A "Hospital-Day-1" Model to Predict the Risk of Discharge to a Skilled Nursing Facility.

OBJECTIVE: To derive and validate a model to predict a patient's probability of skilled nursing facility (SNF) discharge using data available from day 1 of hospitalization. DESIGN: Using a retrospective cohort of 11,380 hospitalized patients, we obtained administrative and electronic medical data to identify predictors of SNF discharge. SETTING AND PARTICIPANTS: Single, urban academic medical center. Patients older than 50 years admitted to the medical service from July 2014 to August 2015. METHODS: Primary outcome defined as SNF discharge. We split the cohort into derivation and validation sets (80/20). We created 1000 bootstrapped samples of the derivation set and used backward selection logistic regression on each bootstrapped sample. The final model included variables selected in ≥60% of the samples. To create a point-based index, a point value was assigned to each predictor variable relative to the logistic regression coefficient. The model's discrimination, calibration, positive predictive value, and negative predictive value tested in the validation set. RESULTS: The overall frequency of SNF discharge was 12%. The final model included 11 variables. Significant demographic variables included age, marital status, insurance type, living alone, residence, and distance from hospital. The final model included 2 significant functional variables (mobility, bathing) and 3 significant clinical variables (admission mode, admission diagnosis, admission day of week). Impairment in mobility [odds ratio (OR) 1.8, 95% confidence interval (CI) 1.4-2.2] and impairment in bathing (OR 1.9, 95% CI 1.6-2.4) were both significant predictors of SNF discharge. The final model discriminated well in the validation cohort (c-statistic = 0.82) and was well calibrated. CONCLUSIONS/IMPLICATIONS: It is possible to predict the day of admission with good accuracy and clinical usability a patient's risk of SNF discharge. The ability to identify early in the hospitalization patients likely to use post-acute services has implications for clinicians, administrators, and policy makers working to improve discharge planning and care transitions.

Living Alone and Discharge to Skilled Nursing Facility Care after Hospitalization in Older Adults.

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.

Randomized trial of a health IT tool to support between-visit-based laboratory monitoring for chronic disease medication prescriptions.

BACKGROUND: Lack of timely medication intensification and inadequate medication safety monitoring are two prevalent and potentially modifiable barriers to effective and safe chronic care. Innovative applications of health information technology tools may help support chronic disease management. OBJECTIVE: To examine the clinical impact of a novel health IT tool designed to facilitate between-visit ordering and tracking of future laboratory testing. DESIGN AND PARTICIPANTS: Clinical trial randomized at the provider level (n = 44 primary care physicians); patient-level outcomes among 3,655 primary care patients prescribed 5,454 oral medicines for hyperlipidemia, diabetes, and/or hypertension management over a 12-month period. MAIN MEASURES: Time from prescription to corresponding follow-up laboratory testing; proportion of follow-up time that patients achieved corresponding risk factor control (A1c, LDL); adverse event laboratory monitoring 4 weeks after medicine prescription. KEY RESULTS: Patients whose physicians were allocated to the intervention (n = 1,143) had earlier LDL laboratory assessment compared to similar patients (n = 703) of control physicians [adjusted hazard ratio (aHR): 1.15 (1.01-1.32), p = 0.04]. Among patients with elevated LDL (486 intervention, 324 control), there was decreased time to LDL goal in the intervention group [aHR 1.26 (0.99-1.62)]. However, overall there were no significant differences between study arms in time spent at LDL or HbA1c goal. Follow-up safety monitoring (e.g., creatinine, potassium, or transaminases) was relatively infrequent (ranging from 7 % to 29 % at 4 weeks) and not statistically different between arms. Intervention physicians indicated that lack of reimbursement for non-visit-based care was a barrier to use of the tool. CONCLUSIONS: A health IT tool to support between-visit laboratory monitoring improved the LDL testing interval but not LDL or HbA1c control, and it did not alter safety monitoring. Adoption of innovative tools to support physicians in non-visit-based chronic disease management may be limited by current visit-based financial and productivity incentives.

Creating a place for caregivers in personal health: the iHealthSpace copilot program and diabetes care.

