The Impact of Nurse Practitioner Care and Accountable Care Organization Assignment on Skilled Nursing Services and Hospital Readmissions

BACKGROUND

Accountable care organizations (ACOs) and the employment of nurse practitioners (NP) in place of physicians are strategies that aim to reduce the cost and improve the quality of routine care delivered in skilled nursing facilities (SNF). The recent expansion of ACOs and nurse practitioners into SNF settings in the United States may be associated with improved health outcomes for patients.

OBJECTIVES

To determine the relationship between ACO attribution and NP care delivery during SNF visits and the relationship between NP care delivery during SNF visits and unplanned hospital readmissions.

METHODS

We obtained a sample of 527,329 fee-for-service Medicare beneficiaries with 1 or more SNF stays between 2012 and 2017. We used logistic regression to measure the association between patient ACO attribution and evaluation and management care delivered by NPs in addition to the relationship between evaluation and management services delivered by NPs and hospital readmissions.

RESULTS

ACO beneficiaries were 1.26% points more likely to receive 1 or more E&M services delivered by an NP during their SNF visits [Marginal Effect (ME): 0.0126; 95% CI: (0.009, 0.0160)]. ACO-attributed beneficiaries receiving most of their E&M services from NPs during their SNF visits were at a lower risk of readmission than ACO-attributed beneficiaries receiving no NP E&M care (5.9% vs. 7.1%; P <0.001).

CONCLUSIONS

Greater participation by the NPs in care delivery in SNFs was associated with a reduced risk of patient readmission to hospitals. ACOs attributed beneficiaries were more likely to obtain the benefits of greater nurse practitioner involvement in their care.

Behavioral symptoms, depression symptoms, and medication use in Michigan nursing home residents with dementia during COVID-19

BACKGROUND

The COVID-19 pandemic significantly disrupted nursing home (NH) care, including visitation restrictions, reduced staffing levels, and changes in routine care. These challenges may have led to increased behavioral symptoms, depression symptoms, and central nervous system (CNS)-active medication use among long-stay NH residents with dementia.

METHODS

We conducted a retrospective, cross-sectional study including Michigan long-stay (≥100 days) NH residents aged ≥65 with dementia based on Minimum Data Set (MDS) assessments from January 1, 2018 to June 30, 2021. Residents with schizophrenia, Tourette syndrome, or Huntington's disease were excluded. Outcomes were the monthly prevalence of behavioral symptoms (i.e., Agitated Reactive Behavior Scale ≥ 1), depression symptoms (i.e., Patient Health Questionnaire [PHQ]-9 ≥ 10, reflecting at least moderate depression), and CNS-active medication use (e.g., antipsychotics). Demographic, clinical, and facility characteristics were included. Using an interrupted time series design, we compared outcomes over two periods: Period 1: January 1, 2018-February 28, 2020 (pre-COVID-19) and Period 2: March 1, 2020-June 30, 2021 (during COVID-19).

RESULTS

We included 37,427 Michigan long-stay NH residents with dementia. The majority were female, 80 years or older, White, and resided in a for-profit NH facility. The percent of NH residents with moderate depression symptoms increased during COVID-19 compared to pre-COVID-19 (4.0% vs 2.9%, slope change [SC] = 0.03, p < 0.05). Antidepressant, antianxiety, antipsychotic and opioid use increased during COVID-19 compared to pre-COVID-19 (SC = 0.41, p < 0.001, SC = 0.17, p < 0.001, SC = 0.07, p < 0.05, and SC = 0.24, p < 0.001, respectively). No significant changes in hypnotic use or behavioral symptoms were observed.

CONCLUSIONS

Michigan long-stay NH residents with dementia had a higher prevalence of depression symptoms and CNS active-medication use during the COVID-19 pandemic than before. During periods of increased isolation, facility-level policies to regularly assess depression symptoms and appropriate CNS-active medication use are warranted.

