Does post acute care reduce the mortality of octogenarian and nonagenarian patients undergoing hip fracture surgery?

BACKGROUND: With the increasing number of elderly individuals worldwide, a greater number of people aged 80 years and older sustain fragility fracture due to osteopenia and osteoporosis. METHODS: This retrospective study included 158 older adults, with a median age of 85 (range: 80-99) years, who sustained hip fragility fracture and who underwent surgery. The patients were divided into two groups, one including patients who joined the post-acute care (PAC) program after surgery and another comprising patients who did not. The mortality, complication, comorbidity, re-fracture, secondary fracture, and readmission rates and functional status (based on the Barthel index score, numerical rating scale score, and Harris Hip Scale score) between the two groups were compared. RESULTS: The patients who presented with fragility hip fracture and who joined the PAC rehabilitation program after the surgery had a lower rate of mortality, readmission rate, fracture (re-fracture and secondary fracture), and complications associated with fragility fracture, such as urinary tract infection, cerebrovascular accident, and pneumonia (acute coronary syndrome, out-of-hospital cardiac arrest, or in-hospital cardiac arrest. CONCLUSIONS: PAC is associated with a lower rate of mortality and complications such as urinary tract infection, bed sore, and pneumonia in octogenarian and nonagenarian patients with hip fragility fracture.

Challenges in Deprescribing among Older Adults in Post-Acute Care Transitions to Home.

OBJECTIVES: Medications with a higher risk of harm or that are unlikely to be beneficial are used by nearly all older patients in home health care (HHC). The objective of this study was to understand stakeholders' perspectives on challenges in deprescribing these medications for post-acute HHC patients. DESIGN: Qualitative individual interviews were conducted with stakeholders involved with post-acute deprescribing. SETTING AND PARTICIPANT: Older HHC patients, HHC nurses, pharmacists, and primary/acute care/post-acute prescribers from 9 US states participated in individual qualitative interviews. MEASURES: Interview questions were focused on the experience, processes, roles, training, workflow, and challenges of deprescribing in hospital-to-home transitions. We used the constant comparison approach to identify and compare findings among patient, prescriber, and pharmacist and HHC nurse stakeholders. RESULTS: We interviewed 9 older patients, 11 HHC nurses, 5 primary care physicians (PCP), 3 pharmacists, 1 hospitalist, and 1 post-acute nurse practitioner. Four challenges were described in post-acute deprescribing for HHC patients. First, PCPs' time constraints, the timing of patient encounters after hospital discharge, and the lack of prioritization of deprescribing make it difficult for PCPs to initiate post-acute deprescribing. Second, patients are often confused about their medications, despite the care team's efforts in educating the patients. Third, communication is challenging between HHC nurses, PCPs, specialists, and hospitalists. Fourth, the roles of HHC nurses and pharmacists are limited in care team collaboration and discussion about post-acute deprescribing. CONCLUSIONS AND IMPLICATIONS: Post-acute deprescribing relies on multiple parties in the care team yet it has challenges. Interventions to align the timing of deprescribing and that of post-acute care visits, prioritize deprescribing and allow clinicians more time to complete related tasks, improve medication education for patients, and ensure effective communication in the care team with synchronized electronic health record systems are needed to advance deprescribing during the transition from hospital to home.

Evaluation of the impact on hospitalization risk of an electronic pill-box to promote therapeutic adherence in post-acute care setting: a pilot study.

Literature review reveals that adherence to prescribed therapy at hospital discharge averages around 50%. The purpose of this study was to evaluate adherence to prescribed therapy assessing the relationship between re-hospitalization rate at 30 days and degree of therapeutic adherence in a sample of elderly patients discharged from an acute geriatric ward using an Electronic Medication Packaging device, MePill. The study population (n = 56) was divided in 3 groups, a counseling group (A), a counseling + MePill device group (B) and a control group (C). Group A had 98.1% adherence to therapy, Group B had 100%, and control group had 90%. Analyzing the rate of hospitalization by type of intervention for Group A and C the hospitalization rate was 21% and 27.7%, respectively, whilst for Group B no patient was hospitalized. Participants in Group A and C had the shorter hospitalization-free survival as compared with subjects in Group B.

