Rural-Urban Differences in Mortality among Mechanically Ventilated Patients in Intensive and Intermediate Care.

Rationale: Intermediate care (also termed "step-down" or "moderate care") has been proposed as a lower cost alternative to care for patients who may not clearly benefit from intensive care unit admission. Intermediate care units may be appealing to hospitals in financial crisis, including those in rural areas. Outcomes of patients receiving intermediate care are not widely described. Objectives: To examine relationships among rurality, location of care, and mortality for mechanically ventilated patients. Methods: Medicare beneficiaries aged 65 years and older who received invasive mechanical ventilation between 2010 and 2019 were included. Multivariable logistic regression was used to estimate the association between admission to a rural or an urban hospital and 30-day mortality, with separate analyses for patients in general, intermediate, and intensive care. Models were adjusted for age, sex, area deprivation index, primary diagnosis, severity of illness, year, comorbidities, and hospital volume. Results: There were 2,752,492 hospitalizations for patients receiving mechanical ventilation from 2010 to 2019, and 193,745 patients (7.0%) were in rural hospitals. The proportion of patients in rural intermediate care increased from 4.1% in 2010 to 6.3% in 2019. Patient admissions to urban hospitals remained relatively stable. Patients in rural and urban intensive care units had similar adjusted 30-day mortality, at 46.7% (adjusted absolute risk difference -0.1% [95% confidence interval, -0.7% to 0.6%]; P = 0.88). However, adjusted 30-day mortality for patients in rural intermediate care was significantly higher (36.9%) than for patients in urban intermediate care (31.3%) (adjusted absolute risk difference 5.6% [95% confidence interval, 3.7% to 7.6%]; P < 0.001). Conclusions: Hospitalization in rural intermediate care was associated with increased mortality. There is a need to better understand how intermediate care is used across hospitals and to carefully evaluate the types of patients admitted to intermediate care units.

Short-Term Outcomes of Transcatheter Aortic Valve Implantation Versus Surgical Aortic Valve Replacement in Kidney Transplant Recipients (from the US Nationwide Representative Study).

Kidney transplant recipients (KTRs) are considered high-risk patients for surgical interventions. Transcatheter aortic valve implantation (TAVI) has been introduced as an alternative to surgical aortic valve replacement (SAVR) in patients with aortic stenosis (AS) at high operative risk. However, the outcomes of TAVI compared with SAVR KTRs have not been well-studied in nationally representative data. Patients with prior history of functioning kidney transplant who were hospitalized for TAVI and SAVR between January 2012 and December 2017 were identified retrospectively in the Nationwide Readmissions Database. Our study included 762 TAVI and 1,278 SAVR KTRs. Compared with SAVR, TAVI patients generally had higher rates of co-morbidities with lower risk of in-hospital mortality (3.1% vs 6.3, p = 0.002), blood transfusion (11.5% vs 38.6%, p <0.001), acute myocardial infarction (3.9% vs 6.5%, p = 0.16), acute kidney injury (24.5% vs 42.1%, p <0.001), sepsis (3.9% vs 9.5%, p <0.001) and discharge with disability (42.6% vs 68.4%, p <0.001). However, the rate of permanent pacemaker implantation was significantly higher in TAVI group (11.4% vs 3.9%, p <0.001). Of note, in-hospital stroke and 30-day readmission were comparable between both groups. These findings were confirmed after adjusting for other co-morbidities. TAVI is growing as a valid and safe alternative for KTRs with severe AS.

Prevalence of opportunistic invasive aspergillosis in COVID-19 patients with severe pneumonia.