Psychotropic medication prescribing in assisted living and nursing home residents with dementia after the National Partnership

BACKGROUND

The Centers for Medicare & Medicaid Services implemented the National Partnership to Improve Dementia Care in Nursing Homes (the Partnership) to decrease antipsychotic use and improve care for nursing home (NH) residents with dementia. We determined whether the extent of antipsychotic and other psychotropic medication prescribing in AL residents with dementia mirrored that of long-stay NH (LSNH) residents after the Partnership.

METHODS

Using a 20% sample of fee-for-service Medicare beneficiaries with Part D, we conducted a retrospective cohort study including AL and LSNH residents with dementia. The monthly prevalence of psychotropic medication prescribing (antipsychotics, antidepressants, anxiolytics/sedative-hypnotics, anticonvulsants/mood stabilizers, benzodiazepines, and antidementia medications) was examined. We used an interrupted time-series analysis to compare medication prescribing before (July 1, 2010-March 31, 2012) and after (April 1, 2012-December 31, 2017) the Partnership in both settings.

RESULTS

We identified 107,931 beneficiaries with ≥1 month as an AL resident and 323,766 beneficiaries with ≥1 month as a LSNH resident with dementia, including 1,923,867 person-months and 4,984,405 person-months, respectively. Antipsychotic prescribing declined over the study period in both settings. After the launch of the Partnership, the rate of decline in antipsychotic prescribing slowed in AL residents with dementia (slope change = 0.03 [95% CLs: 0.02, 0.04]) while the rate of decline in antipsychotic prescribing increased in LSNH residents with dementia (slope change = -0.12 [95% CLs: -0.16, -0.08]). Antidepressants were the most prevalent medication prescribed, anticonvulsant/mood stabilizer prescribing increased, and anxiolytic/sedative-hypnotic and antidementia medication prescribing declined.

CONCLUSIONS

The federal Partnership to reduce antipsychotic prescribing in NH residents did not appear to affect antipsychotic prescribing in AL residents with dementia. Given the increase in the prescribing of mood stabilizers/anticonvulsants that occurred after the launch of the Partnership, monitoring may be warranted for all psychotropic medications in AL and NH settings.

Medicare beneficiary panel characteristics associated with high Part D biologic disease-modifying anti-rheumatic drug prescribing for older adults among rheumatologists

ABSTRACT

The aim of this study was to investigate beneficiary panel characteristics associated with rheumatologists' prescribing of biologic DMARDs (bDMARDs) for older adults.In this retrospective observational study, we used Medicare Public Use Files (PUFs) to identify rheumatologists who met criteria for high-prescribing, defined as bDMARD prescription constituting ≥20% of their DMARD claims for beneficiaries ≥65 years of age. We first used descriptive analysis then multivariable regression model to test the association of high prescribing of bDMARDs with rheumatologists' panel size and beneficiary characteristics. In particular, we quantified the proportion of panel beneficiaries ≥75 years of age to assess how caring for an older panel correlate with prescribing of bDMARDs.We identified 3197 unique rheumatologists, of whom 405 (13%) met criteria for high prescribing of bDMARDs for Medicare beneficiaries ≥65 years of age. The high-prescribers provided care to 12% of study older adults, and yet accounted for 21% of bDMARD prescriptions for them. High prescribing of bDMARDs was associated with smaller panel size, and their beneficiaries were more likely to be non-black, ≥75 years of age, non-dual eligible, have diagnosis of CHF, however, less likely to have CKD.Rheumatologists differ in their prescribing of bDMARDs for older adults, and those caring for more beneficiaries ≥75 years of age are more likely to be high-prescribers. Older adults are more prone to the side-effects of bDMARDs and further investigation is warranted to understand drivers of differential prescribing behaviors to optimize use of these high-risk and high-cost medications.

Diagnosed prevalence of Alzheimer's disease and related dementias in Medicare Advantage plans

INTRODUCTION

One-third of Medicare beneficiaries are enrolled in Medicare Advantage (MA). Yet, little is known about MA beneficiaries diagnosed with Alzheimer's disease (AD) and AD-related dementias (AD/ADRD).

METHODS

We calculated the prevalence of AD/ADRD diagnoses in 2014 and 2016 in three MA plans. We determined the demographic characteristics of beneficiaries diagnosed with AD/ADRD, and whether they disenrolled from the MA plan for any reason within 364 days from the index date.