A deprescribing intervention from hospital to postacute community care.

Overview of: Vasilevskis EE, Shah AS, Hollingsworth EK, et al. deprescribing medications among older adults from end of hospitalization through postacute care: a Shed-MEDS randomized clinical trial. JAMA Intern Med 2023;183:223-31.

Effects of functional performance and national health insurance cost on length of hospitalization for postacute care in stroke: a retrospective observational study.

BACKGROUND: The postacute care for cerebrovascular disease (PAC-CVD) program was launched in Taiwan nearly a decade ago. However, no clear regulations regarding length of stay (LOS) in the program and extension standards exist. Thus, the allocation of limited medical resources such as hospital beds is a major issue. METHODS: This novel study retrospectively investigated the effects of functional performance and national health insurance (NHI) costs on PAC-CVD LOS. Data for 263 patients with stroke who participated in the PAC-CVD program were analysed. Hierarchical multiple regression was used to estimate the effects of functional performance and NHI costs on LOS at three time points: weeks 3, 6, and 9. RESULTS: At week 3, age, NHI costs, modified Rankin scale score, and Barthel index significantly affected LOS, whereas at week 6, age and NHI costs were significant factors. However, functional performance and NHI costs were not significant factors at week 9. CONCLUSIONS: The study provides crucial insights into the factors affecting LOS in the PAC-CVD program, and the results can enable medical decision-makers and health care teams to develop inpatient rehabilitation plans or provide transfer arrangements tailored to patients. Specifically, this study highlights the importance of early functional recovery and consideration of NHI costs when managing LOS in the PAC-CVD program.

Association of Social Support with Rehabilitation Outcome among Older Adults with Hip Fracture Surgery: A Prospective Cohort Study at Post-Acute Care Facility in Asia.

OBJECTIVES: There is growing interest in the role of social support during the recovery after hip fractures. The research to date has been mainly focused on structural support, with few studies concerned with functional support. This study examined the effects of both functional and structural aspects of social support on rehabilitation outcomes among older adults with hip fracture surgery. DESIGN: Prospective cohort study. SETTING AND PARTICIPANTS: Consecutive older adults (≥60 years) with hip fracture surgery who underwent inpatient rehabilitation in a post-acute care facility in Singapore between January 11, 2021, and October 30, 2021 (n = 112). METHODS: We administered the Medical Outcome Study-Social Support Survey (MOS-SSS) to assess perceived functional support of patients and used living arrangement as an indicator for structural support. Participants were followed up over the inpatient stay at the post-acute care facility until discharge; thereafter, rehabilitation efficiency (REy) and rehabilitation effectiveness (REs) were evaluated. Multiple linear regressions were performed to examine the associations of MOS-SSS score and living arrangement with REy and REs, respectively, adjusting for age, gender, ethnicity, comorbidity, body mass index, prefracture function, type of fracture, and length of stay. RESULTS: Perceived functional support had positive associations with rehabilitation outcomes. A 1-unit increase in MOS-SSS total score was associated with 0.15 units (95% CI 0.03-0.3, P = .029) greater gain in physical function after a typical 1-month stay, and 0.21 units (95% CI 0.01-0.41, P = .040) higher achievement in potential functional improvement upon discharge. In contrast, no association was observed between structural support and rehabilitation outcomes. CONCLUSIONS AND IMPLICATIONS: Perceived functional support may significantly impact the recovery of older adults with hip fracture during the inpatient rehabilitation process, independent of structural support. Our findings suggest the potential of incorporating interventions enhancing perceived functional support of patients into the post-acute care model for hip fracture.

Post-Acute Care Outcomes of Cancer Patients <65 Reveal Disparities in Care Near the End of Life.

