Successful Discharge to Community From Home Health Less Likely for People in Late Stages of Dementia.

BACKGROUND AND PURPOSE: Several studies have established the efficacy of home health in meeting the health care needs of people with Alzheimer disease and related dementias (ADRD) and helping them to remain at home. However, transitioning to the community after discharge from home health presents challenges to patient safety and quality of life. The severity of an individual's functional impairments, cognitive limitations, and behavioral and psychological symptoms may compound these challenges. The purpose of this study was to examine the association between dementia severity and successful discharge to community (DTC) from home health. METHODS: This was a retrospective study of 142 376 Medicare beneficiaries with ADRD. Successful DTC was defined as having no unplanned hospitalization or death within 30 days of DTC from home health. Successful DTC rates were calculated, and multilevel logistic regression was used to estimate the relative risk (RR) of successful DTC, by dementia severity category, adjusted for patient and clinical characteristics. Six dementia severity categories were identified using a crosswalk between items on the Outcome and Assessment Information Set and the Functional Assessment Staging Tool. RESULTS AND DISCUSSION: Successful DTC occurred in 71.2% of beneficiaries. Beneficiaries in the 2 most severe dementia categories had significantly lower risk of successful DTC (category 6: RR = 0.90, 95% CI = 0.889-0.910; category 7: RR = 0.737, 95% CI = 0.704-0.770) than those in the least severe dementia category. The RR of successful DTC for people with ADRD decreased as the level of independence with oral medication management decreased and when there was an overall greater need for caregiver assistance. CONCLUSIONS: Patient status at the time of admission to home health is associated with outcomes after discharge from home health. Early identification of people in advanced stages of ADRD provides an opportunity to implement strategies to facilitate successful DTC while people are still receiving home care services. The severity of ADRD and availability of caregiver assistance should be key considerations in planning for successful DTC for people with ADRD.

Achieving Functional Goals During a Skilled Nursing Facility Stay: A National Study of Medicare Beneficiaries.

OBJECTIVES: The aims of the study are to describe the frequency that functional goals are documented on the Minimum Data Set and to identify resident characteristics associated with meeting or exceeding discharge goals. METHODS: We selected Medicare fee-for-service beneficiaries admitted to a skilled nursing facility within 3 days of hospital discharge from October 1, 2018, to December 31, 2019 ( N = 1,228,913). The admission Minimum Data Set was used to describe the discharge goal scores for seven self-care and 16 mobility items. We used the eight self-care and mobility items originally included in a publicly reported quality measure to calculate total scores for discharge goals, admission performance, and discharge performance ( n = 371,801). RESULTS: For all self-care items, more than 70% of residents had a goal score of 1-6 points documented on the admission Minimum Data Set. Chair/bed-to-chair transfer had the highest percentage of residents with a score of 1-6 points (77.1%) and walking up/down 12 steps had the lowest (23.2%). Approximately 44% of residents had a discharge performance score that met or exceeded their goal score. Older age, urinary incontinence, and cognitive impairment had the lowest odds of meeting or exceeding discharge goals. CONCLUSIONS: Assessing a resident's functional goals is important to providing patient-centered care. This information may help skilled nursing facilities determine whether a resident has made meaningful functional improvements.

Financial Performance is Associated With PPE Shortages in Chain-Affiliated Nursing Homes During the COVID-19 Pandemic: A Longitudinal Study.

Many nursing homes operated at thin profit margins prior to the COVID-19 pandemic. This study examines the role of nursing homes' financial performance and chain affiliation in shortages of personal protection equipment (PPE) during the first year of the COVID-19 pandemic. We constructed a longitudinal file of 79 868 nursing home-week observations from 10 872 unique facilities. We found that a positive profit margin was associated with a 21.0% lower probability of reporting PPE shortages in chain-affiliated nursing homes, but not in non-chain nursing homes. Having adequate financial resources may help nursing homes address future emergencies, especially those affiliated with a multi-facility chain.

Addressing non-response data for standardized post-acute functional items.

