Postdischarge Noninvasive Telemonitoring and Nurse Telephone Coaching Improve Outcomes in Heart Failure Patients With High Burden of Comorbidity.

BACKGROUND: Noninvasive telemonitoring and nurse telephone coaching (NTM-NTC) is a promising postdischarge strategy in heart failure (HF). Comorbid conditions and disease burden influence health outcomes in HF, but how comorbidity burden modulates the effectiveness of NTM-NTC is unknown. This study aims to identify patients with HF who may benefit from postdischarge NTM-NTC based on their burden of comorbidity. METHODS AND RESULTS: In the Better Effectiveness After Transition - Heart Failure trial, patients hospitalized for acute decompensated HF were randomized to postdischarge NTM-NTC or usual care. In this secondary analysis of 1313 patients with complete data, comorbidity burden was assessed by scoring complication and coexisting diagnoses from index admissions. Clinical outcomes included 30-day and 180-day readmissions, mortality, days alive, and combined days alive and out of the hospital. Patients had a mean of 5.7 comorbidities and were stratified into low (0-2), moderate (3-8), and high comorbidity (≥9) subgroups. Increased comorbidity burden was associated with worse outcomes. NTM-NTC was not associated with readmission rates in any comorbidity subgroup. Among high comorbidity patients, NTM-NTC was associated with significantly lower mortality at 30 days (hazard ratio 0.25, 95% confidence interval 0.07-0.90) and 180 days (hazard ratio 0.51, 95% confidence interval 0.27-0.98), as well as more days alive (160.1 vs 140.3, P = .029) and days alive out of the hospital (152.0 vs 133.2, P = .044) compared with usual care. CONCLUSIONS: Postdischarge NTM-NTC improved survival among patients with HF with a high comorbidity burden. Comorbidity burden may be useful for identifying patients likely to benefit from this management strategy.

Intervention to improve acute care nurses confidence and knowledge in hospital dementia care.

PROBLEM: Acute care nurses are the front line of hospital care for persons with dementia (PwD), yet many have inadequate dementia education and lack the confidence to appropriately manage PwD in the hospital setting. IMPLEMENTATION: Two acute care units with high rates of PwD in a large tertiary-care hospital were provided an education intervention involving interactive case-based discussion of the challenges of inpatient dementia care. RESULTS: Out of 190 nurses, 171 completed a one-hour virtual educational session, 142 completed pre/post-session confidence surveys, and 123 completed pre/post-session knowledge tests. There was a statistically significant improvement in knowledge scores from 75.8% pre-session to 88.4% post-session (p < 0.001), and pre/post-session dementia care confidence increased from 3.49 to 4.44 ( + 27.22%; p < 0.001) CONCLUSION: An interactive virtual education intervention improves acute care nurses' confidence and knowledge in managing PwD in the acute care setting and may improve hospital outcomes for this population.

Measuring Frailty in Inpatient Rehabilitation.

BACKGROUND: In response to the global aging population, there has been increasing research on frailty. How frailty is conceptualized is shifting with the development of frailty models, especially in the acute care arena. OBJECTIVE: To explore frailty/vulnerability risk factors available at admission that were associated with salient patient outcomes within the context of inpatient rehabilitation. DESIGN: Methodologies in acute care are not easily adapted for a typical admission evaluation or a rehabilitation patient. In this study, the concept of frailty among patients admitted to rehabilitation was developed from risk factors available at admission that were associated with two patient outcomes, adverse hospital outcomes and 30-day hospital readmissions. SETTING: Inpatient rehabilitation. PATIENTS: Data were included on all patients (n = 768) discharged from an inpatient rehabilitation unit of an academic medical center from 1 January 2012 through 31 December 2012. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Adverse events within the inpatient rehabilitation stay and 30-day hospital readmissions. RESULTS: Significant independent factors associated with adverse events in the rehabilitation unit included African American (1.77 OR; 95% CI 1.06-2.96), Hispanic (3.17 OR; 95% CI 1.13-8.94), having >9 total comorbid conditions (1.44 OR; 95% CI 1.244-1.66), and sphincter control domain (including bladder and bowel management) ≤ 9 FIM (0.92 OR; 95% CI 0.86-0.98). For 30-day readmission three variables were found to be significant: onset ≥7 days (2.31 OR; 95% CI 1.28-4.22), requiring a tube for feeding (3.45 OR; 95% CI 1.433-11.12), and being obese (4.72 OR; 95% CI 1.433-15.58). CONCLUSIONS: The findings highlight the need for early admission screening and identification of risk factors which can provide the time in the rehabilitation setting for the clinical team to treat and prevent the potential for poor outcomes.

Variation in Rehabilitation Treatment Patterns for Hip Fracture Treated With Arthroplasty.