Background: Post-acute care outcomes for patients with cancer <65 with multiple payers are largely unknown. Objective: Describe the population and outcomes of younger adults discharged to skilled nursing facility (SNF) and those discharged home or with home health care six months following hospitalization. Design: Descriptive cohort analysis. Setting/Subjects: Using a linkage between the Colorado All Payers Claims Database and the Colorado Central Cancer Registry, we studied patients <65 with stage III or IV advanced cancer between 2012 and 2017. Measurements: Receipt of cancer treatment, 30-day readmission, death, and hospice use. Groups of interest were compared by patient demographics and disease characteristics using chi-square tests. Logistic regression was used to describe unadjusted and adjusted outcome rates among discharge setting. Kaplan-Meier method was used to estimate survival by discharge destination. Results: Three percent of patients were discharged to SNF, 79.0% to home, and 18.0% to home health care. SNF discharges were less likely to receive cancer treatment. Among decedents, 39.0%, 51.0%, and 58.0% of SNF, home, and home health care discharges received hospice, respectively. Patients with Medicaid were more likely to be discharged to an SNF. Black/Hispanic patients were more likely to have Medicaid and received less radiation and hospice care, irrespective of discharge location. Those who were discharged to SNF were more likely to receive radiation compared to White patients. Conclusions: Younger patients with cancer discharged to SNF were unlikely to receive cancer treatment and hospice care before death. Racial disparities exist in cancer treatment receipt and hospice use warranting further investigation.

Deprescribing Medications Among Older Adults From End of Hospitalization Through Postacute Care: A Shed-MEDS Randomized Clinical Trial.

Importance: Deprescribing is a promising approach to addressing the burden of polypharmacy. Few studies have initiated comprehensive deprescribing in the hospital setting among older patients requiring ongoing care in a postacute care (PAC) facility. Objective: To evaluate the efficacy of a patient-centered deprescribing intervention among hospitalized older adults transitioning or being discharged to a PAC facility. Design, Setting, and Participants: This randomized clinical trial of the Shed-MEDS (Best Possible Medication History, Evaluate, Deprescribing Recommendations, and Synthesis) deprescribing intervention was conducted between March 2016 and October 2020. Patients who were admitted to an academic medical center and discharged to 1 of 22 PAC facilities affiliated with the medical center were recruited. Patients who were 50 years or older and had 5 or more prehospital medications were enrolled and randomized 1:1 to the intervention group or control group. Patients who were non-English speaking, were unhoused, were long-stay residents of nursing homes, or had less than 6 months of life expectancy were excluded. An intention-to-treat approach was used. Interventions: The intervention group received the Shed-MEDS intervention, which consisted of a pharmacist- or nurse practitioner-led comprehensive medication review, patient or surrogate-approved deprescribing recommendations, and deprescribing actions that were initiated in the hospital and continued throughout the PAC facility stay. The control group received usual care at the hospital and PAC facility. Main Outcomes and Measures: The primary outcome was the total medication count at hospital discharge and PAC facility discharge, with follow-up assessments during the 90-day period after PAC facility discharge. Secondary outcomes included the total number of potentially inappropriate medications at each time point, the Drug Burden Index, and adverse events. Results: A total of 372 participants (mean [SD] age, 76.2 [10.7] years; 229 females [62%]) were randomized to the intervention or control groups. Of these participants, 284 were included in the intention-to-treat analysis (142 in the intervention group and 142 in the control group). Overall, there was a statistically significant treatment effect, with patients in the intervention group taking a mean of 14% fewer medications at PAC facility discharge (mean ratio, 0.86; 95% CI, 0.80-0.93; P < .001) and 15% fewer medications at the 90-day follow-up (mean ratio, 0.85; 95% CI, 0.78-0.92; P < .001) compared with the control group. The intervention additionally reduced patient exposure to potentially inappropriate medications and Drug Burden Index. Adverse drug event rates were similar between the intervention and control groups (hazard ratio, 0.83; 95% CI, 0.52-1.30). Conclusions and Relevance: Results of this trial showed that the Shed-MEDS patient-centered deprescribing intervention was safe and effective in reducing the total medication burden at PAC facility discharge and 90 days after discharge. Future studies are needed to examine the effect of this intervention on patient-reported and long-term clinical outcomes. Trial Registration: ClinicalTrials.gov Identifier: NCT02979353.

Post-acute Care Needs and Benefits of Inpatient Rehabilitation Care for the Oncology Patient.