BACKGROUND: The post-acute patient standardized functional items (Section GG) include non-response options such as refuse, not attempt and not applicable. We examined non-response patterns and compared four methods to address non-response functional data in Section GG at nation-wide inpatient rehabilitation facilities (IRF). METHODS: We characterized non-response patterns using 100% Medicare 2018 data. We applied four methods to generate imputed values for each non-response functional item of each patient: Monte Carlo Markov Chains multiple imputations (MCMC), Fully Conditional Specification multiple imputations (FCS), Pattern-mixture model (PMM) multiple imputations and the Centers for Medicare and Medicaid Services (CMS) approach. We compared changes of Spearman correlations and weighted kappa between Section GG and the site-specific functional items across impairments before and after applying four methods. RESULTS: One hundred fifty-nine thousand six hundred ninety-one Medicare fee-for-services beneficiaries admitted to IRFs with stroke, brain dysfunction, neurologic condition, orthopedic disorders, and debility. At discharge, 3.9% (self-care) and 61.6% (mobility) of IRF patients had at least one non-response answer in Section GG. Patients tended to have non-response data due to refused at discharge than at admission. Patients with non-response data tended to have worse function, especially in mobility; also improved less functionally compared to patients without non-response data. Overall, patients coded as 'refused' were more functionally independent in self-care and patients coded as 'not applicable' were more functionally independent in transfer and mobility, compared to other non-response answers. Four methods showed similar changes in correlations and agreements between Section GG and the site-specific functional items, but variations exist across impairments between multiple imputations and the CMS approach. CONCLUSIONS: The different reasons for non-response answers are correlated with varied functional status. The high proportion of patients with non-response data for mobility items raised a concern of biased IRF quality reporting. Our findings have potential implications for improving patient care, outcomes, quality reporting, and payment across post-acute settings.

Subtyping Social Determinants of Health in All of Us: Network Analysis and Visualization Approach.

Background: Social determinants of health (SDoH), such as financial resources and housing stability, account for between 30-55% of people's health outcomes. While many studies have identified strong associations among specific SDoH and health outcomes, most people experience multiple SDoH that impact their daily lives. Analysis of this complexity requires the integration of personal, clinical, social, and environmental information from a large cohort of individuals that have been traditionally underrepresented in research, which is only recently being made available through the All of Us research program. However, little is known about the range and response of SDoH in All of Us, and how they co-occur to form subtypes, which are critical for designing targeted interventions. Objective: To address two research questions: (1) What is the range and response to survey questions related to SDoH in the All of Us dataset? (2) How do SDoH co-occur to form subtypes, and what are their risk for adverse health outcomes? Methods: For Question-1, an expert panel analyzed the range of SDoH questions across the surveys with respect to the 5 domains in Healthy People 2030 (HP-30), and analyzed their responses across the full All of Us data (n=372,397, V6). For Question-2, we used the following steps: (1) due to the missingness across the surveys, selected all participants with valid and complete SDoH data, and used inverse probability weighting to adjust their imbalance in demographics compared to the full data; (2) an expert panel grouped the SDoH questions into SDoH factors for enabling a more consistent granularity; (3) used bipartite modularity maximization to identify SDoH biclusters, their significance, and their replicability; (4) measured the association of each bicluster to three outcomes (depression, delayed medical care, emergency room visits in the last year) using multiple data types (surveys, electronic health records, and zip codes mapped to Medicaid expansion states); and (5) the expert panel inferred the subtype labels, potential mechanisms that precipitate adverse health outcomes, and interventions to prevent them. Results: For Question-1, we identified 110 SDoH questions across 4 surveys, which covered all 5 domains in HP-30. However, the results also revealed a large degree of missingness in survey responses (1.76%-84.56%), with later surveys having significantly fewer responses compared to earlier ones, and significant differences in race, ethnicity, and age of participants of those that completed the surveys with SDoH questions, compared to those in the full All of Us dataset. Furthermore, as the SDoH questions varied in granularity, they were categorized by an expert panel into 18 SDoH factors. For Question-2, the subtype analysis (n=12,913, d=18) identified 4 biclusters with significant biclusteredness (Q=0.13, random-Q=0.11, z=7.5, P<0.001), and significant replication (Real-RI=0.88, Random-RI=0.62, P<.001). Furthermore, there were statistically significant associations between specific subtypes and the outcomes, and with Medicaid expansion, each with meaningful interpretations and potential targeted interventions. For example, the subtype Socioeconomic Barriers included the SDoH factors not employed, food insecurity, housing insecurity, low income, low literacy, and low educational attainment, and had a significantly higher odds ratio (OR=4.2, CI=3.5-5.1, P-corr<.001) for depression, when compared to the subtype Sociocultural Barriers. Individuals that match this subtype profile could be screened early for depression and referred to social services for addressing combinations of SDoH such as housing insecurity and low income. Finally, the identified subtypes spanned one or more HP-30 domains revealing the difference between the current knowledge-based SDoH domains, and the data-driven subtypes. Conclusions: The results revealed that the SDoH subtypes not only had statistically significant clustering and replicability, but also had significant associations with critical adverse health outcomes, which had translational implications for designing targeted SDoH interventions, decision-support systems to alert clinicians of potential risks, and for public policies. Furthermore, these SDoH subtypes spanned multiple SDoH domains defined by HP-30 revealing the complexity of SDoH in the real-world, and aligning with influential SDoH conceptual models such as by Dahlgren-Whitehead. However, the high-degree of missingness warrants repeating the analysis as the data becomes more complete. Consequently we designed our machine learning code to be generalizable and scalable, and made it available on the All of Us workbench, which can be used to periodically rerun the analysis as the dataset grows for analyzing subtypes related to SDoH, and beyond.

