Incremental diagnostic yield of chromoendoscopy and outcomes in inflammatory bowel disease patients with a history of colorectal dysplasia on white-light endoscopy.

BACKGROUND AND AIMS: Chromoendoscopy (CE) identifies dysplastic lesions with a higher sensitivity than white-light endoscopy (WLE). The role of CE in the management of dysplasia on surveillance WLE in inflammatory bowel disease (IBD) remains unclear. METHODS: A retrospective cohort of IBD patients with colorectal dysplasia on WLE who subsequently underwent CE between January 1, 2006 and August 31, 2013 was identified. Endoscopic and histologic findings were compared among the index WLE, first CE, and subsequent CE. Outcomes assessed included endoscopic lesion removal, surgery or repeat CE, and diagnosis of colorectal cancer. RESULTS: Ninety-five index cases were identified. The median duration of IBD was 18 years (interquartile range 9.3-29.8); 78 patients had ulcerative colitis. Dysplasia was identified in 55 patients during the index WLE with targeted biopsies of 72 lesions. The first CE visualized dysplastic lesions in 50 patients, including 34 new lesions (not visualized on the index examination). Endoscopic resection was performed successfully of 43 lesions, most in the cecum/ascending colon (n = 20) with sessile morphology (n = 33). After the first CE, 14 patients underwent surgery that revealed 2 cases of colorectal cancer and 3 cases of high-grade dysplasia. Multiple CEs were performed in 44 patients. Of these, 20 patients had 34 visualized lesions, 26 of which were new findings. CONCLUSION: Initial and subsequent CE performed in IBD patients with a history of colorectal dysplasia on WLE frequently identified new lesions, most of which were amenable to endoscopic treatment. These data support the use of serial CEs in this high-risk population.

Cost comparison between home telemonitoring and usual care of older adults: a randomized trial (Tele-ERA).

BACKGROUND: From 1992 to 2008, older adults in the United States incurred more healthcare expense per capita than any other age group. Home telemonitoring has emerged as a potential solution to reduce these costs, but evidence is mixed. The primary aim of the study was to evaluate whether the mean difference in total direct medical cost consequence between older adults receiving additional home telemonitoring care (TELE) (n=102) and those receiving usual medical care (UC) (n=103) were significant. Inpatient, outpatient, emergency department, decedents, survivors, and 30-day readmission costs were evaluated as secondary aim. MATERIALS AND METHODS: Multivariate generalized linear models (GLMs) and parametric bootstrapping method were used to model cost and to determine significance of the cost differences. We also compared the differences in arithmetic mean costs. RESULTS: From the conditional GLMs, the estimated mean cost differences (TELE versus UC) for total, inpatient, outpatient, and ED were -$9,537 (p=0.068), -$8,482 (p =0.098), -$1,160 (p=0.177), and $106 (p=0.619), respectively. Mean postenrollment cost was 11% lower than the prior year for TELE versus 22% higher for UC. The ratio of mean cost for decedents to survivors was 2.1:1 (TELE) versus 12.7:1 (UC). CONCLUSIONS: There were no significant differences in the mean total cost between the two treatment groups. The TELE group had less variability in cost of care, lower decedents to survivors cost ratio, and lower total 30-day readmission cost than the UC group.

Impact of Program Changes Including Telemedicine and Telephonic Care During the COVID-19 Pandemic in Preventing 30-Day Hospital Readmission for Patients in a Care Transitions Program.