PURPOSE OF REVIEW: This study aims to assess recent literature published on the post-acute care needs of cancer patients, specifically focusing on the acute inpatient rehabilitation setting. RECENT FINDINGS: The neurologic cancer population appears to be the most studied oncologic population in acute inpatient rehabilitation studies within the past 5 years. This finding is consistent with prior findings from the past several decades. Recent trends in inpatient cancer rehabilitation note a population with lower admission functional status and shorter lengths of stay compared to prior studies. Despite these findings, the percentage discharged to the community remains high. With new treatments yielding improved survival, cancer patients may live longer and risk accumulating more functional impairments. Physicians involved in their care must understand post-acute care needs and work in a multidisciplinary group to best determine post-acute disposition. This decision remains very individualized and should consider both oncologic and functional needs.

[Trauma rehabilitation : Implementation and challenges]. / Traumarehabilitation : Implementation und Herausforderungen.

The current state of posttraumatic rehabilitation in Germany is on the one hand shaped by the efforts of the primary care providers in the acute setting to transfer patients as soon as possible to rehabilitation in accordance with the requirement for a continuous chain of rehabilitation. On the other hand, there are still important treatment gaps due to a lack of options, specialized structures and financing. This has the consequence that severely injured patients sometimes experience substantial difficulties, setbacks and delays on their way back to social participation. This article presents the various phases of rehabilitation and the existing challenges in order to guarantee the universally acknowledged demand for a continuous rehabilitation chain. Reference is made to the missing structures and simultaneously to the necessary continuity of the processes, the quality assurance and the financial prerequisites for new forms of care. This is exemplified by how the continuum of posttraumatic rehabilitation of the German statutory accident insurance with the successful reintegration of trauma victims in work and social life could be a model for insured persons of the statutory health insurance and the German pension fund. The scientific societies of trauma surgery and rehabilitation medicine also promote the model of a differentiated trauma rehabilitation and sustain the idea of a trauma rehabilitation network to increase the chances of the severely injured for the best possible quality of life and social participation.

Postacute Care Utilization and Episode of Care Payments Following Common Elective Operations.

OBJECTIVE: To describe PAC utilization and associated payments for patients undergoing common elective procedures. SUMMARY OF BACKGROUND DATA: Utilization and costs of PAC are well described for benchmarked conditions and operations but remain understudied for common elective procedures. METHODS: Cross-sectional study of adult patients in a statewide administrative claims database undergoing elective cholecystectomy, ventral or incisional hernia repair (VIHR), and groin hernia repair from 2012 to 2019. We used multivariable logistic regression to estimate the odds of PAC utilization, and multivariable linear regression to determine the association of 90-day episode of care payments and PAC utilization. RESULTS: Among 34,717 patients undergoing elective cholecystectomy, 0.7% utilized PAC resulting in significantly higher payments ($19,047 vs $7830, P < 0.001). Among 29,826 patients undergoing VIHR, 1.7% utilized PAC resulting in significantly higher payments ($19,766 vs $9439, P < 0.001). Among 37,006 patients undergoing groin hernia repair, 0.3% utilized PAC services resulting in significantly higher payments ($14,886 vs $8062, P < 0.001). We found both modifiable and non-modifiable risk factors associated with PAC utilization. Morbid obesity was associated with PAC utilization following VIHR [odds ratio (OR) 1.61, 95% confidence interval (CI) 1.29-2.02, P < 0.001]. Male sex was associated with lower odds of PAC utilization for VIHR (OR 0.43, 95% CI 0.35-0.51, P < 0.001) and groin hernia repair (OR 0.62, 95% CI 0.39-0.98, P = 0.039). CONCLUSIONS: We found both modifiable (eg, obesity) and nonmodifiable (eg, female sex) patient factors that were associated with PAC. Optimizing patients to reduce PAC utilization requires an understanding of patient risk factors and systems and processes to address these factors.

Development and internal validation of predictive models to assess risk of post-acute care facility discharge in adults undergoing multi-level instrumented fusions for lumbar degenerative pathology and spinal deformity.