Association Between Cognitive Impairment and Repeat Fractures in Medicare Beneficiaries Recently Hospitalized for Hip Fracture.

BACKGROUND: Repeat fractures contribute substantially to fracture incidents in older adults. We examined the association between cognitive impairment and re-fractures during the first 90 days after older adults with hip fractures were discharged home from a skilled nursing facility rehabilitation short stay. METHODS: Multilevel binary logistic regression was used to analyze 100% of U.S. national postacute-care fee-for-service Medicare beneficiaries who had a hospital admission for hip fracture from January 1, 2018, to July 31, 2018; were admitted for a skilled nursing facility stay within 30 days of hospital discharge; and were discharged to the community after a short stay. Our primary outcome was rehospitalization for any re-fractures within 90 days of skilled nursing facility discharge. Cognitive status assessed at skilled nursing facility admission or before discharge was classified as either intact or having mild or moderate/severe impairment. RESULTS: In 29 558 beneficiaries with hip fracture, odds of any re-fracture were higher in those with minor (odds ratio: 1.48; 95% confidence interval: 1.19-1.85; p < .01) and moderate/major cognitive impairment (odds ratio: 1.42; 95% confidence interval: 1.07-1.89; p = .0149) than in those classified as intact. CONCLUSIONS: Beneficiaries with cognitive impairment were more likely than their counterparts with no cognitive impairment to experience re-fractures. Community-dwelling older adults with minor cognitive impairment may experience a higher likelihood of experiencing a repeat fracture leading to rehospitalization.

Hospitalizations and Emergency Room Admissions by Mexican American Older Adults with and without Dementia and Caregiver Mental Health.

BACKGROUND: Evidence from predominately non-Hispanic White populations indicates that emergency room (ER) admissions and hospitalizations by older adults with and without dementia are associated with caregiver stress and depressive symptoms. These results may not generalize to Hispanic populations because of cultural differences in caregiving roles, responsibilities, and perspectives about care burden. OBJECTIVE: Investigate the association between ER admissions and hospitalizations by Mexican American older adults with and without dementia and symptoms of depression and stress among family caregivers. METHODS: Data came from the 2010/11 wave of the Hispanic Established Populations for the Epidemiologic Study of the Elderly and Medicare claims files. The final sample included 326 older adults and their caregivers. Negative binomial regression was used to model the association between hospitalizations and ER admissions by older adults in the previous two years and caregivers' depressive symptoms and stress in 2010/11. RESULTS: The number of older adult ER admissions and hospitalizations was not associated with caregiver depressive symptoms. Two or more ER admissions (incident rate ratio [IRR] = 1.26, 95% CI = 1.05-1.51) and two or more hospitalizations (IRR = 1.32, 95% CI = 1.07-1.61) were associated with significantly higher caregiver stress. Additionally, ER admissions and hospitalizations for a circulatory disease or injury and poisoning were associated with significantly higher caregiver stress. These associations were not modified by the care recipient's dementia status. CONCLUSION: Hospitalizations and ER admissions by older Mexican Americans were associated with greater caregiver stress but not depressive symptoms. These associations were similar for caregivers to older adults with and without dementia.