INTRODUCTION/OBJECTIVES: To describe health outcomes of older adults enrolled in the Mayo Clinic Care Transitions (MCCT) program before and during the COVID-19 pandemic compared to unenrolled patients. METHODS: We conducted a retrospective cohort study of adults (age >60 years) in the MCCT program compared to a usual care control group from January 1, 2019, to September 20, 2022. The MCCT program involved a home, telephonic, or telemedicine visit by an advanced care provider. Outcomes were 30- and 180-day hospital readmissions, emergency department (ED) visit, and mortality. We performed a subgroup analysis after March 1, 2020 (during the pandemic). We analyzed data with Cox proportional hazards regression models and hazard ratios (HRs) with 95% CIs. RESULTS: Of the 1,012 patients total, 354 were in the MCCT program and 658 were in the usual care group with a mean (SD) age of 81.1 (9.1) years overall. Thirty-day readmission was 16.9% (60 of 354) for MCCT patients and 14.7% (97 of 658) for usual care patients (HR, 1.24; 95% CI, 0.88-1.75). During the pandemic, the 30-day readmission rate was 15.1% (28 of 186) for MCCT patients and 14.9% (68 of 455) for usual care patients (HR, 1.20; 95% CI, 0.75-1.91). There was no difference between groups for 180-day hospitalization, 30- or 180-day ED visit, and 30- or 180-day mortality. CONCLUSIONS: Numerous factors involving patients, providers, and health care delivery systems during the pandemic most likely contributed to these findings.

Impact of telemonitoring on older adults health-related quality of life: the Tele-ERA study.

PURPOSE: Telemonitoring is being increasingly used for chronic disease monitoring. While the primary aim of telemonitoring is to improve chronic disease management and decrease hospitalizations, the potential impact on patient's health-related quality of life may be an additional benefit. METHODS: Two hundred and five patients aged 60 years and older with multiple medical conditions were enrolled in a one-year randomized controlled trial of daily home telemonitoring. Health-related quality of life was measured with the 12-Item Short-Form at the beginning and at the completion of the study. Per protocol analysis of the 166 patients responding to the follow-up survey was performed. RESULTS: Among the 166 responders, there were no significant differences at baseline in the physical component summary (PCS) scores (p value = 0.32), nor the mental component summary (MCS) scores (p value = 0.12) between the telemonitored group and the usual care group. There was also no difference in the 12-month PCS scores (p value = 0.39) or MCS scores (p value = 0.10) between groups. There was no difference in the change from baseline to 12-month MCS scores between groups (p value = 0.89); however, there was a significant difference in the baseline to 12-month change of PCS scores between groups, with the telemonitored group having a greater decrease in PCS scores (-4.3 ± 9.3), compared to the usual care group (-1.2 ± 8.5) over the course of the study (p value = 0.03). CONCLUSION: Home telemonitoring in older adults with multiple comorbidities does not significantly improve self-perception of mental well-being (as measured by MCS scores) and may worsen self-perception of physical health (as measured by PCS scores).

Emerging technologies to support independent living of older adults at risk.

The aging of the population is expected to place an unprecedented strain on health care systems over the next two decades and beyond. Emerging electronic monitoring technologies provide opportunities to learn about the aging process, age-related diseases, and contribute to new, cost effective care models that preserve independence at home for older adults at risk. The goals of this article are to familiarize the reader with emerging technologies and potential applications to older adults' at-risk, review the current literature about the clinical and economic outcomes of emerging technologies, and to outline future directions and challenges.

Posthospital Multidisciplinary Care for AKI Survivors: A Feasibility Pilot.