RESULTS

In 2014 and 2016, the overall prevalence of AD/ADRD diagnoses was 5.6% and 6.5%, respectively. In 2016, AD/ADRD beneficiaries were on average 82.4 (SD = 7.4) years of age, 61.8% female, and had multiple comorbidities. By 364 days post-index date, 32% of beneficiaries with AD/ADRD had disenrolled from their plan. The demographic characteristics of 2014 beneficiaries with diagnosed AD/ADRD were similar to their 2016 counterparts.

DISCUSSION

The prevalence of AD/ADRD diagnosis in MA is lower than rates reported in Medicare fee-for-service.

The natural history of urinary incontinence subtypes in the Nurses' Health Studies

BACKGROUND

Urinary incontinence subtypes often differ by symptom severity and treatment profiles; in particular, mixed urinary incontinence is generally associated with worse symptoms and less successful treatment. Yet, limited information exists on the natural history of different urinary incontinence subtypes, which could help to better identify and treat patients prior to development of more intractable disease.

OBJECTIVE

To evaluate the onset of urinary incontinence subtypes, and transitions between subtypes over 8 years, using 2 large cohorts of middle-aged and older women with incident urinary incontinence.

MATERIALS AND METHODS

We identified 10,349 women with incident urinary incontinence (stress, urgency, and mixed subtypes) from the Nurses' Health Study and the Nurses' Health Study II who were 41-83 years of age, using repeated mailed questionnaires. We defined stress urinary incontinence as leakage with coughing, sneezing, or activity; urgency urinary incontinence as urine loss with a sudden feeling of bladder fullness or when a toilet was inaccessible; and mixed urinary incontinence when women reported that stress and urgency symptoms occurred equally. In subsequent questionnaires 4 and 8 years later, we continued to track symptom severity and subtypes. In addition, to obtain predicted probabilities of urinary incontinence subtypes 4 years and 8 years after urinary incontinence onset, we used multivariable-adjusted generalized estimating equations with a multinomial outcome.

RESULTS

At urinary incontinence onset in 2004-2005, 56% of women reported stress urinary incontinence symptoms, 23% reported urgency urinary incontinence symptoms, and 21% reported mixed urinary incontinence symptoms. Women with stress urinary incontinence or urgency urinary incontinence at onset were likely to report the same urinary incontinence type 4 and 8 years later (stress urinary incontinence at onset: 70% and 60% reported stress urinary incontinence at years 4 and 8, respectively; urgency urinary incontinence at onset: 68% and 64% reported urgency urinary incontinence at years 4 and 8, respectively). Nonetheless, for both stress and urgency urinary incontinence, women with more severe symptoms at onset were more likely to progress to mixed urinary incontinence. Women with mixed urinary incontinence at onset had more variation over time, although the largest subset continued to report mixed urinary incontinence (45% reported mixed urinary incontinence at year 4; 43% reported mixed urinary incontinence at year 8). Few women across all urinary incontinence subtypes reported resolution of symptoms over 4-8 years of follow-up (4-12%). When considering the likelihood of remaining with or progressing to mixed urinary incontinence over follow-up, according to age, body mass index, and urinary incontinence severity, we found that older and younger women had similar predicted probability of remaining with or progressing to mixed urinary incontinence (eg, women <60 years of age at onset with severe mixed urinary incontinence had a 54% (95% confidence interval, 53-55) probability of mixed urinary incontinence 8 years later, vs 57% (95% confidence interval, 56-58) of women ≥70 years of age with severe mixed urinary incontinence at onset). Obese women were somewhat more likely to progress to mixed urinary incontinence regardless of urinary incontinence type at onset (eg, women with body mass index <25 kg/m² at onset with severe stress urinary incontinence had a 30% predicted probability of mixed urinary incontinence 8 years after onset, vs 36% of women with body mass index of 30+ kg/m² at onset with severe stress urinary incontinence).