Characteristics Associated With Mexican-American Hospice Use: Retrospective Cohort Study Using the Hispanic Established Population for the Epidemiologic Study of the Elderly (H-EPESE).

BACKGROUND: Hospice use is lower among ethnic/racial minorities in the United States, though little is known about trends, associated factors and duration of hospice use by Mexican-Americans. AIM: The purpose of this study is to examine Mexican-American characteristics associated with hospice stay, both ≤ and > 7 days. DESIGN: This retrospective cohort study used data from the Hispanic Established Population for the Epidemiological Study of the Elderly (H-EPESE) and the Centers for Medicare and Medicaid Services. Multivariate logistic regression models were used to estimate the ORs and 95% CIs for hospice stay among Mexican-Americans, both ≤ and > 7 days. SETTING AND PARTICIPANTS: The first cohort (N = 970) includes H-EPESE participants who died between 2004 and 2016 who had Medicare parts A and B. The second cohort (N = 403) includes participants who completed the H-EPESE survey within the last 2 years of life. RESULTS: Although hospice use increased among Mexican-Americans between 2004 and 2016 (OR 1.88, 95% CI 1.19-2.97), 38% of participants died within the first week of hospice care. Mexican-Americans in New Mexico and Arizona were 2-4 times more likely to use hospice than those in Texas and Colorado. Dementia was associated with hospice use (OR 1.47, 95% CI 1.11-1.94). Characteristics, like church attendance and living alone, were not associated with hospice use. CONCLUSIONS: The substantial proportion of Mexican-Americans with 7 days or less of hospice use underscores the need for early palliative/hospice intervention to mitigate variation in use.

Association of Dementia Severity and Caregiver Support With Early Discharge From Home Health.

INTRODUCTION: The objective of this study was to examine the relationship between dementia severity and early discharge from home health. METHODS: This was a retrospective study of 100% national Medicare home health da ta files (2016-2017). Multilevel logistic regression was used to study the relationship of dementia severity, caregiver support, and medication assistance with early discharge from home health. RESULTS: The final cohort consisted of 91 302 Medicare beneficiaries with an ADRD diagnosis. A pattern of early discharge rates across dementia severity levels was not demonstrated. The relative risk for early discharge was lower for individuals who needed assistance with medication and for those with unmet caregiver needs. DISCUSSION: The findings of this study do not support the hypothesis that dementia severity contributes to early discharge from home health. Further research is needed to fully understand key factors contributing to early discharge from home health.

The Influence of Prior Functional Status on Self-Care Improvement During a Skilled Nursing Facility Stay.

OBJECTIVES: Older adults' prior health status can influence their recovery after a major illness. We investigated the association between older adults' independence in self-care tasks prior to a skilled nursing facility (SNF) stay and their self-care function at SNF admission, discharge, and the change in self-care function during an SNF stay. DESIGN: Retrospective study of 100% national CMS data files from October 1, 2018, to December 31, 2019. SETTINGS AND PARTICIPANTS: The sample included 616,073 Medicare fee-for-service beneficiaries who were discharged from an SNF between October 1, 2018, and December 31, 2019. METHODS: The admission Minimum Data Set (MDS) was used to determine residents' prior ability (independent, some help, dependent) to complete self-care tasks before the current illness, exacerbation, or injury. Seven self-care tasks from MDS Section GG were used to calculate total scores (range 7-42 points) for self-care at admission, discharge, and the change in self-care between admission and discharge. RESULTS: Most residents (62.0%) were independent, 35.3% needed some help, and 2.64% were dependent in self-care prior to SNF admission. Nearly 25% of residents with urinary incontinence, 28.8% with bowel incontinence, and 31.7% with moderate-severe cognitive impairment were independent in self-care prior to SNF admission compared with approximately 70% of residents without these conditions. Compared with residents who were dependent in self-care prior to SNF admission, those who were independent or needed some help had significantly higher self-care total scores at admission (5.67 vs 4.21 points, respectively) and discharge (6.44 vs 3.82 points, respectively) and exhibited greater improvement in self-care (3.48 vs 1.62 points, respectively). CONCLUSIONS AND IMPLICATIONS: Our findings are evidence that the new MDS item for a resident's independence in self-care tasks before SNF admission is a valid measure of their prior self-care function. This is clinically useful information and should be considered when developing rehabilitation goals.