Rationale & Objective: Innovative models are needed to address significant gaps in kidney care follow-up for acute kidney injury (AKI) survivors. Study Design: This quasi-experimental pilot study reports the feasibility of the AKI in Care Transitions (ACT) program, a multidisciplinary approach to AKI survivor care based in the primary care setting. Setting & Participants: The study included consenting adults with stage 3 AKI discharged home without dialysis. Interventions: The ACT intervention included predischarge education from nurses and coordinated postdischarge follow-up with a primary care provider and pharmacist within 14 days. ACT was implemented in phases (Usual Care, Education, ACT). Outcomes: The primary outcome was feasibility. Secondary outcomes included process and clinical outcomes. Results: In total, 46 of 110 eligible adults were enrolled. Education occurred in 18/18 and 14/15 participants in the Education and ACT groups, respectively. 30-day urine protein evaluation occurred in 15%, 28%, and 87% of the Usual Care, Education, and ACT groups, respectively (P < 0.001). Cumulative incidence of provider (primary care or nephrologist) and laboratory follow-up at 14 and 30 days was different across groups (14 days: Usual care 0%, Education 11%, ACT 73% [P < 0.01]; 30 days: 0%, 22%, and 73% [P < 0.01]). 30-day readmission rates were 23%, 44%, and 13% in the Usual Care, Education, and ACT groups, respectively (P = 0.13). Limitations: Patients were not randomly assigned to treatment groups. The sample size limited the ability to detect some differences or perform multivariable analysis. Conclusions: This study demonstrated the feasibility of multidisciplinary AKI survivor follow-up beginning in primary care. We observed a higher cumulative incidence of laboratory and provider follow-up in ACT participants. Trial Registration: ClinicalTrials.gov (NCT04505891). Plain-Language Summary: Abrupt loss of kidney function in hospitalized patients, acute kidney injury (AKI), increases the chances of long-term kidney disease and a worse health care experience for patients. One out of 3 people who experience AKI do not get the follow-up kidney care they need. We performed a pilot study to test whether a program that facilitates structured AKI follow-up in primary care called the AKI in Care Transitions (ACT) program was possible. ACT brings together the unique expertise of nurses, doctors, and pharmacists to look at the patient's kidney health plan from all angles. The study found that the ACT program was possible and led to more complete kidney care follow-up after discharge than the normal approach to care.

Telehealth Use and Hospital Readmission Rates in Long-term Care Facilities in Southeastern Minnesota During the COVID-19 Pandemic.

Objective: To determine whether the length of a telehealth visit predicted the risk of hospital readmission at 30 days in skilled nursing facilities (SNFs) in southeastern Minnesota during the coronavirus disease 2019 pandemic. Patients and Methods: This was a retrospective cohort study conducted in SNFs located in southeastern Minnesota from March 1, 2020 through July 15, 2020. The primary outcomes included hospitalization within 30 days of a video visit, and the secondary outcome was the number of provider video visits during the stay at an SNF. The primary predictor was the duration of video visits, and we collected the data regarding other known predictors of hospitalization. We used the χ2 test for categorical variables and multivariate conditional logistic regression. Results: We included 722 patients (mean age, 82.8 years [SD, 10.8 years]). Of those, 76 SNF residents (10.5%) were rehospitalized within 30 days. The average length of a video visit was 34.0 minutes (SD, 22.7 minutes) in admitted residents compared with 30.0 minutes (SD, 15.9 minutes) in nonadmitted residents. After full adjustment, there was no difference in the video visit duration between admitted and nonadmitted residents (odds ratio, 1.01; 95% CI, 0.99-1.03). The number of subsequent provider video visits was 2.26 (SD, 1.9) in admitted residents vs 1.58 (SD, 1.6), which was significant after adjustment (odds ratio, 1.17; 95% CI, 1.02-1.34). Conclusion: There was no difference in the length of video visits for hospitalized SNF residents vs those who were not hospitalized within 30 days of a video visit. There were more visits in residents with hospital readmission. This may reflect the acuity of care for patients requiring a hospital stay. More research is needed to determine the ideal use of telehealth during the coronavirus disease 2019 pandemic in the postacute and long-term care environment.

Risk Prediction Model for 6-Month Mortality for Patients Discharged to Skilled Nursing Facilities.