BACKGROUND: As the global coronavirus pandemic (COVID-19) spreads across the world, new clinical challenges emerge in the hospital landscape. Among these challenges, the increased risk of coinfections is a major threat to the patients. Although still in a low number, due to the short time of the pandemic, studies that identified a significant number of hospitalised patients with COVID-19 who developed secondary fungal infections that led to serious complications and even death have been published. OBJECTIVES: In this scenario, we aim to determine the prevalence of invasive fungal infections (IFIs) and describe possible associated risk factors in patients admitted due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. PATIENTS/METHODS: We designed an open prospective observational study at the Rey Juan Carlos University Hospital (Mostoles, Spain), during the period from February 1 to April 30, 2020. RESULTS: In this article, we reported seven patients with COVID-19-associated pulmonary aspergillosis (CAPA) who had a poor prognosis. Severely ill patients represent a high-risk group; therefore, we must actively investigate the possibility of aspergillosis in all of these patients. Larger cohort studies are needed to unravel the role of COVID-19 immunosuppressive therapy as a risk factor for aspergillosis. CONCLUSIONS: As the pandemic continues to spread across the world, further reports are needed to assess the frequency of emergent and highly resistant reemergent fungal infections during severe COVID-19. These coinfections are leading a significant number of patients with COVID-19 to death due to complications following the primary viral disease.

Lower limb deep vein thrombosis in COVID-19 patients admitted to intermediate care respiratory units.

COVID-19 has been associated with an increased risk of thrombotic events; however, the reported incidence of deep vein thrombosis varies depending, at least in part, on the severity of the disease. Aim of this prospective, multicenter, observational study was to investigate the incidence of lower limb deep vein thrombosis as assessed by compression ultrasound in consecutive patients admitted to three pulmonary medicine wards designated to care for patients with COVID-19 related pneumonia, with or without respiratory failure but not requiring admission to an intensive care unit. Consecutive patients admitted between March 27 and May 6, 2020 were enrolled. Patients were excluded if they were less than 18-year-old or if compression ultrasound could not be performed for any reason. Patients were assessed at admission (t0) and after 7 days (t1). Major and non-major clinically relevant bleedings were recorded. Sixty-eight patients were enrolled. Two were excluded due to anatomical abnormalities that prevented compression ultrasound; sixty patients were retested at (t1). All patients were started on antithrombotic prophylaxis, unless therapeutic anticoagulation was required. Deep vein thrombosis as assessed by compression ultrasound was observed in 2 patients (3%); one of them was later deemed to represent a previous episode. No new episodes were detected at t1. One major and 2 non-major clinically relevant bleedings were observed. In the setting of patients with COVID-related pneumonia not requiring admission to an intensive care unit, the incidence of deep vein thrombosis is low and our data support not screening asymptomatic patients.

Clinical effectiveness of an intermediate care inpatient model based on integrated care pathways.

AIM: The aim of this study was to compare the clinical impact of two intermediate care pathways. METHODS: A prospective, uncontrolled before-after study was carried out to compare two non-synchronic intermediate care frameworks in Spain. Participants in the control group were transferred to the intermediate care center by hospital request, whereas those in the intervention group (Badalona Integrated Care Model [BICM]) were transferred based on a territory approach considering the assessment of an intermediate care team. The clinical characteristics of study participants were assessed at admission and discharge. RESULTS: Compared with participants in the control group, those in the BICM group were significantly older (mean age 81.6 years [SD 10.3] vs 78.3 years [10.1], P < 0.001) and had a lower Barthel score (mean score 32.8 [SD 25.9] vs 39.9 [28.4]; P < 0.001), and a higher proportion of participants with total dependence (38.4% vs 32.2%; P = 0.001). The length of stay in intermediate care was similar in both groups; however, stay in acute care was significantly shorter in the BICM group than in the control group (mean 21 days [SD 19.5] vs 25 days [SD 23]; P < 0.001). No significant differences were found regarding the Barthel Index at discharge, although participants in the BICM group had significantly higher functional gain. CONCLUSIONS: The implementation of a territory-based integrated care pathway in an intermediate care center shifted the profile of admitted patients toward higher complexity. Despite this, patients managed under the integrated care model reduced their dependency and the referral rate to an acute unit during their stay in the intermediate care center. Geriatr Gerontol Int 2020; 20: 366-372.

Intermediate Care Units: A Survey of Organization Practices Across the United States.