Racial and ethnic differences in the improvement in daily activities during a nursing home stay.

BACKGROUND: Improving independence in daily activities is an important outcome of postacute nursing home care. We investigated racial and ethnic differences in the improvement in activities of daily living (ADL) during a skilled nursing facility (SNF) stay among Medicare fee-for-service beneficiaries with a hip fracture, joint replacement, or stroke. METHODS: This was a retrospective study of Medicare beneficiaries admitted to a SNF between 01/01/2013 and 9/30/2015. The final sample included 428,788 beneficiaries admitted to a SNF within 3 days of hospital discharge for a hip fracture (n = 118,790), joint replacement (n = 245,845), or stroke (n = 64,153). Data from residents' first and last Minimum Data Set were used to calculate ADL total scores for self-performance in dressing, personal hygiene, toileting, locomotion on the unit, transferring, bed mobility, and eating. Residents were dichotomized according to having had any improvement in the ADL total score. Multivariable logistic regression models that included a random intercept for the facility were used to estimate the adjusted odds ratios for any improvement in ADL function among black and Hispanic residents compared to white residents. RESULTS: A total of 299,931 residents (69.9%) had any improvement in ADL function. Black residents (OR:0.94; 95% CI: 0.91-0.98) but not Hispanic residents (OR: 0.98; 95% CI: 0.94-1.03) had significantly lower odds to have any improvement in ADL function. Analyses stratified by the reason for prior hospitalization indicated that black residents discharged for hip fracture (OR: 0.87; 95% CI: 0.80-0.93) and stroke (OR: 0.87; 95% CI: 0.83-0.93), but not joint replacement (OR: 1.02; 95% CI: 0.97-1.06) had significantly lower odds for any ADL improvement compared to white residents. CONCLUSIONS: Our findings are evidence for racial disparities in the improvement in ADL function during a SNF stay. Future research should investigate systemic factors that may contribute to disparities in the improvement in ADL function during a SNF stay.

Association Between Cognitive Status and Falls With and Without Injury During a Skilled Nursing Facility Short Stay.

OBJECTIVES: To examine the relationship between cognitive status and falls with and without injury among older adults during the first 18 days of a skilled nursing facility (SNF) and determine if this association is mediated by limitations in activities of daily living (ADL) and impaired balance. DESIGN: Cohort study of Medicare fee-for-service beneficiaries admitted to an SNF between October 1, 2016, and September 31, 2017. SETTINGS AND PARTICIPANTS: 815,927 short-stay nursing home residents admitted to an SNF within 3 days of hospital discharge. METHODS: Cognitive status at SNF admission was classified as intact, mild, moderate, or severe impairment. Residents were classified as having no falls, a fall without injury, and a fall with a minor or major injury. We used ordinal logistic regression to model the association between cognitive status and falls adjusting for resident and facility characteristics. A causal mediation analysis was used to test for the mediating effects of ADL limitations and impaired balance on the association between cognitive status and falls with an injury. RESULTS: Mild, moderate, and severe cognitive impairment were associated with 1.72 (95% CI: 1.68-1.75), 2.72 (95% CI: 2.66-2.78), and 2.61 (95% CI: 2.48-2.75) higher odds of being in a higher fall severity category, respectively, compared to being cognitively unimpaired. Greater ADL limitations and impaired balance were significantly associated with falls, but each mediated the association between cognitive status and falls by less than 2%. CONCLUSIONS AND IMPLICATIONS: Older adults with cognitive impairment are more likely to experience a fall during an SNF stay. ADL limitations and impaired balance are risk factors for falls but may not contribute to the increased fall risk for SNF residents with cognitive impairment. Continued research is needed to better understand the risk factors for falls among SNF residents with cognitive impairment.

Effect of Demographic and Health Dynamics on Cognitive Status in Mexico between 2001 and 2015: Evidence from the Mexican Health and Aging Study.