PURPOSE: To develop a model for factors predictive of Post-Acute Care Facility (PACF) discharge in adult patients undergoing elective multi-level (≥ 3 segments) lumbar/thoracolumbar spinal instrumented fusions. METHODS: The State Inpatient Databases acquired from the Healthcare Cost and Utilization Project from 2005 to 2013 were queried for adult patients who underwent elective multi-level thoracolumbar fusions for spinal deformity. Outcome variables were classified as discharge to home or PACF. Predictive variables included demographic, pre-operative, and operative factors. Univariate and multivariate logistic regression analyses informed development of a logistic regression-based predictive model using seven selected variables. Performance metrics included area under the curve (AUC), sensitivity, and specificity. RESULTS: Included for analysis were 8866 patients. The logistic model including significant variables from multivariate analysis yielded an AUC of 0.75. Stepwise logistic regression was used to simplify the model and assess number of variables needed to reach peak AUC, which included seven selected predictors (insurance, interspaces fused, gender, age, surgical region, CCI, and revision surgery) and had an AUC of 0.74. Model cut-off for predictive PACF discharge was 0.41, yielding a sensitivity of 75% and specificity of 59%. CONCLUSIONS: The seven variables associated significantly with PACF discharge (age > 60, female gender, non-private insurance, primary operations, instrumented fusion involving 8+ interspaces, thoracolumbar region, and higher CCI scores) may aid in identification of adults at risk for discharge to a PACF following elective multi-level lumbar/thoracolumbar spinal fusions for spinal deformity. This may in turn inform discharge planning and expectation management.

Intravascular Laser Irradiation of Blood Improves Functional Independence in Subacute Post-Stroke Patients: A Retrospective Observational Study from a Post-Stroke Acute Care Center in Taiwan.

Objective: To investigate the effect of intravascular laser irradiation of blood (ILIB) in patients with post-stroke disability. Background: Helium-neon intravascular laser at a wavelength of 632.8 nm has been applied in post-stroke rehabilitation for many years in Taiwan. Data were collected from our practice to validate its effectiveness. Materials and methods: This was a single-center, retrospective, observational study. Data from 34 patients with first-episode ischemic stroke who participated in the post-acute care program and had an initial modified Rankin Scale (mRS) score of 4 between July 2018 and June 2021 were retrospectively reviewed. Twelve patients who received conventional rehabilitation plus ILIB were in the ILIB group. Twenty-two patients who received conventional rehabilitation only were in the control group. Assessments, including the mRS, Barthel Index (BI), Berg Balance Scale (BBS), 6-min walk test (6MWT), and Fugl-Meyer Assessment of the upper extremity (FMA-UE), were performed to evaluate any post-treatment improvement. Results: Patients who received ILIB had significantly superior mRS scores than those who received only conventional rehabilitation (p = 0.028). Patients in the ILIB group experienced more improvements in the BI, 6MWT, and FMA-UE; however, these were nonsignificant. In addition, the control group experienced a greater improvement in the BBS than the ILIB group. Further studies are required to elucidate the mechanism of action of ILIB therapy fully. There was no major adverse event reported in patients receiving ILIB therapy. Conclusions: ILIB improved independence in post-stroke patients, suggesting that ILIB is a promising treatment for facilitating post-stroke recovery.

Activity Measure for Post-acute Care Mobility Scoring System: Comparison of Nursing and Physical Therapy Evaluation for Primary Hip and Knee Arthroplasty Patients.

BACKGROUND: Optimizing resource utilization after total joint arthroplasty (TJA) has become increasingly vital. The Activity Measure for Post-acute Care (AM-PAC) "6-clicks" scoring system is a validated, physical therapist (PT)-administered metric of patient basic mobility and predicts discharge disposition. This study aimed to determine whether the use of AM-PAC scoring by nurses in the postoperative period could (1) substitute for AM-PAC scoring by therapists and (2) predict 90-day outcomes in TJA patients. METHODS: We retrospectively reviewed all primary TJAs conducted by two surgeons at a single institution from 2019 to 2021. Patients underwent postoperative AM-PAC evaluation by nursing and physical therapy within 24 hours of surgery, and specific timing of nursing and PT scores was determined. Inter-rater reliability between therapy and nursing scores was analyzed. Multiple regression was used to determine the association between AM-PAC scores and readmissions, complications, length of stay, and nonhome discharge. RESULTS: In total, 1,119 patients were included. Agreement testing between therapy and nursing scores was weak for all six AM-PAC components, with a Spearman correlation of 0.437. Nursing scores were typically conducted earlier than therapist scores (204.0 ± 249.9 minutes versus 523.5 ± 449.4 minutes; P < 0.001). Therapy and nursing scores were not notable predictors for 90-day complications or readmissions. However, higher therapy and nursing scores were predictors of less than 2-day hospitalization (odds ratio [OR] 0.63, P < 0.001; OR 0.88, P < 0.001) and fewer nonhome discharges (OR 0.62, P < 0.001; OR 0.84, P < 0.001). CONCLUSION: Although nursing-driven mobility assessments could potentially improve efficiency of patient discharge and control costs, nursing AM-PAC scoring did not serve as an appropriate substitute for PT scoring in patients undergoing primary total hip and knee arthroplasty at our institution.