PURPOSE: Intermediate care units (IMCUs) represent an alternative care setting with nurse staffing levels between those of the general ward and the intensive care unit (ICU). Despite rising prevalence, little is known about IMCU practices across US hospitals. The purpose of this study is to characterize utilization patterns and assess for variation. MATERIALS AND METHODS: A 14-item survey was distributed to a random nationwide sample of pulmonary and critical care physicians between January and April 2017. RESULTS: A total of 51 physicians from 24 different states completed the survey. Each response represented a unique institution, the majority of which were public (59%), academic (73%), and contained at least 1 IMCU (65%). Of the IMCUs surveyed, 58% operated as 1 mixed unit that admitted medical, cardiac, and surgical patients as opposed to having separate subspecialty units. Ninety-one percent of units admitted step-down patients from the ICU, but 39% of units accepted a mix of step-up patients, step-down patients, postoperative patients, and patients from the emergency department. Intensivists managed care in 21% of units whereas 36% had no intensivist involvement. CONCLUSION: Organization practices vary considerably between IMCUs across institutions. The impact of different organization practices on patient outcomes should be assessed.

Which Patients Require Unexpected Admission to Postacute Care Facilities After Total Hip Arthroplasty?

BACKGROUND: Many surgeons prefer to discharge patients home due to patient preferences, improved outcomes, and decreased costs. Despite an institutional protocol to send total hip arthroplasty (THA) patients home, some patients still required postacute care (PAC) facilities. This study aimed to create two predictive models based on preoperative and postoperative risk factors to identify which patients require PAC facilities. METHODS: A retrospective review of 2,372 patients undergoing primary unilateral THA at a single institution from 2012 to 2017 was done. An electronic query followed by manual review identified discharge disposition, demographic factors, comorbidities, and other patient factors. Of the 2,372 patients, 6.2% were discharged to skilled nursing facilities or inpatient rehabilitation facilities and 93.8% discharged home. Univariate and multivariate analysis were conducted to create two predictive models for patient discharge: preoperative visit and postoperative hospital course. RESULTS: Of 45 variables evaluated, 7 were found to be notable predictors for PAC facility discharge. In descending order, these included age 65 years or greater, non-Caucasian race, history of depression, female sex, and greater comorbidities. In addition to preoperative factors, in-hospital complications and surgical duration of 90 minutes or greater led to a higher likelihood of PAC facility discharge. Both models had excellent predictive assessments with area under curve values of 0.77 and 0.80 for the preoperative visit and postoperative models, respectively. DISCUSSION: This study identifies both preoperative and postoperative risk factors that predispose patients to nonroutine discharges after THA. Orthopaedic surgeons may use these models to better predict which patients are predisposed to discharge to PAC facilities.

Measuring the impact of step down intermediate care on delayed discharge: an interrupted time series analysis.

BACKGROUND: Intermediate care (IC) acts as a bridging service between hospital and home, for those deemed medically fit for discharge but who are delayed in hospital. The aim of this study was to measure the effect of IC and a 72-hour discharge target on days delayed. METHODS: Rate of days delayed per 1000 population aged 75 years+ in Glasgow City was compared before and after onset of IC with a 6-month phase-in period, using segmented linear regression. Inverclyde and West Dunbartonshire (IWD) was a control. Autoregressive and moving average terms were included in the model, as well as a Fourier term to adjust for seasonality. RESULTS: Prior to IC, rate of days delayed increased in both Glasgow City and the rest of Scotland. There was a large reduction in rate of days delayed in Glasgow during the phase-in period, greater than the rest of Scotland but comparable with that observed in IWD, with subsequent increases thereafter. Adjusting for changes in IWD, the impact of IC and the discharge target in Glasgow City was a level change of -15.20 (95% CI -17.52 to -12.88) and a trend change of -0.29 (95% CI -0.55 to -0.02). This is equivalent to a predicted reduction due to IC of -16.04 days delayed per 1000 population per month, in June 2016, and a relative reduction of 35%. CONCLUSION: IC and the 72-hour discharge target were associated with a reduction in days delayed. Rate of days delayed continued to increase over time, although at a slower rate than if IC had not been implemented.