Sources of health disparities such as educational attainment, cardiovascular risk factors, and access to health care affect cognitive impairment among older adults. To examine the extent to which these counteracting changes affect cognitive aging over time among Mexican older adults, we examine how sociodemographic factors, cardiovascular diseases, and their treatment relate to changes in cognitive function of Mexican adults aged 60 and older between 2001 and 2015. Self and proxy respondents were classified as dementia, cognitive impairment no dementia (CIND), and normal cognition. We use logistic regression models to examine the trends in dementia and CIND for men and women aged 60 years or older using pooled national samples of 6822 individuals in 2001 and 10,219 in 2015, and sociodemographic and health variables as covariates. We found higher likelihood of dementia and a lower risk of CIND in 2015 compared to 2001. These results remain after adjusting for sociodemographic factors, cardiovascular diseases, and their treatment. The improvements in educational attainment, treatment of diabetes and hypertension, and better access to health care in 2015 compared to 2001 may not have been enough to counteract the combined effects of aging, rural residence disadvantage, and higher risks of cardiovascular disease among older Mexican adults.

Documentation of Dementia as a Cause of Death Among Mexican-American Decedents Diagnosed with Dementia.

BACKGROUND: Hispanic older adults are a high-risk population for Alzheimer's disease and related dementias (ADRD) but are less likely than non-Hispanic White older adults to have ADRD documented as a cause of death on a death certificate. OBJECTIVE: To investigate characteristics associated with ADRD as a cause of death among Mexican-American decedents diagnosed with ADRD. METHODS: Data came from the Hispanic Established Populations for the Epidemiologic Study of the Elderly, Medicare claims, and National Death Index. RESULTS: The final sample included 853 decedents diagnosed with ADRD of which 242 had ADRD documented as a cause of death. More health comorbidities (OR = 0.40, 95% CI = 0.28-0.58), older age at death (OR = 1.18, 95% CI = 1.03-1.36), and longer ADRD duration (OR = 1.08, 95% CI = 1.03-1.14) were associated with ADRD as a cause of death. In the last year of life, any ER admission without a hospitalization (OR = 0.45, 95% CI = 0.22-0.92), more physician visits (OR = 0.96, 95% CI = 0.93-0.98), and seeing a medical specialist (OR = 0.46, 95% CI = 0.29-0.75) were associated with lower odds for ADRD as a cause of death. In the last 30 days of life, any hospitalization with an ICU stay (OR = 0.55, 95% CI = 0.36-0.82) and ER admission with a hospitalization (OR = 0.67, 95% CI = 0.48-0.94) were associated with lower odds for ADRD as a cause of death. Receiving hospice care in the last 30 days of life was associated with 1.98 (95% CI = 1.37-2.87) higher odds for ADRD as a cause of death. CONCLUSION: Under-documentation of ADRD as a cause of death may reflect an underestimation of resource needs for Mexican-Americans with ADRD.

Social Engagement and Cognitive Function of Older Adults in Mexico and the United States: How Universal Is the Interdependence in Couples?

OBJECTIVES: Increased social engagement in older adults has been linked to positive cognitive outcomes; however, it is unclear if the social engagement of husbands and wives influences their own cognition as well as each other's cognition. Moreover, it is unknown if any such patterns persist in different country contexts. METHODS: Data from the 2001 Mexican Health and Aging Study (MHAS) and the 2000 Health and Retirement Study (HRS) were combined, and comparable samples of married couples without cognitive impairment at baseline were drawn. Follow-up cognition data was obtained from the 2012 MHAS and the 2012 HRS. Structural equation models (SEM) were used to test the actor-partner interdependence model with moderating effect of country on the association of social engagement with cognition. RESULTS: Significant actor effects were observed for wives in both countries. Actor effects for husbands were observed in the United States only. In Mexico, a significant partner effect was observed where wives' social engagement benefited their own cognition as well as their husbands', but not vice versa. Partner effects were not observed in the United States. No moderation effects of country were observed. DISCUSSION: Our results suggest asymmetric patterns of actor-partner interdependence in Mexico, which may be reflective of the more traditional social role of women, and codependence within the couple. On the other hand, our results for the United States, where each spouse had significant actor effects but no partner effects, may suggest more independence within the couple.

Relationship Between Nursing Home Compare Improvement in Function Quality Measure and Physical Recovery After Hip Replacement.

