Relationship between Dysphagia and Home Discharge among Older Patients Receiving Hospital Rehabilitation in Rural Japan: A Retrospective Cohort Study

Characteristics of first-time users of the nursing small-scale multifunctional home care service: a pooled cross-sectional study using Japanese long-term care insurance claims data from 2012 to 2019

OBJECTIVES

In April 2012, the Japanese government launched a new nursing service called the nursing small-scale multifunctional home care (NSMHC) to meet the nursing care demands of individuals with moderate-to-severe activities of daily living (ADLs) dysfunction and who require medical care, thereby allowing them to continue living in the community. We aimed to preliminarily analyse the characteristics of first-time users of NSMHC service.

DESIGN

This pooled cross-sectional study used the Japanese long-term care insurance (LTCI) claims data from the users' first use of NSMHC (from April 2012 to December 2019).

SETTING

NSMHC includes nursing home visits, home care, daycare, overnight stays and medical treatment.

PARTICIPANTS

The study population included LTCI beneficiaries who received their first long-term care requirement certification in Japan from April 2012 onwards, died between April 2012 and December 2019, and used any LTCI service at least once.

RESULTS

Among the 836 563 individuals who used any LTCI service at least once, 3957 (0.47%) used NSMHC. We analysed 3634 individuals without any missing data regarding long-term care requirement certification. Most individuals were aged 80 years or older, with 64.3% requiring care level 3 or above, indicating complete assistance with ADLs. Regarding ADLs in individuals with dementia, 70.6% were at level 2 or below, indicating they can live almost independently even with dementia. A large proportion of NSMHC users availed the service approximately 6 months before death, with no prior use of any LTCI services; they continued using the service for around 4 months, although some people continued to use NSMHC until their month of death.

CONCLUSIONS

Using individual data on nationwide LTCI, we described the characteristics of first-time users of NSMHC among those who died within 7.5 years from the first certification of care needs. Further studies are needed to investigate the effect of NSMHC use on user outcomes.

Multimorbidity, consisting of a combination of chronic diseases and geriatric syndromes, predicts the risk of difficulty in discharge home in older patients admitted to acute care hospital

AIM

To determine whether multimorbidity, consisting of chronic diseases and geriatric syndromes, is associated with home discharge difficulties in older patients.

METHODS

A total of 522 older adults (mean age: 85 ± 7 years) who were admitted to an acute care hospital were enrolled. Multimorbidity was assessed by calculating the number of 16 chronic conditions (CCs): 8 chronic diseases (cardiac diseases, diabetes mellitus, chronic kidney disease, respiratory diseases, gastrointestinal diseases, anemia, dementia, and Parkinson disease) and 8 geriatric syndromes (depression, constipation, chronic pain, polypharmacy, dysphagia, underweight, hypoalbuminemia, and functional limitations). The patients were divided into four groups based on the number of CCs. The outcome was difficulty in discharging home (transfer to other facilities or in-hospital death). Multivariate logistic regression analysis was performed to assess independent associations between four CC groups and failure to discharge home after adjusting for age, sex, living alone, and Barthel index and odds ratio (OR) and 95% confidence interval (CI) were calculated.

RESULTS

Of the 522 patients, 18.8% were transferred to other facilities or died. The proportion of poor outcome in those with 0-2, 3-4, 5-6, and ≥7 CCs was 4.4%, 14.8%, 25.5%, and 37.5%, respectively. Logistic regression analysis after adjusting for covariates revealed that multimorbidity increased the risk of difficulty in discharging home (OR, 2.9 [95% CI, 1.1-8.0] for 3-4 CCs; OR, 4.9 [95% CI, 1.8-13.5] for 5-6 CCs; OR, 8.7 [95% CI, 3.1-24.6] for ≥7 CCs).

CONCLUSION

Multimorbidity, consisting of chronic diseases and geriatric syndromes, predicted difficulty in discharge home in older patients. Geriatr Gerontol Int 2024; 24: 300-305.