BACKGROUND: Recommendations for health care redesign often advocate for comparative effectiveness research that is patient-centered. For patients who require rehabilitation services, a first step in this research process is to understand current practices for specific patient groups. OBJECTIVE: To document in detail the physical and occupational therapy treatment activities for inpatient hip fracture rehabilitation among 3 patient subgroups distinguished by their early rate of functional recovery between time of surgery to rehabilitation admission. DESIGN: Multicenter prospective observational cohort, practice-based evidence, study. SETTING: Seven skilled nursing facilities and 11 inpatient rehabilitation facilities across the United States. PARTICIPANTS: A total of 226 patients with hip fractures treated with hip arthroplasty. METHODS: Comparisons of physical and occupational therapy treatment activities among 3 groups with different initial recovery trajectory (IRT) rates (slower, moderate, faster). MAIN OUTCOME MEASURE(S): Percent of patients in each IRT group exposed to each physical and occupational therapy activity (exposure), and mean minutes per week for each activity (intensity). RESULTS: The number of patients exposed to different physical or occupational therapy activities varied within the entire sample. More specifically, among the 3 IRT groups, significant differences in exposure occurred for 44% of physical therapy activities and 39% of occupational therapy activities. More patients in the slower recovery group, IRT 1, received basic activities of daily living treatments and more patients in the faster recovery group, IRT 3, received advanced activities. The moderate recovery group, IRT 2, had some treatments similar to IRT 1 group and others similar to IRT 3 group. CONCLUSIONS: Analyses of practice-based evidence on inpatient rehabilitation of hip fracture patients treated with arthroplasty identified differences in therapy activities among three patient groups classified by IRT rates. These results may enhance physiatrists', other physicians', and rehabilitation teams' understanding of inpatient rehabilitation for these patients and help design future comparative effectiveness research.

Effectiveness of Remote Patient Monitoring After Discharge of Hospitalized Patients With Heart Failure: The Better Effectiveness After Transition -- Heart Failure (BEAT-HF) Randomized Clinical Trial.

IMPORTANCE: It remains unclear whether telemonitoring approaches provide benefits for patients with heart failure (HF) after hospitalization. OBJECTIVE: To evaluate the effectiveness of a care transition intervention using remote patient monitoring in reducing 180-day all-cause readmissions among a broad population of older adults hospitalized with HF. DESIGN, SETTING, AND PARTICIPANTS: We randomized 1437 patients hospitalized for HF between October 12, 2011, and September 30, 2013, to the intervention arm (715 patients) or to the usual care arm (722 patients) of the Better Effectiveness After Transition-Heart Failure (BEAT-HF) study and observed them for 180 days. The dates of our study analysis were March 30, 2014, to October 1, 2015. The setting was 6 academic medical centers in California. Participants were hospitalized individuals 50 years or older who received active treatment for decompensated HF. INTERVENTIONS: The intervention combined health coaching telephone calls and telemonitoring. Telemonitoring used electronic equipment that collected daily information about blood pressure, heart rate, symptoms, and weight. Centralized registered nurses conducted telemonitoring reviews, protocolized actions, and telephone calls. MAIN OUTCOMES AND MEASURES: The primary outcome was readmission for any cause within 180 days after discharge. Secondary outcomes were all-cause readmission within 30 days, all-cause mortality at 30 and 180 days, and quality of life at 30 and 180 days. RESULTS: Among 1437 participants, the median age was 73 years. Overall, 46.2% (664 of 1437) were female, and 22.0% (316 of 1437) were African American. The intervention and usual care groups did not differ significantly in readmissions for any cause 180 days after discharge, which occurred in 50.8% (363 of 715) and 49.2% (355 of 722) of patients, respectively (adjusted hazard ratio, 1.03; 95% CI, 0.88-1.20; P = .74). In secondary analyses, there were no significant differences in 30-day readmission or 180-day mortality, but there was a significant difference in 180-day quality of life between the intervention and usual care groups. No adverse events were reported. CONCLUSIONS AND RELEVANCE: Among patients hospitalized for HF, combined health coaching telephone calls and telemonitoring did not reduce 180-day readmissions. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01360203.

A pilot study to investigate shoulder muscle fatigue during a sustained isometric wheelchair-propulsion effort using surface EMG.

