston, Massachusetts
| | - David C Grabowski
- Harvard Medical School, Department of Health Care Policy, Boston, Massachusetts
| | - John Hsu
- Massachusetts General Hospital, Department of Medicine, Boston, Massachusetts
- Harvard Medical School, Department of Health Care Policy, Boston, Massachusetts
| | - Joshua P Metlay
- Massachusetts General Hospital, Department of Medicine, Boston, Massachusetts
- Harvard Medical School, Department of Health Care Policy, Boston, Massachusetts
| | - Sachin J Shah
- University of California San Francisco, Department of Medicine, San Francisco, California
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O'Brien SR, Zhang N. Association Between Therapy Intensity and Discharge Outcomes in Aged Medicare Skilled Nursing Facilities Admissions. Arch Phys Med Rehabil 2017; 99:107-115. [PMID: 28860096 DOI: 10.1016/j.apmr.2017.07.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 06/23/2017] [Accepted: 07/18/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To determine the association between therapy intensity and discharge outcomes for aged Medicare skilled nursing facilities (SNFs) fee-for-service beneficiaries and to determine the association between therapy intensity and time to community discharge. DESIGN Retrospective observational design. SETTING SNFs. PARTICIPANTS Aged Medicare fee-for-service beneficiaries (N=311,338) in 3605 SNFs. INTERVENTIONS The total minutes of physical therapy, occupational therapy, and speech therapy per day were divided into intensity groups: high (≥60min); medium-high (45-<60min); medium-low (30-<45min); and low (<30min). MAIN OUTCOME MEASURES Four discharge outcomes-community, hospitalization, permanent placement, and death-were examined using a multivariate competing hazards model. For those associated with community discharge, a Poisson multivariate model was used to determine whether length of stay differed by intensity. RESULTS High intensity therapy was associated with more community discharges in comparison to the remaining intensity groups (hazard ratio, .84, .68, and .433 for medium-high, medium-low, and low intensity groups, respectively). More hospitalizations and deaths were found as therapy intensity decreased. Only high intensity therapy was associated with a 2-day shorter length of stay (incident rate ratio, .95). CONCLUSIONS High intensity therapy was associated with desirable discharge outcomes and may shorten SNF length of stay. Despite growing reimbursements to SNFs for rehabilitation services, there may be desirable benefits to beneficiaries who receive high intensity therapy.
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Affiliation(s)
- Suzanne R O'Brien
- Department of Public Health Sciences, University of Rochester School of Medicine, Rochester, NY.
| | - Ning Zhang
- Department of Public Health Sciences, University of Rochester School of Medicine, Rochester, NY
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24
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Shah CK, Keswani A, Chi D, Sher A, Koenig KM, Moucha CS. Nonelective Primary Total Hip Arthroplasty: The Effect of Discharge Destination on Postdischarge Outcomes. J Arthroplasty 2017; 32:2363-2369. [PMID: 28455179 DOI: 10.1016/j.arth.2017.03.042] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 03/13/2017] [Accepted: 03/17/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Medicare has enacted a mandatory bundled payment program for primary total joint arthroplasty that includes nonelective primary total hip arthroplasty (THA). Efficient postacute care management has been identified as an opportunity to improve value for patients. We aimed to identify risk factors for and compare rates of complications by discharge destination and then use those factors to risk-stratify non-elective THA patients. METHODS Patients who underwent nonelective primary THA from 2011 to 2014 were identified in the American College of Surgeons National Surgical Quality Improvement Program database and categorized into those discharged to skilled nursing facility or inpatient rehabilitation facility vs home self-managed/home health (HHH). Bivariate and multivariate analyses of risk factors for postdischarge adverse events were performed using patient characteristics and intraoperative variables. RESULTS In bivariate analysis, skilled nursing facility or inpatient rehabilitation facility patients compared with HHH patients, had lower rates of postdischarge severe adverse events (SAEs; 49% vs 58%; P < .001) and unplanned 30-day readmissions (71% vs 83%; P < .001). HHH discharged patients with 1 or more of risk factors had a 1.85-6.18 times odds of complications within the first 14 days. CONCLUSION The most important risk factors for predicting postdischarge SAE and readmission are predischarge SAE, dependent functional status, body mass index >40 kg/m2, smoking, diabetes, chronic steroid use, and American Society of Anesthesiologists class 3/4. Nonelective THA patients without these risk factors may be safely discharged to home after THA. Orthopedic surgeons and their nonelective THA patients must agree on the most appropriate discharge destination through a shared decision-making process that takes into account these significant risk factors and other psychosocial factors.
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Affiliation(s)
- Chirag K Shah
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Aakash Keswani
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Debbie Chi
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alex Sher
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Karl M Koenig
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, Texas
| | - Calin S Moucha
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
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Osakwe ZT, Larson E, Agrawal M, Shang J. Assessment of Activity of Daily Living Among Older Adult Patients in Home Healthcare and Skilled Nursing Facilities: An Integrative Review. Home Healthc Now 2017; 35:258-267. [PMID: 28471793 PMCID: PMC5419038 DOI: 10.1097/nhh.0000000000000537] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Older adult's ability to self-manage illness is dependent on their ability to perform activities of daily living (ADL). Forty-five percent of those older than 65 years will have ongoing clinical needs after hospital discharge and require postacute care (PAC) services in settings such as home healthcare (HHC) and skilled nursing facilities (SNF). The Improving Medicare Post-Acute Care Transformation Act of 2014 requires PAC providers to begin collecting and reporting ADL data to build a coordinated approach to payment and standardize patient assessments and quality measurement. The aim of this integrative review was to compare the methods of assessing ADLs in HHC to SNF. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement was used to ensure results were reported systematically. A scientific literature search without date restriction within the PubMed and Cumulative Index of Nursing and Allied Health Literature databases was conducted. Two independent investigators assessed study quality using the quality appraisal instrument developed by Kmet et al. Study quality was high. Of the 18,749 articles identified by the search, 8 met inclusion criteria and four tools were identified that are used to assess ADLs in SNF and HHC. Although SNF and HHC collect similar ADL information, the range of content covered, item definitions, scoring, and psychometrics are not comparable across settings.
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Affiliation(s)
- Zainab Toteh Osakwe
- Zainab Toteh Osakwe, MSN, is PhD Student, School of Nursing, Columbia University, New York, New York. Elaine Larson, PhD, is Professor and Associate Dean of Research, School of Nursing and Mailman School of Public Health, Columbia University, New York, New York. Mansi Agrawal, MPH, is PhD Student, Mailman School of Public Health, Columbia University, New York, New York. Jinjing Shang, PhD, is an Assistant Professor, School of Nursing, Columbia University, New York, New York
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