Frailty Syndrome in Rural Communities: A Narrative Review and Interviews With Rural Individuals

Background With the global increase in aging populations, frailty syndrome, characterized by decreased strength, endurance, and physiological function, has become a critical issue. This study focuses on rural Japanese communities, where the prevalence of frailty syndrome can be notably high due to factors such as multimorbidity, polypharmacy, and a significant population of elderly individuals. This research addresses the gap in understanding frailty's manifestations and impacts in rural settings, considering unique challenges such as social isolation, limited healthcare access, and the broader social determinants of health. Methodology The study employs a narrative review with PubMed and a thematic analysis of semi-structured interviews with 21 elderly community workers in Unnan City. The analysis used the framework of frailty syndrome affected by physiological, social, psychological, and economic factors. The analysis focused on identifying themes related to the social determinants of health affecting frailty and potential solutions. Results The following five themes emerged from the analysis: Aging, Rural Contexts, Isolation, Lack of Knowledge of Frailty Syndrome, and Lack of Help-Seeking Behavior for Frailty Syndrome. Four solution-oriented themes were identified, namely, Public Dialogue and Educational Workshops, Frailty Syndrome Health Meetings, Social Engagement Activities, and Political Advocacy for Accessibility to Community Centers. These findings highlight the critical role of community engagement, education, and infrastructure improvements in addressing frailty syndrome in rural areas. Conclusions This study underscores the complexity of frailty syndrome in rural Japanese communities, emphasizing the need for targeted interventions that address the unique challenges faced by these populations. By fostering public dialogue, improving healthcare access, and enhancing social support, it is possible to mitigate the impacts of frailty syndrome and improve the quality of life for elderly residents in rural settings. This research contributes to a deeper understanding of frailty in aging societies and the importance of considering social determinants of health in developing effective solutions.

Decision-Making in the Admission of Older Patients: A Thematic Analysis From Multiple-Stakeholder Perspectives

Introduction As rural healthcare systems grapple with an aging population, understanding the factors influencing hospital admission decisions for elderly patients is crucial. This study explores the complex interplay of medical, social, and psychological factors that shape these decisions, as perceived by multiple stakeholders, including physicians, patients, and their families. Method This study was conducted in Unnan City Hospital, a rural community hospital in Unnan, Japan, using a qualitative thematic analysis approach. Participants included general physicians, patients admitted more than once, and their families. One-on-one semi-structured interviews were conducted in Japanese, recorded, transcribed, and analyzed. The analysis focused on identifying themes that influence decision-making processes regarding the admission of elderly patients. The research team, comprising family medicine, public health, and community health care experts, ensured a multi-perspective approach through collaborative coding and discussion. Results Three primary themes emerged from the analysis: "dilemma between medical indications and social admissions," "risks and benefits of hospitalization in response to unpredictable changes in the elderly," and "social factors intertwined with the multilayered nature of hospital admission decisions." Physicians reported a conflict between their medical training and the social needs of patients, often leading to stress and negative emotions. The unpredictable health trajectories of elderly patients necessitated a nuanced risk-benefit analysis for hospitalization. In addition, social factors, such as bed availability, patient's living environment, and psychosocial contexts, significantly influenced admission decisions. Conclusion The study highlights the need for a more holistic approach to medical education and practice, especially in rural healthcare settings. Recognizing the complexity of factors influencing hospitalization decisions, including medical, social, and individual patient circumstances, is vital. The findings underscore the importance of integrating biopsychosocial aspects into the decision-making process for the hospitalization of elderly patients, advocating for patient-centered care that respects the unique challenges in rural healthcare environments.

Bacterial Translocation As the Origin of Gram-Negative Rods Bloodstream Infection Among Older Patients in Rural Hospitals: A Cross-Sectional Study

Introduction Bloodstream infections caused by Gram-negative rods are a pressing concern for the aging global population, particularly in rural settings. This study investigates the prevalence and entry pathways of Gram-negative rod bloodstream infections in elderly patients at a rural Japanese hospital, aiming to clarify the frequency and associated factors of straightforward entry and bacterial translocation. Method In this cross-sectional study, we analyzed electronic medical records of patients over 18 years of age with symptomatic Gram-negative rod bloodstream infections at Unnan City Hospital, Japan, from September 2021 to August 2023. We used multivariate logistic regression to assess factors of age, sex, body mass index, care dependency, and comorbidities. Results Among the participants who met the inclusion criteria, significant differences were observed in age, sex, inpatient status, and prevalence of conditions like respiratory diseases and cancer between the straightforward entry and bacterial translocation groups. Escherichia coli was the most common pathogen identified. Conclusion The study emphasizes the need for tailored medical approaches for elderly patients with bloodstream infections, considering their unique health profiles and risks. It highlights the importance of age, inpatient status, and cancer in determining infection risks, pointing to areas for further research to enhance infection management and healthcare outcomes in older populations.