BACKGROUND: As America's baby boom generation reaches retirement, the number of elders, and, in turn, the number of lay individuals who support them, will continue to increase. With the important services caregivers provide, it is critical that we recognize and provide assistance to the informal caregivers who play this important role in our society. The network of support provisioned by relatives, partners, friends, and neighbors suggests that the dyadic, unidirectional caregiver-care recipient relationship assumed by caregiver research so far and by resources deployed to assist caregivers may be insufficient to ascertain and meet the needs of the care community. METHODS: In this article, we describe the extension of a Web-based personal health record system, iHealthSpace, for explicitly and openly incorporating caregivers into the care community. RESULTS: Using this portal, a set of business rules was implemented to support the creation of custodial accounts. These business rules will be used to create modules that support diabetes care in an adult population. CONCLUSIONS: We successfully extended an existing patient portal to accommodate the creation of custodial accounts. We will use this portal to assess the impact of custodial access in the care of older patients with diabetes.

Facilitating transitions to EMR adoption through client-side electronic documentation.

We provide a description of a web-based, client-side application to facilitate physician documentation of hospital admissions and progress notes. This system is currently being used in an Oregon academic medical center independent from and in conjunction with computerized hospital information systems. Unique features of the application include clickable and modifiable review of systems and physical exam templates, automatic incorporation of electronic information from the existing electronic systems, and creation of a centralized note repository.

GFP-tagged PrP supports compromised prion replication in transgenic mice.

The ability of green fluorescent protein (GFP)-prion protein (PrP) fusions to support prion propagation has not been demonstrated. Here, we show that while transgenic mice expressing PrP tagged at its amino terminus with enhanced GFP, referred to as EGFPrP-N, supported prion replication, disease onset was prolonged, the brains of diseased mice did not exhibit typical disease neuropathology and disease-associated EGFPrP-N lacked the full spectrum of biochemical properties normally associated with PrP(Sc). Co-expression of wild-type PrP and EGFPrP-N substantially reduced prion incubation times and resulted in accumulation of protease-resistant EGFPrP(Sc)-N in the brains of transgenic mice as well as chronically infected cultured cells, suggesting that wild-type PrP rescued a compromised amino terminal function in EGFPrP-N. While our results show that EGFPrP(C)-N adopts a conformation necessary for the production of infectious prions, the synergistic interaction of wild-type and EGFPrP-N underscores the importance of the amino terminus in modulating prion pathogenesis.

Residual oil fly ash increases the susceptibility to infection and severely damages the lungs after pulmonary challenge with a bacterial pathogen.

Inhalation of residual oil fly ash (ROFA), a component of ambient particulate matter, has been shown to increase pulmonary morbidity and impair lung defense mechanisms in exposed workers. Our objective was to evaluate the effect of ROFA preexposure on lung defense and injury after pulmonary challenge with a bacterial pathogen. Male Sprague-Dawley rats were dosed intratracheally at day 0 with saline (control) or ROFA (0.2 or 1 mg/100 g body weight). Three days later, a low (5 x 10(3)) or high (5 x 10(5)) dose of Listeria monocytogenes was instilled intratracheally into the ROFA- and saline-treated rats. Bronchoalveolar lavage was performed on the right lungs at days 6, 8, and 10. The recovered cells were differentiated, and chemiluminescence (CL) and nitric oxide (NO) production, two indices of alveolar macrophage (AM) function, were measured. At the same time points, the left lung and spleen were removed, homogenized, and cultured, and colony-forming units were counted after an overnight incubation. Exposure to ROFA and the high dose of L. monocytogenes led to marked lung injury and inflammation as well as to an increase in mortality, compared with rats treated with saline and the high dose of L. monocytogenes. Preexposure to ROFA significantly enhanced injury and delayed the pulmonary clearance of L. monocytogenes at both bacterial doses when compared to the saline-treated control rats. ROFA had no effect on AM CL but caused a significant suppression of AM NO production, as compared to the saline control rats. We have demonstrated that acute exposure to ROFA slowed the pulmonary clearance of L. monocytogenes. The suppression in AM NO production by ROFA pretreatment likely plays an important role. These results suggest that pulmonary exposure to ROFA may alter AM function and lead to increased susceptibility to lung infection in exposed populations.