Mortality among referrals to a community-based intermediate care team.

OBJECTIVES: Intermediate care services have been introduced to help mitigate unnecessary hospital demand and premature placement in long-term residential care. Many patients are elderly and/or with complex comorbidities, but little consideration has been given to the palliative care needs of patients referred to intermediate care services. The objective of this study is to determine the proportion of patients referred to a community-based intermediate care team who died during care and up to 24 months after discharge and so to help inform the development of supportive and palliative care in this setting. METHODS: A retrospective cohort study of all 4770 adult patients referred to Northamptonshire Intermediate Care Team (ICT) between 11 April 2010 and 10 April 2011. RESULTS: Of 4770 patients referred, 60% were 75 years or older and 32% were 85 years of age or older. 4.0% of patients died during their ICT stay and 11% within 30 days of discharge. At the end of 12 months, 25% of the patients had died, increasing to 32% before the end of the second year. About 34% of all deaths occurred during the ICT stay or within 30 days of discharge, and a further 46% by the end of the first year. Male gender and higher age were associated with greater likelihood of death. CONCLUSIONS: It is important for ICT clinicians to consider immediate and longer-term palliative care needs among patients referred to ICTs. Care models involving ICTs and palliative care teams working together could enable more people with end-stage non-cancer illnesses to die at home.

Levels of type 1 diabetes care in children and adolescents for countries at varying resource levels.

Optimal care for children and adolescents with type 1 diabetes is well described in guidelines, such as those of the International Society for Pediatric and Adolescent Diabetes. High-income countries can usually provide this, but the cost of this care is generally prohibitive for lower-income countries. Indeed, in most of these countries, very little care is provided by government health systems, resulting in high mortality, and high complications rates in those who do survive. As lower-income countries work toward establishing guidelines-based care, it is helpful to describe the levels of care that are potentially affordable, cost-effective, and result in substantially improved clinical outcomes. We have developed a levels of care concept with three tiers: "minimal care," "intermediate care," and "comprehensive (guidelines-based) care." Each tier contains levels, which describe insulin and blood glucose monitoring regimens, requirements for hemoglobin A1c (HbA1c) testing, complications screening, diabetes education, and multidisciplinary care. The literature provides various examples at each tier, including from countries where the life for a child and the changing diabetes in children programs have assisted local diabetes centres to introduce intermediate care. Intra-clinic mean HbA1c levels range from 12.0% to 14.0% (108-130 mmol/mol) for the most basic level of minimal care, 8.0% to 9.5% (64-80 mmol/mol) for intermediate care, and 6.9% to 8.5% (52-69 mmol/mol) for comprehensive care. Countries with sufficient resources should provide comprehensive care, working to ensure that it is accessible by all in need, and that resulting HbA1c levels correspond with international recommendations. All other countries should provide Intermediate care, while working toward the provision of comprehensive care.

In-hospital dementia-related deaths following implementation of the national dementia plan: observational study of national death certificates from 1996 to 2016.

OBJECTIVE: To examine changes in places of dementia-related death following implementation of the national dementia plan and other policy initiatives. DESIGN: Observational study. SETTING: Japan between October 1996 and September 2016. Four major changes in health and social care systems were identified: (1) the public long-term care insurance programme (April 2000); (2) community centres as a first access point for older residents (April 2006); (3) medical care system for older people (April 2008) and (4) the national dementia plan (April 2013). PARTICIPANTS: 9 60 423 decedents aged 65 years or older whose primary cause of death was Alzheimer's disease, vascular or other types of dementia or senility. MAIN OUTCOME MEASURES: Place of death which was classified into 'hospital', 'intermediate geriatric care facility' (rehabilitation facility aimed at home discharge), 'nursing home' or 'own home'. RESULTS: The annual number of deaths at hospital was consistently increased over time from 1996 to 2016 (age-adjusted OR: 6.01; 95% CI 5.81 to 6.21 versus home deaths). Controlling for individual characteristics, regional supply of hospital and nursing home beds and other changes in health and social care systems, death from dementia following the national dementia plan was likely to occur in hospital (adjusted OR: 1.21; 95% CI 1.18 to 1.24), intermediate geriatric care facility (adjusted OR: 1.53; 95% CI 1.48 to 1.58) or nursing home (adjusted OR: 1.64; 95% CI 1.60 to 1.69) rather than at home. CONCLUSIONS: As the number of deaths from dementia increased over the decades, in-hospital deaths increased regardless of the national dementia plan. Further strategies should be explored to improve the availability of palliative and end-of-life care at patients' places of residence.