OBJECTIVE: Hospitalized patients discharged to skilled nursing facilities (SNFs) for post-acute care are at high risk for adverse outcomes. Yet, absence of effective prognostic tools hinders optimal care planning and decision making. Our objective was to develop and validate a risk prediction model for 6-month all-cause death among hospitalized patients discharged to SNFs. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: Patients discharged from 1 of 2 hospitals to 1 of 10 SNFs for post-acute care in an integrated health care delivery system between January 1, 2009, and December 31, 2016. METHODS: Gradient-boosting machine modeling was used to predict all-cause death within 180 days of hospital discharge with use of patient demographic characteristics, comorbidities, pattern of prior health care use, and clinical parameters from the index hospitalization. Area under the receiver operating characteristic curve (AUC) was assessed for out-of-sample observations under 10-fold cross-validation. RESULTS: We identified 9803 unique patients with 11,647 hospital-to-SNF discharges [mean (SD) age, 80.72 (9.71) years; female sex, 61.4%]. These discharges involved 9803 patients alive at 180 days and 1844 patients who died between day 1 and day 180 of discharge. Age, comorbid burden, health care use in prior 6 months, abnormal laboratory parameters, and mobility status during hospital stay were the most important predictors of 6-month death (model AUC, 0.82). CONCLUSION AND IMPLICATIONS: We derived a robust prediction model with parameters available at discharge to SNFs to calculate risk of death within 6 months. This work may be useful to guide other clinicians wishing to develop mortality prediction instruments specific to their post-acute SNF populations.

Role of senescence in the chronic health consequences of COVID-19.

While the full impact of COVID-19 is not yet clear, early studies have indicated that upwards of 10% of patients experience COVID-19 symptoms longer than 3 weeks, known as Long-Hauler's Syndrome or PACS (postacute sequelae of SARS-CoV-2 infection). There is little known about risk factors or predictors of susceptibility for Long-Hauler's Syndrome, but older adults are at greater risk for severe outcomes and mortality from COVID-19. The pillars of aging (including cellular senescence, telomere dysfunction, impaired proteostasis, mitochondrial dysfunction, deregulated nutrient sensing, genomic instability, progenitor cell exhaustion, altered intercellular communication, and epigenetic alterations) that contribute to age-related dysfunction and chronic diseases (the "Geroscience Hypothesis") may interfere with defenses against viral infection and consequences of these infections. Heightening of the low-grade inflammation that is associated with aging may generate an exaggerated response to an acute COVID-19 infection. Innate immune system dysfunction that leads to decreased senescent cell removal and/or increased senescent cell formation could contribute to accumulation of senescent cells with both aging and viral infections. These processes may contribute to increased risk for long-term COVID-19 sequelae in older or chronically ill patients. Hence, senolytics and other geroscience interventions that may prolong healthspan and alleviate chronic diseases and multimorbidity linked to fundamental aging processes might be an option for delaying, preventing, or alleviating Long-Hauler's Syndrome.

Telemonitoring increases patient awareness of health and prompts health-related action: initial evaluation of the TELE-ERA study.

INTRODUCTION: Telemonitoring is being increasingly used for chronic disease monitoring. Understanding elderly patients' feelings and perspectives toward telemonitoring is important to minimize any barriers to implementation in this population. METHODS: Twenty Tele-Era Trial participants completed qualitative interviews assessing opinions about their telemonitoring experience. Participants also rated telemonitoring on burden, communication with clinicians, impact on medical condition knowledge, and confidence in using the monitor. RESULTS: On an average, participants rated telemonitoring as minimally burdensome, rated themselves confident in using the monitor, and positively rated telemonitoring for clinical communication. Qualitative analysis revealed a predominant theme that telemonitoring increases patient awareness of their health and also that telemonitoring prompts action. CONCLUSION: Elderly patients find home telemonitoring to be an acceptable and satisfying experience that can increase their awareness of their health and provide a sense of safety in their home. Home telemonitoring can lead to earlier evaluation of decline in health status.

Health Care Costs and Utilization Predictions by the Skilled Nursing Facility Readmission Risk Instrument.