OBJECTIVE: To determine whether patients with a total or partial hip replacement admitted to a skilled nursing facility (SNF) after the improvement in function quality measure was added to Nursing Home Compare in July 2016 have greater physical recovery than patients admitted before July 2016. DESIGN: Pre (January 1, 2015-June 30, 2016) vs post (July 1, 2016-December 31, 2017) design. SETTING: Skilled nursing facilities (n=12,829). PARTICIPANTS: Medicare fee-for-service beneficiaries (N=106,832) discharged from acute hospitals to SNF after hip replacement between January 1, 2015 and December 31, 2017. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The 5- and 14-day minimum data set assessments were used to calculate total scores for the quality measure, self-care, mobility, and balance. We calculated the average adjusted change per 10 days and any improvement between the 5- and 14-day assessments. RESULTS: The average adjusted change per 10 days for the quality measure total score for patients admitted before July 2016 and after July 2016 was 1.00 points (standard error, 0010) and 1.06 points (standard error, 0.010), respectively (P<.01). This was a relative increase of 6.0%. Among patients admitted to a SNF before July 2016, 44.4% (standard error, 0.06) had any improvement in the quality measure total score compared with 45.5% (standard error, 0.23) of patients admitted after July 2016 (P<.01). This was a relative increase of 2.5%. The adjusted change per 10 days and percentage of patients who had any improvement in the total scores for self-care, mobility, and balance were all significantly higher after July 2016. CONCLUSIONS: Patients admitted to a SNF after a hip replacement after July 2016 had greater physical recovery than patients admitted before the improvement in function quality measure was added to Nursing Home Compare.

Association of Occupational and Physical Therapy With Duration of Prescription Opioid Use After Hip or Knee Arthroplasty: A Retrospective Cohort Study of Medicare Enrollees.

OBJECTIVE: To establish whether nonpharmacologic interventions, such as occupational and physical therapy, were associated with a shorter duration of prescription opioid use after hip or knee arthroplasty. DESIGN: This retrospective cohort study used data from a national 5% Medicare sample database between January 1, 2010 and December 31, 2015. SETTING: Home health or outpatient. PARTICIPANTS: Adults 66 years or older with an inpatient total hip (n=4272) or knee (n=9796) arthroplasty (N=14,068). INTERVENTIONS: We dichotomized patients according to whether they had received any nonpharmacologic pain intervention within 1 year after hospital discharge (eg, occupational or physical therapy evaluation). Using Cox proportional hazards, we treated exposure to nonpharmacologic interventions as time dependent to determine if skilled therapy was associated with duration of opioid use. MAIN OUTCOME MEASURES: Duration of prescription opioid use. RESULTS: Median time to begin nonpharmacologic interventions was 91 days (95% confidence interval [CI], 74-118d) for hip and 27 days (95% CI, 27-28d) for knee arthroplasty. Median time to discontinue prescription opioids was 16 days (hip: 95% CI, 15-16d) and 30 days (knee: 95% CI, 29-31d). Nonpharmacologic interventions delivered with home health increased the likelihood of discontinuing opioids after hip (hazard ratio [HR], 1.15; 95% CI, 1.01-1.30) and knee (HR, 1.10; 95% CI, 1.03-1.17) arthroplasty. A sensitivity analysis found these estimates to be robust and conservative. CONCLUSIONS: Occupational and physical therapy with home health was associated with a shorter duration of prescription opioid use after hip and knee arthroplasty. Occupational and physical therapy can address pain and sociobehavioral factors associated with postsurgical opioid use.

Mobility and Self-Care are Associated With Discharge to Community After Home Health for People With Dementia.