Predictors of Surgical Site Infection After Nonemergent Craniotomy: A Nationwide Readmission Database Analysis.

OBJECTIVE: Surgical site infections (SSIs) carry significant patient morbidity and mortality and are a major source of readmissions after craniotomy. Because of their deleterious effects on health care outcomes and costs, identifying modifiable risk factors holds tremendous value. However, because SSIs after craniotomy are rare and most existing data comprise single-institution studies with small sample sizes, many are likely underpowered to discern for such factors. The objective of this study was to use a large hetereogenous patient sample to determine SSI incidence after nonemergent craniotomy and identify factors associated with readmission and subsequent need for wound washout. METHODS: We used the 2010-2014 Nationwide Readmissions Database cohorts to discern for factors predictive of SSI and washout. RESULTS: We identified 93,920 nonemergent craniotomies. There were 2079 cases of SSI (2.2%) and 835 reoperations for washout (0.89%) within 30 days of index admission and there were 2761 cases of SSI (3.6%) and 1220 reoperations for washout (1.58%) within 90 days. Several factors were predictive of SSI in multivariate analysis, including tumor operations, external ventricular drain (EVD), age, length of stay, diabetes, discharge to an intermediate-care facility, insurance type, and hospital bed size. Many of these factors were similarly implicated in reoperation for washout. CONCLUSIONS: SSI incidence in neurosurgery is low and most readmissions occur within 30 days. Several factors predicted SSI after craniotomy, including operations for tumor, younger age, hospitalization length, diabetes, discharge to institutional care, larger hospital bed size, Medicaid insurance, and presence of an EVD. Diabetes and EVD placement may represent modifiable factors that could be explored in subsequent prospective studies for their associations with cranial SSIs.

Workload and severity of illness of patients on intensive care units with available intermediate care units: a multicenter cohort study.

BACKGROUND: Intermediate Care Units (IMCU) are established in many hospitals to better match the requirements of patient care with respect to their personnel, equipment and other resources. This should relieve Intensive Care Unit (ICU) capacities for more severely ill patients and reduce readmissions to ICU. This study was conducted to investigate the effects of IMCU use on ICU populations. METHODS: This is a retrospective analysis of the German National Registry of Intensive Care from the years 2000 to 2010. RESULTS: We included 39 ICUs with high and 11 ICUs with low IMCU use. Patients in ICUs with high IMCU use were younger (mean age [high vs. low]: 60.5 vs. 64.5 years, P<0.001), while the severity of illness was higher (percentage of ventilated patients during ICU stay [high vs. low ICMU use]: 67.2% vs. 40.2%, P<0.001; patients ventilated >24 hours: 22% vs. 18%, P<0.001; mean therapeutic intervention scoring system-28 (TISS-28) score: 25.7 vs. 23.3, P<0.001). Readmission rates to ICU did not differ between ICU groups ([high vs. low]: 4.5% vs. 4.4%, P=0.25). ICUs with high IMCU use discharged 90.3% of all patients who were discharged to the IMCU or general ward between the regular workday hours of 06:00 and 14:59, while ICUs with low IMCU use discharged 83.8% of all patients discharged to the general ward in the same time period. CONCLUSIONS: The use of IMCUs influences resource utilization of ICUs. Severity of illness and workload was higher in ICUs with high IMCU and more scheduled discharges occurred during the main working hours while readmission rates were similar.