OBJECTIVES: Health care providers at hospitals and skilled nursing facilities (SNFs) are increasingly expected to optimize care of post-acute patients to reduce hospital readmissions and contain costs. To achieve these goals, providers need to understand their patients' risk of hospital readmission and how this risk is associated with health care costs. A previously developed risk prediction model identifies patients' probability of 30-day hospital readmission at the time of discharge to an SNF. With a computerized algorithm, we translated this model as the Skilled Nursing Facility Readmission Risk (SNFRR) instrument. Our objective was to evaluate the relationship between 30-day health care costs and hospital readmissions according to the level of risk calculated by this model. DESIGN: This retrospective cohort study used SNFRR scores to evaluate patient data. SETTING AND PARTICIPANTS: The patients were discharged from Mayo Clinic Rochester hospitals to 11 area SNFs. METHODS: We compared the outcomes of all-cause 30-day standardized direct medical costs and hospital readmissions between risk quartiles based on the distribution of SNFRR scores for patients discharged to SNFs for post-acute care from April 1 through November 30, 2017. RESULTS: Mean 30-day all-cause standardized costs were positively associated with SNFRR score quartiles and ranged from $9199 in the fourth quartile (probability of readmission, 0.27-0.66) to $2679 in the first quartile (probability of readmission, 0.07-0.13) (P ≤ .05). Patients in the fourth SNFRR score quartile had 5.68 times the odds of 30-day hospital readmission compared with those in the first quartile. CONCLUSIONS AND IMPLICATIONS: The SNFRR instrument accurately predicted standardized direct health care costs for patients on discharge to an SNF and their risk for 30-day hospital readmission. Therefore, it could be used to help categorize patients for preemptive interventions. Further studies are needed to confirm its validity in other institutions and geographic areas.

Outcomes of a Nursing Home-to-Community Care Transition Program.

OBJECTIVES: Most transitional care initiatives to reduce rehospitalization have focused on the transition that occurs between a patient's hospital discharge and return home. However, many patients are discharged from a skilled nursing facility (SNF) to their homes. The goal was to evaluate the effectiveness of the Mayo Clinic Care Transitions (MCCT) program (hereafter called program) among patients discharged from SNFs to their homes. DESIGN: Propensity-matched control-intervention trial. INTERVENTION: Patients in the intervention group received care management following nursing stay (a home visit and nursing phone calls). SETTING AND PARTICIPANTS: Patients enrolled after discharge from an SNF to home were matched to patients who did not receive intervention because of refusal, program capacity, or distance. Patients were aged ≥60 years, at high risk for hospitalization, and discharged from an SNF. METHODS: Program enrollees were matched through propensity score to nonenrollees on the basis of age, sex, comorbid health burden, and mortality risk score. Conditional logistic regression analysis examined 30-day hospitalization and emergency department (ED) use; Cox proportional hazards analyses examined 180-day hospital stay and ED use. RESULTS: Each group comprised 160 patients [mean (standard deviation) age, 85.4 (7.4) years]. Thirty-day hospitalization and ED rates were 4.4% and 10.0% in the program group and 3.8% and 10.0% in the group with usual care (P = .76 for hospitalization; P > .99 for ED). At 180 days, hospitalization and ED rates were 30.6% and 46.3% for program patients compared with 11.3% and 25.0% in the comparison group (P < .001). CONCLUSIONS AND IMPLICATIONS: We found no evidence of reduced hospitalization or ED visits by program patients vs the comparison group. Such findings are crucial because they illustrate how aggressive stabilization care within the SNF may mitigate the program role. Furthermore, we found higher ED and hospitalization rates at 180 days in program patients than the comparison group.

Design and Implementation of a Skilled Nursing Facility COVID-19 Unit.

Coronavirus disease 2019 (COVID-19) has challenged the health care system's capacity to care for acutely ill patients. In a collaborative partnership between a health system and a skilled nursing facility (SNF), we developed and implemented an SNF COVID-19 unit to allow expedited hospital discharge of COVID-positive older adults who are clinically improving, and to provide an alternative to hospitalization for those who require SNF care but do not require or necessarily desire aggressive disease-modifying interventions.