Factors Associated With Blood Culture Contamination in Rural Hospitals in Japan: A Cross-Sectional Study

Background Blood culture, a cornerstone diagnostic test, is paramount for identifying bacteremia due to serious infections. However, its accuracy is jeopardized by contamination, often due to inappropriate collection procedures. Resource constraints and a limitation in specialized staff can heighten contamination risks in rural hospitals, underscoring the need to understand the associated demographics and conditions. This study aimed to elucidate the demographics and conditions associated with heightened blood culture contamination risk in rural hospitals to optimize testing practices and improve patient care. Methods A single-center, cross-sectional study was conducted in Unnan City Hospital, Unnan, Japan with participants suspected of having bacteremia. Data from the electronic medical records of 455 patients were analyzed using multivariate logistic regression with contamination as the dependent variable. Results Of the 455 patients who underwent blood culture testing, 321 and 134 tests were negative and positive for contamination, respectively. Older age and blood obtained from arteries were associated with a reduced risk of contamination (odds ratio (OR)=0.97; p=0.012, and OR=0.17; p=0.00069, respectively). Patients with dependencies exhibited an increase in contamination risk (OR=1.81; p=0.044). Patients admitted for infection demonstrated a reduced likelihood of sample contamination (OR=0.44; p=0.0034). The predominant organisms identified varied, with Escherichia coli being more frequent in uncontaminated blood samples and Staphylococcus epidermidis in the contaminated samples. Conclusion This study reveals a complex relationship between patient demographics, clinical practices, and the risk of contamination. Factors such as age, dependency status, and reason for admission were associated with sample contamination. Enhanced procedural stringency, microbial surveillance, and continuous training could mitigate these risks, particularly in resource-constrained settings. Identifying and understanding the factors influencing blood culture contamination can significantly bolster clinical practice in rural settings. While this study provides foundational insights, future research can deepen our understanding, ensuring the refinement of patient care protocols in similar environments.

Development of the ward nurses' discharge-oriented dietary support scale for older adult patients in Japan

AIM

This study aimed to develop a ward nurses' dietary support scale, including physical, psychological, and social background factors in preparation for older adult patients' life after discharge.

METHODS

We conducted a cross-sectional study using a self-reported questionnaire. Scale items were created based on a conceptual analysis, and refined by a Delphi survey. In total, 696 nurses across 16 acute care hospitals in Japan were eligible to participate. The questionnaire comprised 51 items that used a five-point Likert-type scale. These items were evaluated using exploratory factor analysis. Reliability was evaluated using Cronbach's alpha and intraclass correlation coefficients (ICC). Pearson's correlation coefficients were calculated to determine concurrent validity, and construct validity was analyzed using confirmatory factor analysis.

RESULTS

Altogether, 241 surveys were included in the data analysis; 236 nurses participated in both the test and the retest. The exploratory factor analysis identified 20 items from three factors as follows: "Assessment for healthy eating behavior," "Adjustment of the living environment, including family and caregiver, together with other professions," and "Continual frailty assessment." In the confirmatory factor analysis, the fitness indices supported these results. Cronbach's alpha was 0.932 and ICC was 0.867 for the overall scale. In the concurrent validity, the three factors had a moderate correlation (r = 0.295-0.537, P < .01 and r = 0.254-0.648, P < .01), except for one subscale.

CONCLUSIONS

We developed a ward nurses' dietary support scale, including physical, psychological, and social background factors in preparation for older adult patients' life after discharge. Its reliability and validity were confirmed.