Factors Affecting Discharge to Home of Geriatric Intermediate Care Facility Residents in Japan.

OBJECTIVES: To investigate factors associated with lower likelihood of discharge to home from geriatric intermediate care facilities in Japan. DESIGN: Retrospective cohort study. SETTING: We used data from the nationwide long-term care (LTC) insurance claims database (April 2012-March 2014). PARTICIPANTS: Study participants were 342,758 individuals newly admitted to 3,459 geriatric intermediate care facilities during the study period. MEASUREMENTS: The primary outcome was discharge to home. We performed a multivariable competing-risk Cox regression with adjustment for resident-, facility-, and region-level characteristics. Resident level of care needs and several medical conditions were included as time-varying covariates. Death, admission to a hospital, and admission to another LTC facility were treated as competing risks. RESULTS: During the 2-year follow-up period, 19% of participants were discharged to home. In the multivariable competing-risk Cox regression, the following factors were significantly associated with lower likelihood of discharge to home: older age, higher level of care need, having several medical conditions, private ownership of the facility, more beds in the facility, and more LTC facility beds per 1,000 adults aged 65 and older in the region. CONCLUSION: Only 19% of residents were discharged to home. Our results are useful for policy-makers to promote discharge to home of older adults in geriatric intermediate care facilities.

Outcomes of Laparoscopic Colectomy in Younger and Older Patients: An Analysis of Nationwide Readmission Database.

BACKGROUND: Prior studies report safety and effectiveness of laparoscopic colectomy in older patients. The study aimed to examine the impact of laparoscopic colectomy on 30-day readmissions, discharge destination, hospital length of stay, and cost in younger (19-65 years) and older adults (>65 years). MATERIALS AND METHODS: We used the nationwide readmission database from 2013 to study adults undergoing elective colectomy. The outcomes were 30-day readmissions, discharge destination for the index hospitalization (routine, skilled nursing facility [SNF]/intermediate care facility [ICF], home healthcare), length of stay, and cost. Multivariable analyses were conducted to determine the association of laparoscopic colectomy on outcome; logistic regression for 30-day readmission, multinomial logistic regression for discharge destination, and linear regression for length of stay and cost. An interaction between age and colectomy approach was included, and all models controlled gender, income, insurance status, All Patients Refined Diagnosis Related Groups (APR-DRG), Elixhauser comorbidities, hospital bed size, ownership, and teaching status. RESULTS: Of 79,581 colectomies, 40.2% were laparoscopic. Laparoscopic colectomy was more frequent in younger patients (41.9% versus 38.5%, p < .0001). Regardless of age, patients undergoing laparoscopic colectomy were 20% less likely to be readmitted within 30 days (odds ratio [OR] 0.80, confidence interval [95% CI] 0.75-0.85). For postdischarge destination, laparoscopic colectomy offered higher benefits to younger patients (SNF/ICF: OR 0.42, 95% CI 0.36-0.49; home health: OR 0.32, 95% CI 0.30-0.35) than older patients (SNF/ICF: OR 0.50, 95% CI 0.47-0.54; home health: OR 0.59, 95% CI 0.55-0.62). Regardless of age, laparoscopic colectomy resulted in 1.46 days (p < .0001) shorter hospital stays compared to open colectomy. Laparoscopic colectomy had significantly lower cost compared to open approach, particularly in younger ($1,466) versus older ($632) patients. CONCLUSIONS: Laparoscopic colectomy is superior to an open approach, with fewer 30-day readmissions, fewer discharges to SNF/ICF or home health, shorter hospital stays, and less overall cost; younger patients benefit more than older patients.

Pediatric intermediate care and pediatric intensive care units: PICU metrics and an analysis of patients that use both.