Use of a Computerized Algorithm to Evaluate the Proportion and Causes of Potentially Preventable Readmissions Among Patients Discharged to Skilled Nursing Facilities.

OBJECTIVES: Older patients discharged to skilled nursing facilities (SNFs) for post-acute care are at high risk for hospital readmission. Yet, as in the community setting, some readmissions may be preventable with optimal transitional care. This study examined the proportion of 30-day hospital readmissions from SNFs that could be considered potentially preventable readmissions (PPRs) and evaluated the reasons for these readmissions. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: Post-acute practice of an integrated health care delivery system serving 11 SNFs in the US Midwest. Patients discharged from the hospital to an SNF and subsequently readmitted to the hospital within 30 days from January 1, 2009, through November 31, 2016. METHODS: A computerized algorithm evaluated the relationship between initial and repeat hospitalizations to determine whether the repeat hospitalization was a PPR. We assessed for changes in PPR rates across the system over the study period and evaluated the readmission categories to identify the most prevalent PPR categories. RESULTS: Of 11,976 discharges to SNFs for post-acute care among 8041 patients over the study period, 16.6% resulted in rehospitalization within 30 days, and 64.8% of these rehospitalizations were considered PPRs. Annual proportion of PPRs ranged from 58.2% to 66.4% [mean (standard deviation) 0.65 (0.03); 95% confidence interval CI 0.63-0.67; P = .36], with no discernable trend. Nearly one-half (46.2%) of all 30-day readmissions were classified as potentially preventable medical readmissions related to recurrence or continuation of the reason for initial admission or to complications from the initial hospitalization. CONCLUSIONS AND IMPLICATIONS: For this cohort of patients discharged to SNFs, a computerized algorithm categorized a large proportion of 30-day hospital readmissions as potentially preventable, with nearly one-half of those linked to the reason for the initial hospitalization. These findings indicate the importance of improvement in postdischarge transitional care for patients discharged to SNFs.

Fisetin for COVID-19 in skilled nursing facilities: Senolytic trials in the COVID era.

The burden of senescent cells (SnCs), which do not divide but are metabolically active and resistant to death by apoptosis, is increased in older adults and those with chronic diseases. These individuals are also at the greatest risk for morbidity and mortality from SARS-CoV-2 infection. SARS-CoV-2 complications include cytokine storm and multiorgan failure mediated by the same factors as often produced by SnCs through their senescence-associated secretory phenotype (SASP). The SASP can be amplified by infection-related pathogen-associated molecular profile factors. Senolytic agents, such as Fisetin, selectively eliminate SnCs and delay, prevent, or alleviate multiple disorders in aged experimental animals and animal models of human chronic diseases, including obesity, diabetes, and respiratory diseases. Senolytics are now in clinical trials for multiple conditions linked to SnCs, including frailty; obesity/diabetes; osteoporosis; and cardiovascular, kidney, and lung diseases, which are also risk factors for SARS-CoV-2 morbidity and mortality. A clinical trial is underway to test if senolytics decrease SARS-CoV-2 progression and morbidity in hospitalized older adults. We describe here a National Institutes of Health-funded, multicenter, placebo-controlled clinical trial of Fisetin for older adult skilled nursing facility (SNF) residents who have been, or become, SARS-CoV-2 rtPCR-positive, including the rationale for targeting fundamental aging mechanisms in such patients. We consider logistic challenges of conducting trials in long-term care settings in the SARS-CoV-2 era, including restricted access, consent procedures, methods for obtaining biospecimens and clinical data, staffing, investigational product administration issues, and potential solutions for these challenges. We propose developing a national network of SNFs engaged in interventional clinical trials.

Use of an electronic administrative database to identify older community dwelling adults at high-risk for hospitalization or emergency department visits: the elders risk assessment index.