ACO Participation Associated With Decreased Spending For Medicare Beneficiaries With Serious Mental Illness.

Serious mental illness (SMI) is a major source of suffering among Medicare beneficiaries. To date, limited evidence exists evaluating whether Medicare accountable care organizations (ACOs) are associated with decreased spending among people with SMI. Using national Medicare data from the period 2009-17, we performed difference-in-differences analyses evaluating changes in spending and use associated with enrollment in the Medicare Shared Savings Program (MSSP) among beneficiaries with SMI. After five years, participation in MSSP ACOs was associated with small savings for beneficiaries with SMI (-$233 per person per year) in total health care spending, primarily related to savings from chronic medical conditions (excluding mental health; -$227 per person per year) and not from savings related to mental health services (-$6 per person per year). Savings were driven by reductions in acute and postacute care for medical conditions. Further work is needed to ensure that Medicare ACOs invest in strategies to reduce potentially unnecessary care related to mental health disorders and to improve health outcomes.

Medicare Accountable Care Organizations: Post-acute Care Use and Post-surgical Outcomes in Urologic Cancer Surgery.

OBJECTIVE: To evaluate association between Medicare accountable care organizations (ACOs) participation of hospitals on post-acute care (PAC) use and spending, and post-surgical outcomes in Medicare beneficiaries undergoing urologic cancer surgeries. Despite increasing prevalence of urologic cancer and surgical care contributing to a large proportion of total health care costs, and recent Medicare payment reforms such as accountable care organizations, the role of ACOs in urologic cancer care has been unexplored. METHODS: We conducted a longitudinal analysis of 2011-2017 Medicare claims data to compare post-surgical outcomes between Medicare ACO and non-ACO patients before and after implementation of Medicare shared savings program (MSSP). Our outcomes of interest were Post-acute care (PAC) use (overall, institutional, and home health), Skilled Nursing Facility (SNF) length of stay and Medicare spending for SNF patients, 30-day and 90-day unplanned readmissions and complications after index procedure. RESULTS: Study sample included a total of 334,514 Medicare patients undergoing bladder, prostate, kidney cancer surgeries at 524 Medicare ACO and 2066 non-ACO hospitals. For bladder cancer surgery, Medicare ACO participation was associated with significantly reduced overall post-acute care use, but not with changes in readmission or complication rate. For prostate cancer and kidney cancer surgery, we found no significant association between hospital participation in Medicare ACOs and PAC use or post-surgical outcomes. CONCLUSION: Hospital participation in MSSP ACOs leads to lower post-acute care use without compromising patient outcomes for Medicare beneficiaries undergoing bladder cancer surgery. Future research is needed to understand longer-term impact of ACO participation on urologic cancer surgery outcomes.

Post-Acute Care Outcomes and Functional Status Changes of Adults with New Cancer Discharged to Skilled Nursing Facilities.