PURPOSE: To examine how intermediate care units (IMCUs) are used in relation to pediatric intensive care units (PICUs), characterize PICU patients that utilize IMCUs, and estimate the impact of IMCUs on PICU metrics. MATERIALS & METHODS: Retrospective study of PICU patients discharged from 108 hospitals from 2009 to 2011. Patients admitted from or discharged to IMCUs were characterized. We explored the relationships between having an IMCU and several PICU metrics: physical length-of-stay (LOS), medical LOS, discharge wait time, admission severity of illness, unplanned PICU admissions from wards, and early PICU readmissions. RESULTS: Thirty-three percent of sites had an IMCU. After adjusting for known confounders, there was no association between having an IMCU and PICU LOS, mean severity of illness of PICU patients admitted from general wards, or proportion of PICU readmissions or unplanned ward admissions. At sites with an IMCU, patients waited 3.1h longer for transfer from the PICU once medically cleared (p<0.001). CONCLUSIONS: There was no association between having an IMCU and most measures of PICU efficiency. At hospitals with an IMCU, patients spent more time in the PICU once they were cleared for discharge. Other ways that IMCUs might affect PICU efficiency or particular patient populations should be investigated.

Rehabilitation Profiles of Older Adult Stroke Survivors Admitted to Intermediate Care Units: A Multi-Centre Study.

BACKGROUND: Stroke is a major cause of disability in older adults, but the evidence around post-acute treatment is limited and heterogeneous. We aimed to identify profiles of older adult stroke survivors admitted to intermediate care geriatric rehabilitation units. METHODS: We performed a cohort study, enrolling stroke survivors aged 65 years or older, admitted to 9 intermediate care units in Catalonia-Spain. To identify potential profiles, we included age, caregiver presence, comorbidity, pre-stroke and post-stroke disability, cognitive impairment and stroke severity in a cluster analysis. We also proposed a practical decision tree for patient's classification in clinical practice. We analyzed differences between profiles in functional improvement (Barthel index), relative functional gain (Montebello index), length of hospital stay (LOS), rehabilitation efficiency (functional improvement by LOS), and new institutionalization using multivariable regression models (for continuous and dichotomous outcomes). RESULTS: Among 384 patients (79.1±7.9 years, 50.8% women), we identified 3 complexity profiles: a) Lower Complexity with Caregiver (LCC), b) Moderate Complexity without Caregiver (MCN), and c) Higher Complexity with Caregiver (HCC). The decision tree showed high agreement with cluster analysis (96.6%). Using either linear (continuous outcomes) or logistic regression, both LCC and MCN, compared to HCC, showed statistically significant higher chances of functional improvement (OR = 4.68, 95%CI = 2.54-8.63 and OR = 3.0, 95%CI = 1.52-5.87, respectively, for Barthel index improvement ≥20), relative functional gain (OR = 4.41, 95%CI = 1.81-10.75 and OR = 3.45, 95%CI = 1.31-9.04, respectively, for top Vs lower tertiles), and rehabilitation efficiency (OR = 7.88, 95%CI = 3.65-17.03 and OR = 3.87, 95%CI = 1.69-8.89, respectively, for top Vs lower tertiles). In relation to LOS, MCN cluster had lower chance of shorter LOS than LCC (OR = 0.41, 95%CI = 0.23-0.75) and HCC (OR = 0.37, 95%CI = 0.19-0.73), for LOS lower Vs higher tertiles. CONCLUSION: Our data suggest that post-stroke rehabilitation profiles could be identified using routine assessment tools and showed differential recovery. If confirmed, these findings might help to develop tailored interventions to optimize recovery of older stroke patients.

The influence of an intermediate care hospital on health care utilization among elderly patients--a retrospective comparative cohort study.