BACKGROUND: The prevention of recurrent hospitalizations in the frail elderly requires the implementation of high-intensity interventions such as case management. In order to be practically and financially sustainable, these programs require a method of identifying those patients most at risk for hospitalization, and therefore most likely to benefit from an intervention. The goal of this study is to demonstrate the use of an electronic medical record to create an administrative index which is able to risk-stratify this heterogeneous population. METHODS: We conducted a retrospective cohort study at a single tertiary care facility in Rochester, Minnesota. Patients included all 12,650 community-dwelling adults age 60 and older assigned to a primary care internal medicine provider on January 1, 2005. Patient risk factors over the previous two years, including demographic characteristics, comorbid diseases, and hospitalizations, were evaluated for significance in a logistic regression model. The primary outcome was the total number of emergency room visits and hospitalizations in the subsequent two years. Risk factors were assigned a score based on their regression coefficient estimate and a total risk score created. This score was evaluated for sensitivity and specificity. RESULTS: The final model had an AUC of 0.678 for the primary outcome. Patients in the highest 10% of the risk group had a relative risk of 9.5 for either hospitalization or emergency room visits, and a relative risk of 13.3 for hospitalization in the subsequent two year period. CONCLUSIONS: It is possible to create a screening tool which identifies an elderly population at high risk for hospital and emergency room admission using clinical and administrative data readily available within an electronic medical record.

A randomized controlled trial of telemonitoring in older adults with multiple chronic conditions: the Tele-ERA study.

BACKGROUND: Older adults with multiple chronic illnesses are at risk for worsening functional and medical status and hospitalization. Home telemonitoring may help slow this decline. This protocol of a randomized controlled trial was designed to help determine the impact of home telemonitoring on hospitalization. The specific aim of the study reads as follows: to determine the effectiveness of home telemonitoring compared with usual care in reducing the combined outcomes of hospitalization and emergency department visits in an at-risk population 60 years of age or older. METHODS/DESIGN: Two-hundred patients with the highest 10% Mayo Clinic Elder Risk Assessment scores will be randomly assigned to one of two interventions. Home telemonitoring involves the use of a computer device, the Intel Health Guide, which records biometric and symptom data from patients in their homes. This information is monitored by midlevel providers associated with a primary care medical practice. Under the usual care scenario, patients make appointments with their providers as problems arise and use ongoing support such as a 24-hour nurse line.Patients will have initial evaluations of gait and quality of life using instruments such as the SF-12 Health Survey, the Kokmen Short Test of Mental Status, and the PHQ-9 health questionnaire. Patients will be followed for 1 year for primary outcomes of hospitalizations and emergency department visits. Secondary analysis will include quality of life, compliance with the device, and attitudes about telemonitoring. Sample size is based on an 80% power to detect a 36% difference between the two groups. The primary analysis will involve Cox proportional time-to-event analysis. Secondary analysis will use t-test comparisons for continuous variables and the chi square test for proportional analysis. DISCUSSION: Patients randomized to home telemonitoring will have daily assessments of their health status using the device. Registered nurse monitoring will assess any change in status followed by videoconferencing by a mid-level provider. We obtained trial registration and Institutional Review Board approval. TRIAL REGISTRATION: Trial registration number through http://www.clinicaltrials.gov: NCT01056640.

Hospital to Community Transitions for Older Adults: An Update for the Practicing Clinician.