OBJECTIVE: Older hospitalized adults with an existing diagnosis of cancer rarely receive cancer treatment after discharge to a skilled nursing facility (SNF). It is unclear to what degree these outcomes may be driven by cumulative effects of previous cancer treatment and their complications vs an absolute functional threshold from which it is not possible to return. We sought to understand post-acute care outcomes of adults newly diagnosed with cancer and explore functional improvement during their SNF stay. DESIGN: Retrospective cohort study, 2011-2013. SETTING AND PARTICIPANTS: Surveillance, Epidemiology, and End Results - Medicare database of patients with new stage II-IV colorectal, pancreatic, bladder, or lung cancer discharged to SNF. METHODS: Primary outcome was time to death after hospital discharge. Covariates include cancer treatment receipt and hospice use. A Minimum Data Set (MDS)-Activities of Daily Living (ADL) score was calculated to measure changes in ADLs during SNF stay. Patient groups of interest were compared descriptively using means and standard deviations for continuous variables and frequencies and percentages for categorical variables. Logistic regression was used to compare patient groups. RESULTS: A total of 6791 cases were identified. Forty-six percent of patients did not receive treatment or hospice, 25.0% received no treatment but received hospice, 20.8% received treatment but no hospice, and 8.5% received both treatment and hospice. Only 43% of decedents received hospice. Patients who received treatment but not hospice had the best survival. There were limited improvements in MDS-ADL scores in the subset of patients for whom we have complete data. Those with greater functional improvement had improved survival. CONCLUSIONS AND IMPLICATIONS: The majority of patients did not receive future cancer treatment or hospice care prior to death. There was limited improvement in MDS-ADL scores raising concern this population might not benefit from the rehabilitative intent of SNFs.

Standardized assessment of depression symptoms in post-acute care: A screening threshold approach.

BACKGROUND: Depression symptoms have impacts on quality of life, rehabilitation and treatment adherence, and resource utilization among patients in post-acute care (PAC) settings. The PHQ-2 and PHQ-9 are instruments for the assessment of depression, previously used in PAC settings, that have tradeoffs in terms of measurement depth versus respondent/assessor burden. Therefore, the present study tested a gateway version of the protocol (PHQ-2 to 9). METHODS: In 143 PAC settings in 14 U.S. markets across 10 states from November 2017 to August 2018, facility and research nurses administered the PHQ-2 to communicative patients (n = 3010). Nurses administered the full PHQ-9 if the patient screened positive for either of the two cardinal symptoms assessed by the PHQ-2 (depressed mood and anhedonia). We assessed the prevalence and frequency of depression symptoms using the PHQ-2 to 9, associations between depression screening results and patient characteristics and clinical conditions, and feasibility indicators. RESULTS: More than 1 in 4 patients (28%) screened positive on the PHQ-2. Only 6% of those completing the full PHQ-9 had a score indicating "minimal" severity. The average score (M = 11.9) met the threshold for moderate depression. Positive PHQ-2 screening was associated with age, female gender, disposition at discharge, septicemia/severe sepsis, and dependence for ADLs of toileting and lying to sitting mobility. Age was also associated with full PHQ-9 scores; patients ages 45-64 had the highest mean score. Length of stay was not associated with PHQ-2 screening results or full PHQ-2 to 9 scores. Missing data were minimal (<2.4%). The average time to complete was 2.3 min. Interrater reliability and percent agreement were excellent. CONCLUSIONS: These findings suggest the feasibility of a gateway scoring approach to standardized assessment of depression symptoms among PAC patients, and that depression symptoms are relatively common among this inpatient population.

Older Patient and Surrogate Attitudes Toward Deprescribing During the Transition From Acute to Post-Acute Care.

Attitudes toward deprescribing among hospitalized older patients transitioning to post-acute care in the United States are less known. This study describes older patients' and their surrogate's attitudes using all items of the Patient Attitudes Toward Deprescribing (PATD) questionnaire and compares perceived pill burden to the actual count of total daily pills and potentially inappropriate medications (PIMs). Overall, 93% of participants were willing to deprescribe if their physician agreed. Compared to patients, surrogates had 64% reduced odds (95% CI: 0.18-0.74) of believing that all of the care recipient's medications were necessary and 61% reduced odds (95% CI: 0.17-0.88) of attributing cost as a factor in deprescribing. Perceptions of medication burden were associated with patients' total daily pills (median 16) and PIMS (median 7), yet 61% agreed that all their medicines were necessary. Patients and surrogates typically express a willingness to deprescribe but have differing perceptions of medication appropriateness.