BACKGROUND: An intermediate care hospital (ICH) was established in a municipality in Central Norway in 2007 to improve the coordination of services and follow-up among elderly and chronically ill patients after hospital discharge. The aim of this study was to compare health care utilization by elderly patients in a municipality with an ICH to that of elderly patients in a municipality without an ICH. METHODS: This study was a retrospective comparative cohort study of all hospitalized patients aged 60 years or older in two municipalities. The data were collected from the national register of hospital use from 2005 to 2012, and from the local general hospital and two primary health care service providers from 2008 to 2012 (approx. 1,250 patients per follow-up year). The data were analyzed using descriptive statistics and analysis of covariance (ANCOVA). RESULTS: The length of hospital stay decreased from the time the ICH was introduced and remained between 10% and 22% lower than the length of hospital stay in the comparative municipality for the next five years. No differences in the number of readmissions or admissions during one year follow-up after the index stay at the local general hospital or changes in primary health care utilization were observed. In the year after hospital discharge, the municipality with an ICH offered more hour-based care to elderly patients living at home (estimated mean = 234 [95% CI 215-252] versus 175 [95% CI 154-196] hours per person and year), while the comparative municipality had a higher utilization of long-term stays in nursing homes (estimated mean = 33.3 [95% CI 29.0-37.7] versus 21.9 [95% CI 18.0-25.7] days per person and year). CONCLUSIONS: This study indicates that the introduction of an ICH rapidly reduces the length of hospital stay without exposing patients to an increased health risk. The ICH appears to operate as an extension of the general hospital, with only a minor impact on the pattern of primary health care utilization.

The impact of the organization of high-dependency care on acute hospital mortality and patient flow for critically ill patients.

RATIONALE: Little is known about the utility of provision of high-dependency care (HDC) that is in a geographically separate location from a primary intensive care unit (ICU). OBJECTIVES: To determine whether the availability of HDC in a geographically separate unit affects patient flow or mortality for critically ill patients. METHODS: Admissions to ICUs in the United Kingdom, from 2009 to 2011, who received Level 3 intensive care in the first 24 hours after admission and subsequently Level 2 HDC. We compared differences in patient flow and outcomes for patients treated in hospitals providing some HDC in a geographically separate unit (dual HDC) with patients treated in hospitals providing all HDC in the same unit as intensive care (integrated HDC) using multilevel mixed effects models. MEASUREMENTS AND MAIN RESULTS: In 192 adult general ICUs, 21.4% provided dual HDC. Acute hospital mortality was no different for patients cared for in ICUs with dual HDC versus those with integrated HDC (adjusted odds ratio, 0.94 [0.86-1.03]; P = 0.16). Dual HDC was associated with a decreased likelihood of a delayed discharge from the primary unit. However, total duration of critical care and the likelihood of discharge from the primary unit at night were increased with dual HDC. CONCLUSIONS: Availability of HDC in a geographically separate unit does not impact acute hospital mortality. The potential benefit of decreasing delays in discharge should be weighed against the increased total duration of critical care and greater likelihood of a transfer out of the primary unit at night.

Depression in older residents with stroke living in long-term care facilities.

BACKGROUND: Stroke is the third leading cause of death in Taiwan. Poststroke older adults are often admitted to long-term care facilities. The impacts of the two concurrent life events of stroke and relocation may increase the risk of depression in stroke survivors. Depression in elderly stroke survivor residents of long-term care facilities has not been studied. PURPOSE: This study explores the factors associated with depression in older residents with stroke living in long-term care facilities. METHODS: A cross-sectional design was used. Twenty-three institutions in southern Taiwan participated in this study, including seven nursing homes, 11 intermediate-care facilities, and five domiciliary-care facilities. Purposive sampling enrolled 111 participants who met the following inclusion criteria: 65 years or older, experienced a stroke that did not cause cognitive defects, and capable of verbal communication. Data were collected using a sociodemographic data questionnaire, Barthel's Index, and the Taiwan Geriatric Depression Scale. RESULTS: Depression was experienced by 41 of the 111 participants (36.9%). Prevalence of depression was 45.7% in nursing homes, 36.2% in intermediate-care facilities, and 22.2% in domiciliary-care facilities. Participants living in nursing homes and intermediate-care facilities and illiterate participants with low Barthel's Index scores showed more depressive symptoms. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: Healthcare providers should conduct depression screening for elderly residents with stroke on admission to long-term care facilities. Regular assessment and monitoring of depressive symptoms, especially in residents with less formal education and limited physical functions, are important in nursing homes and intermediate-care facilities.