Spurred by changes in both population demographics and health care reimbursement, health care providers are responding by using new models to more fully support the posthospital transition. This paper reviews common models for posthospital transition and also describes the Mayo Clinic model for care transition. Models are designed with the intent of managing the cost of health care by reducing 30-day hospital readmissions and improving management of chronic disease. Meta-analyses have proved helpful in identifying the most effective program elements designed to reduce 30-day hospital readmissions. These elements include a bundled and multidisciplinary approach to best meet the needs of patients. Successful care teams also emphasize self-empowerment for both patients and caregivers. There are 2 general types of practice. In 1 model, introduced by Mary Naylor, an advanced-practice provider cares for the patient for a set period of time, which includes home visits. In the second model, introduced by Eric Coleman, a transitions coach, who can be an RN, a social worker, or a trained volunteer, serves as the health care coach, while improving self-efficacy. Both models have been successful. At Mayo Clinic, the Mayo Clinic Care Transitions program has encompassed a 7-year experience, using the services of an advanced practice provider. In previous studies, this model demonstrated a 20.1% (95% confidence interval [CI], 15.8 to 24.1%) decrease in 30-day readmission in controls compared with 12.4% (95% CI, 8.9 to 15.7%) in the control group. Although this model was successful in reducing 30-day readmissions, there was no difference between groups at 180 days. In patients experiencing the highest deciles of cost (8th decile), enrollment in a care transitions program reduced their overall cost by $2700. This cost savings was statistically significant. Both patients and caregivers participating in the program appreciated the home visits and felt more comfortable communicating at home.

Educational effectiveness of a personal digital assistant-based geriatric assessment tool.

BACKGROUND: Although personal digital assistant use among residents is common, few outcomes-based studies have examined the impact of this technology on medical education. AIMS: We evaluated the educational effectiveness of a personal digital assistant-based geriatric assessment tool. METHODS: Internal medicine residents were enrolled as subjects. Personal digital assistant users were randomly assigned to receive or not receive a geriatric assessment tool for use on their device. Outcome measures included pretest/posttest performance and tabulation of geriatric functional issues on hospital dismissal summaries. RESULTS: Seventy-two residents participated. Of these, 38 (53%) reported personal digital assistant use. Twenty were assigned to receive the geriatric assessment tool. Average change between pretest and posttest scores was highest for the group using the geriatric assessment tool on a personal digital assistant (2.8, P=0.01). This group also had the highest average posttest score and the highest average number of geriatric functional issues identified on dismissal summaries, but neither value was significantly different from respective averages for the other study groups. CONCLUSIONS: Residents who used a personal digital assistant-based geriatric assessment tool demonstrated greater improvement in geriatric knowledge than peers who did not use this resource. Curricula adapted to this technology may prove useful in medical education.

Risk of 30-Day Hospital Readmission Among Patients Discharged to Skilled Nursing Facilities: Development and Validation of a Risk-Prediction Model.

OBJECTIVES: Patients discharged to a skilled nursing facility (SNF) for post-acute care have a high risk of hospital readmission. We aimed to develop and validate a risk-prediction model to prospectively quantify the risk of 30-day hospital readmission at the time of discharge to a SNF. DESIGN: Retrospective cohort study. SETTING: Ten independent SNFs affiliated with the post-acute care practice of an integrated health care delivery system. PARTICIPANTS: We evaluated 6032 patients who were discharged to SNFs for post-acute care after hospitalization. MEASUREMENTS: The primary outcome was all-cause 30-day hospital readmission. Patient demographics, medical comorbidity, prior use of health care, and clinical parameters during the index hospitalization were analyzed by using gradient boosting machine multivariable analysis to build a predictive model for 30-day hospital readmission. Area under the receiver operating characteristic curve (AUC) was assessed on out-of-sample observations under 10-fold cross-validation. RESULTS: Among 8616 discharges to SNFs from January 1, 2009, through June 30, 2014, a total of 1568 (18.2%) were readmitted to the hospital within 30 days. The 30-day hospital readmission prediction model had an AUC of 0.69, a 16% improvement over risk assessment using the Charlson Comorbidity Index alone. The final model included length of stay, abnormal laboratory parameters, and need for intensive care during the index hospitalization; comorbid status; and number of emergency department and hospital visits within the preceding 6 months. CONCLUSIONS AND IMPLICATIONS: We developed and validated a risk-prediction model for 30-day hospital readmission in patients discharged to a SNF for post-acute care. This prediction tool can be used to risk stratify the complex population of hospitalized patients who are discharged to SNFs to prioritize interventions and potentially improve the quality, safety, and cost-effectiveness of care.