Superiority of Percutaneous Endoscopic Gastrostomy Over Nasogastric Feeding for Stroke-Induced Severe Dysphagia: A Comparative Study

BACKGROUND Patients with dysphagia due to stroke may require enteral feeding using either a nasogastric (NG) feeding tube or a percutaneous endoscopic gastrostomy (PEG) tube. This study aimed to compare outcomes from NG tube and PEG tube feeding in 40 patients with severe dysphagia due to stroke. MATERIAL AND METHODS We enrolled 40 patients admitted to the hospital from April 2019 to December 2022 due to severe stroke dysphagia, who were divided into the gastrostomy group (20 patients) and the nasogastric feeding group (20 patients) in accordance with the random number table method. Percutaneous endoscopic gastrostomy was performed in both groups and we assessed differences in swallowing function, nutritional recovery, safety, and hope levels. RESULTS Standardized Swallowing Assessment (SSA) scores in both groups clearly decreased after the intervention, but there was greater reduction in the gastrostomy group (P<0.001). Both groups had distinct improvements of the levels of a variety of nutritional indicators after the intervention, but there was greater improvement in the gastrostomy group (P<0.001). The gastrostomy group also had fewer overall complications (P<0.001). Herth Hope Scale scores in both groups were significantly increased after intervention, and the gastrostomy group had a larger increase that the nasogastric feeding group (P<0.001). CONCLUSIONS Compared with nasogastric tube feeding, percutaneous endoscopic gastrostomy has advantages in SSA score, protein level, and Herth Hope Scale in the treatment of stroke patients with dysphagia.

The Effectiveness of Family Medicine-Driven Interprofessional Collaboration on the Readmission Rate of Older Patients

Interprofessional collaboration (IPC) for older patient care among family physicians, dentists, therapists, nutritionists, nurses, and pharmacists in the rural hospital care of older patients could improve the hospital readmission rate. However, there is a lack of interventional studies on IPC for improving the readmission rate among Japanese older patients in rural hospitals. This quasi-experimental study was performed on patients >65 years who were discharged from a rural community hospital. The intervention was IPC implementation with effective information sharing and comprehensive management of older patients’ conditions for effective discharge and readmission prevention; implementation started on 1 April 2021. The study lasted 2 years, from 1 April 2021 to 31 March 2022 for the intervention group and from 1 April 2020 to 31 March 2021 for the comparison group. The average participant age was 79.86 (standard deviation = 15.38) years and the proportion of men was 45.0%. The Cox hazard model revealed that IPC intervention could reduce the readmission rate after adjustment for sex, serum albumin, polypharmacy, dependent condition, and Charlson Comorbidity Index score (hazard ratio = 0.66, 95% confidence interval: 0.54−0.81). Rural IPC intervention can improve inpatient care for older patients and decrease readmission rates. Thus, for effective rural IPC interventions, family physicians in hospitals should proactively collaborate with various medical professionals to improve inpatient health outcomes.

Association between Survival Duration of Older Patients with Advanced Unresectable Pancreatic Cancer and Appetite Loss: A Retrospective Cohort Study

This retrospective cohort study clarified associations between trajectories in palliative care and appetite loss among older patients with advanced unresectable pancreatic cancer and reviewed pancreatic cancer diagnosis among these populations in rural community hospitals. Patients aged >65 years and with pancreatic cancer in a rural community hospital were enrolled. The primary outcome was survival duration from the time of pancreatic cancer diagnosis. Participants were divided into those with and without appetite loss. Cumulative event-free survival rates were calculated using the Kaplan−Meier method, analyzed using the log-rank test, and stratified by factors with statistically significant between-group differences (serum albumin). The mean participant age was 84.14 (SD, 8.34) years; 31.4% were men. Significant between-group differences were noted in albumin concentration and survival duration. Kaplan−Meier curves showed a significant between-group difference in survival probability (p < 0.001). Survival duration significantly differed after stratification by albumin level (p < 0.001). Appetite loss may be a useful symptom for predicting mortality among older patients with unresectable pancreatic cancer, and hypoalbuminemia may accelerate deterioration in their conditions. Accordingly, subjective appetite loss observed by patients and families should be assessed to predict mortality, and it is advisable for physicians to promptly discuss relevant and advanced directives at appropriate timings.