OBJECTIVES: A priority health outcome for patients, families, and the Centers for Medicare & Medicaid Services (CMS) is a patient's ability to return home and remain in the community without adverse events following discharge from post-acute care services. Successful discharge to community (DTC) is defined as being discharged to the community and not experiencing a readmission or death within 30 days of discharge. The objective of this study was to determine the association between patient factors and successful DTC after home health for individuals with Alzheimer's disease and related dementias (ADRD). DESIGN: This retrospective study derived data from 100% national CMS data files from October 1, 2016, through September 30, 2017. SETTINGS AND PARTICIPANTS: Criteria from the Home Health Quality Reporting program were used to identify a cohort of 790,439 Medicare home health beneficiaries, 143,164 (18.0%) with ADRD. MEASURES: Successful DTC rates with associated 95% confidence intervals (CIs) were calculated for each patient characteristic. Multilevel logistic regression was used to estimate the relative risk (RR) of successful DTC after home health, by ADRD diagnosis, mobility, self-care, caregiver support, and medication management, adjusted for patient demographics and clinical characteristics. RESULTS: Overall, 79.4% of beneficiaries had a successful DTC. Beneficiaries with ADRD had a significantly lower odds of successful DTC than those without ADRD (RR=0.947, 95% CI=0.944-0.950). This association remained significant after adjustment for caregiver support, assistance with medications, independence in mobility, and level of self-care. Greater need for caregiver support, greater need for assistance with medications, greater dependence in mobility, and greater self-care dependence were all associated with decreased risk of successful DTC. CONCLUSIONS AND IMPLICATIONS: Older adults with ADRD receiving home health had decreased RR of successful DTC. To have a successful DTC, older adults with ADRD need sufficient support from caregivers and independence in functioning.

Changes in Health Care Use by Mexican American Medicare Beneficiaries Before and After a Diagnosis of Dementia.

BACKGROUND: Evidence from predominantly non-Hispanic White cohorts indicates health care utilization increases before Alzheimer's disease and related dementias (ADRD) is diagnosed. We investigated trends in health care utilization by Mexican American Medicare beneficiaries before and after an incident diagnosis of ADRD. METHODS: Data came from the Hispanic Established Populations for the Epidemiological Study of the Elderly that has been linked with Medicare claims files from 1999 to 2016 (n = 558 matched cases and controls). Piecewise regression and generalized linear mixed models were used to compare the quarterly trends in any (ie, one or more) hospitalizations, emergency room (ER) admissions, and physician visits for 1 year before and 1 year after ADRD diagnosis. RESULTS: The piecewise regression models showed that the per-quarter odds for any hospitalizations (odds ratio [OR] = 1.62, 95% CI = 1.43-1.84) and any ER admissions (OR = 1.40, 95% CI = 1.27-1.54) increased before ADRD was diagnosed. Compared to participants without ADRD, the percentage of participants with ADRD who experienced any hospitalizations (27.2% vs 14.0%) and any ER admissions (19.0% vs 11.7%) was significantly higher at 1 quarter and 3 quarters before ADRD diagnosis, respectively. The per-quarter odds for any hospitalizations (OR = 0.88, 95% CI = 0.80-0.97) and any ER admissions (OR = 0.89, 95% CI = 0.82-0.97) decreased after ADRD was diagnosed. Trends for any physician visits before or after ADRD diagnosis were not statistically significant. CONCLUSIONS: Older Mexican Americans show an increase in hospitalizations and ER admissions before ADRD is diagnosed, which is followed by a decrease after ADRD diagnosis. These findings support the importance of a timely diagnosis of ADRD for older Mexican Americans.

Educational Benefits and Cognitive Health Life Expectancies: Racial/Ethnic, Nativity, and Gender Disparities.

BACKGROUND AND OBJECTIVES: To examine racial/ethnic, nativity, and gender differences in the benefits of educational attainment on cognitive health life expectancies among older adults in the United States. RESEARCH DESIGN AND METHODS: We used data from the Health and Retirement Study (1998-2014) to estimate Sullivan-based life tables of cognitively healthy, cognitively impaired/no dementia, and dementia life expectancies by gender for older White, Black, U.S.-born Hispanic, and foreign-born Hispanic adults with less than high school, high school, and some college or more. RESULTS: White respondents lived a greater percentage of their remaining lives cognitively healthy than their minority Black or Hispanic counterparts, regardless of level of education. Among respondents with some college or more, versus less than high school, Black and U.S.-born Hispanic women exhibited the greatest increase (both 37 percentage points higher) in the proportion of total life expectancy spent cognitively healthy; whereas White women had the smallest increase (17 percentage points higher). For men, the difference between respondents with some college or more, versus less than high school, was greatest for Black men (35 percentage points higher) and was lowest for U.S.-born Hispanic men (21 percentage points higher). DISCUSSION AND IMPLICATIONS: Our results provide evidence that the benefits of education on cognitive health life expectancies are largest for Black men and women and U.S.-born Hispanic women. The combination of extended longevity and rising prevalence of Alzheimer's disease points to the need for understanding why certain individuals spend an extended period of their lives with poor cognitive health.