CONCLUSION

Most women with incident stress and urgency urinary incontinence continued to experience similar subtype symptoms over 8 years. However, obese women and those with more severe symptoms were more likely to remain with or progress to mixed urinary incontinence.

Uptake of the centers for medicare and medicaid obesity benefit: 2012-2013

OBJECTIVE

To assess the use of the Medicare Obesity Benefit (MOB) by a licensed physician or associate provider in an outpatient setting in older adults.

METHODS

A serial cross-sectional analysis of fee-for-service Medicare claims (2012 and 2013) was used to assess the use of the MOB. Number and proportion of Medicare beneficiaries over age 65 using the benefit were assessed. Correlation between state-obesity rates and MOB uptake was determined based on state-specific obesity prevalence data from the Behavioral Risk Factor Surveillance System. Results There were 27,338 (0.10%) Medicare beneficiaries over age 65 in 2012 using the MOB and slightly more in 2013 (n = 46,821 [0.17%]). Mean age of MOB users in both years was 73 years, and 62% were females. Use declined with older age and was highest in the Northeast and lowest in the Midwest. High state obesity prevalence was not correlated with higher uptake of the MOB. Estimated proportion of persons with obesity using the MOB was 0.35% and 0.60% in successive years. A mean of 1.99 and 2.16 claims/MOB user was observed.

CONCLUSIONS

While the rate of MOB use increased in the second full year of its implementation, few were availing themselves of this benefit.

Dementia in the USA: state variation in prevalence

BACKGROUND

The number of dementia patients will increase over the next decades. However, we lack information on the geographic distribution of these patients. We aimed to describe the variation of dementia prevalence and to then compare the observed to expected prevalence.

METHODS

This study is based on a 20% sample of Medicare beneficiaries in 2008. The crude dementia prevalence was calculated and age/sex standardized to the US population for states. We used the World Alzheimer Report 2009 prevalence to compare estimates.

RESULTS

4.8 million persons were included. The adjusted prevalence is 8.24%, varying from 5.96 to 9.55% across states. The diagnosed prevalence is lower than the expected in most states. Overall, we estimate over 100 000 undiagnosed dementia patients in Medicare.

CONCLUSIONS

The high state variation suggests that the number of diagnosed dementia cases does not fall evenly across all states and hence may require different levels of state-level planning.

Functional disability among older women with fecal incontinence

OBJECTIVE

The prevalence of functional disability for basic activities of daily living (ADLs) in older women with fecal incontinence (FI) is not well characterized. Our objective was to determine the prevalence of functional disability among community-dwelling older women with FI.

STUDY DESIGN

We conducted a secondary database analysis of the 2005-2006 National Social Life, Health and Aging Project, a cross-sectional study of community-dwelling older adults that had been conducted by single in-home interviews. FI was defined as an affirmative answer to the question, "Have you lost control of your bowels (stool incontinence or anal incontinence)?" with a frequency of "at least monthly." We then examined functional status. Women were asked about 7 basic ADLs. Statistical analyses with percentage estimates and 95% confidence intervals (CIs) were performed.

RESULTS

We included 1412 women in our analysis. FI, at least monthly, was reported by 5.5% of community-dwelling older women (n = 77); 63.2% (95% CI, 50.1-76.4) of the women with FI reported difficulty or dependence with ≥1 ADLs, and 31.2% (95% CI, 18.9-43.6) of the women specifically reported difficulty or dependence with using the toilet. After adjustment for age category, race/ethnicity, education level, women with FI had 2.6 increased odds (95% CI, 1.26-5.35) of difficulty or dependence compared with women with no FI. Other significant risk factors for increased functional difficulty/dependence included obesity (body mass index, ≥30 kg/m(2)) and depressive symptoms.

CONCLUSION

Consistent with other large epidemiologic studies, we found monthly FI was reported by 5.5% of older women (n/N = 77/1412). More than 60% of community-dwelling older women with FI report functional difficulty or dependence with ≥1 ADL and specifically; more than 30% of women with FI report difficulty or dependence using/reaching the toilet. Because of the high prevalence of functional disability in older women with FI, we purpose that initial evaluation and treatment of FI may be improved by considering functional status.