OBJECTIVE: The primary aim of this pilot study was to develop a testing protocol for gathering shoulder muscle surface electromyography (EMG) data during a sustained submaximal isometric wheelchair-propulsion effort. Of special interest was analysis of the median frequency of the surface EMG signal power spectrum; a negative median frequency shift during a sustained effort is an indicator of muscle fatigue. The long-term goal is to improve our understanding of how fatigue and muscle imbalance might play a role in the development of a broad array of upper-extremity overuse syndromes. METHOD: Participants were a convenience sample of seven male manual-wheelchair users with spinal cord injury and 14 able-bodied males. Surface EMG in six right-side shoulder muscles was recorded while subjects resisted a static force equal to 60% of their maximum wheelchair-propulsion strength until fatigued. Percent of maximum voluntary contraction and the median frequency shift for each muscle were analyzed. RESULTS: The able-bodied group used a higher percent of maximum than the manual-wheelchair group (p< .05), and a more pronounced negative median frequency shift was evident in the able-bodied group (p < .10). CONCLUSION: Patterns that emerged suggest that spectral analysis of the surface electromyographhic signal has promise as a clinically useful tool to authenticate muscle fatigue in the upper extremities during occupational performance. Such data in the future could be used to justify the need for and benefits of adapted performance techniques and assistive technology.

Initial recovery trajectories among patients with hip fracture: a conceptual approach to exploring comparative effectiveness in postacute care.

OBJECTIVE: To assess whether clusters of patients with hip fracture and with distinct initial recovery trajectories (IRT) could be identified by using practice-based evidence data and to examine the validity of these data. DESIGN: Analysis of multisite prospective observational cohort study database. SETTING: Eighteen skilled nursing and inpatient rehabilitation facilities. PATIENTS: Patients with hip fractures (N = 226) treated with joint replacement and admitted to skilled nursing or inpatient rehabilitation facilities, subset (n = 85), with telephone follow-up results approximately 8 months after rehabilitation discharge. Patients' ages were 76.8 ± 11.4 years; the majority were women (78%) and white (87%). METHODS: Measurements included medical severity by using the Comprehensive Severity Index and functional levels by using Functional Independence Measure (FIM). The IRT was calculated for each patient as the rate of change in function from the time of surgery to rehabilitation admission. We used cluster analysis to partition patients into subsets that shared common IRT scores. Validity was explored by comparing subgroups across patient characteristics and treatment patterns. Significance was defined as P ≤ .05. MAIN OUTCOMES MEASUREMENTS: IRT grouping, Comprehensive Severity Index, FIM, discharge location, living location at follow-up. RESULTS: We identified 3 patient clusters with differentiated IRT scores: group 1: 4.96 ± 2.45 (range, 0.4-8.6) FIM point change per day; group 2: 12.42 ± 2.51 (range, 8.9-17.0); group 3: 26.80 ± 13.78 (range, 17.5-70.0). Clinical group validation was established from statistically different Comprehensive Severity Index scores on admission; FIM scores at admission, discharge, and follow-up; and discharge and 8-month living settings. Calculation of IRT recovery curves by using FIM scores and associated time in days through logarithmic regression curves confirmed each group's IRT remained distinct through rehabilitation and follow-up. CONCLUSIONS: The IRT concept appears to be valid in patients with hip fracture who were treated with hip arthroplasty, and may assist in evaluating and comparing the effectiveness of postacute rehabilitation services.

Outcomes and weight-bearing status during rehabilitation after arthroplasty for hip fractures.

OBJECTIVE: To examine the association of weight-bearing status with patient-related variables and outcomes of inpatient rehabilitation after hip arthroplasty for acute hip fracture. DESIGN: A multi-site prospective observational cohort study. SETTING: Eighteen skilled nursing and inpatient rehabilitation facilities. SUBJECTS: Patients with hip fractures (N = 224) treated with hip arthroplasty and admitted to either skilled nursing or inpatient rehabilitation facilities; a subset (N = 84) with telephone follow-up outcomes 8 months after rehabilitation discharge. METHODS: Measurements included demographic variables, medical severity using the Comprehensive Severity Index, and functional levels using the Functional Independence Measure. MAIN OUTCOMES MEASUREMENT: Cognitive, motor, and total Functional Independence Measure scores at rehabilitation discharge and at 8-month follow-up; living location at discharge and follow-up. RESULTS: Patients on average (standard deviation) were 76.8 ± 11.4 years old, mainly women (78%), and mainly white (87%). In unadjusted analysis, weight bearing as tolerated (WBAT) was associated with less osteoarthritis (P = .025) and lower admission medical severity (ACSI) (P = .014). One participating facility had a significant preponderance of restricted weight-bearing cases. WBAT had no bivariate association with cognitive or motor function at discharge. Therapists cited restricted weight bearing as a barrier to therapy in 11% of cases. In logistic regressions, lower medical admission severity, older age, and one specified site significantly predicted WBAT (c statistic = 0.714). Significant predictors for home discharge included lower maximum severity (P < .001), younger age (P < .001), higher cognition (P = .037), and WBAT (P = .051) (c statistic = 0.863). CONCLUSIONS: WBAT is associated with a greater likelihood of home discharge and had similar functional outcomes compared with restricted weight bearing. These findings add support for allowing WBAT after arthroplasty for hip fracture.