Nurse Practitioner Care, Scope of Practice, and End-of-Life Outcomes for Nursing Home Residents With Dementia.

Importance: Nursing home residents with Alzheimer disease and related dementias (ADRD) often receive burdensome care at the end of life. Nurse practitioners (NPs) provide an increasing share of primary care in nursing homes, but how NP care is associated with end-of-life outcomes for this population is unknown. Objectives: To examine the association of NP care with end-of-life outcomes for nursing home residents with ADRD and assess whether these associations differ according to state-level NP scope of practice regulations. Design, Setting, and Participants: This cohort study using fee-for-service Medicare claims included 334 618 US nursing home residents with ADRD who died between January 1, 2016, and December 31, 2018. Data were analyzed from April 6, 2015, to December 31, 2018. Exposures: Share of nursing home primary care visits by NPs, classified as minimal (<10% of visits), moderate (10%-50% of visits), and extensive (>50% of visits). State NP scope of practice regulations were classified as full vs restrictive in 2 domains: practice authority (authorization to practice and prescribe independently) and do-not-resuscitate (DNR) authority (authorization to sign DNR orders). Main Outcomes and Measures: Hospitalization within the last 30 days of life and death with hospice. Linear probability models with hospital referral region fixed effects controlling for resident characteristics, visit volume, and geographic factors were used to estimate whether the associations between NP care and outcomes varied across states with different scope of practice regulations. Results: Among 334 618 nursing home decedents (mean [SD] age at death, 86.6 [8.2] years; 69.3% female), 40.5% received minimal NP care, 21.4% received moderate NP care, and 38.0% received extensive NP care. Adjusted hospitalization rates were lower for residents with extensive NP care (31.6% [95% CI, 31.4%-31.9%]) vs minimal NP care (32.3% [95% CI, 32.1%-32.6%]), whereas adjusted hospice rates were higher for residents with extensive (55.6% [95% CI, 55.3%-55.9%]) vs minimal (53.6% [95% CI, 53.3%-53.8%]) NP care. However, there was significant variation by state scope of practice. For example, in full practice authority states, adjusted hospice rates were 2.88 percentage points higher (95% CI, 1.99-3.77; P < .001) for residents with extensive vs minimal NP care, but the difference between these same groups was 1.77 percentage points (95% CI, 1.32-2.23; P < .001) in restricted practice states. Hospitalization rates were 1.76 percentage points lower (95% CI, -2.52 to -1.00; P < .001) for decedents with extensive vs minimal NP care in full practice authority states, but the difference between these same groups in restricted practice states was only 0.43 percentage points (95% CI, -0.84 to -0.01; P < .04). Similar patterns were observed in analyses focused on DNR authority. Conclusions and Relevance: The findings of this cohort study suggest that NPs appear to be important care providers during the end-of-life period for many nursing home residents with ADRD and that regulations governing NP scope of practice may have implications for end-of-life hospitalizations and hospice use in this population.

Characteristics and End-of-Life Care Pathways of Decedents From a National Cohort of Assisted Living Residents.

BACKGROUND: Assisted living (AL) is an increasingly common, place of care for dying persons. However, it remains unclear to what extent residents are able to age in place or if AL represents an additional transition before death. OBJECTIVES: Examine the sociodemographic characteristics, comorbidities, health care utilization, and end-of-life care pathways of AL residents before death. RESEARCH DESIGN: A national cohort study of fee-for-service Medicare beneficiaries residing in large AL communities (25+ beds) during the month of January 2017 with 3 years of follow-up, using administrative claims data. SUBJECTS: 268,812 AL residents. MEASURES: Sociodemographic characteristics, comorbidities, and health care utilization at the end of life. RESULTS: Between 2017 and 2019, 35.1% of the study cohort died. Decedents were more likely than the overall AL population to be 85 years old or older (76.5% vs. 59.5%), and diagnosed with Alzheimer's disease and related dementia (70.3% vs. 51.6%). Most decedents (96.2%) had some presence in AL during the last year of life, but over 1 in 5 left AL before the last month of life. Among those in AL on day 30 before death, nearly half (46.4%) died in place without any health care transition, while 13.2% had 3 or more transfers before dying. CONCLUSIONS: AL is an important place of care for dying persons, especially for those with dementia. These findings indicate a need to assess existing policies and processes guiding the care of the frail and vulnerable population of dying AL residents.

Identifying Medicare beneficiaries with Alzheimer's disease and related dementia using home health OASIS assessments.

BACKGROUND: Home health services are an important site of care following hospitalization among Medicare beneficiaries, providing health assessments that can be leveraged to detect diagnoses that are not available in other data sources. In this work, we aimed to develop a parsimonious and accurate algorithm using home health outcome and assessment information set (OASIS) measures to identify Medicare beneficiaries with a diagnosis of Alzheimer's disease and related dementia (ADRD). METHODS: We conducted a retrospective cohort study of Medicare beneficiaries with a complete OASIS start of care assessment in 2014, 2016, 2018, or 2019 to determine how well the items from various versions could identify those with an ADRD diagnosis by the assessment date. The prediction model was developed iteratively, comparing the performance of different models in terms of sensitivity, specificity, and accuracy of prediction, from a multivariable logistic regression model using clinically relevant variables, to regression models with all available variables and predictive modeling techniques, to estimate the best performing parsimonious model. RESULTS: The most important predictors of having a diagnosis of ADRD by the start of care OASIS assessment were a prior discharge diagnosis of ADRD among those admitted from an inpatient setting, and frequently exhibiting symptoms of confusion. Results from the parsimonious model were consistent across the four annual cohorts and OASIS versions with high specificity (above 96%), but poor sensitivity (below 58%). The positive predictive value was high, over 87% across study years. CONCLUSIONS: The proposed algorithm has high accuracy, requires a single OASIS assessment, is easy to implement without sophisticated statistical models, and can be used across four OASIS versions and in situations where claims are not available to identify individuals with a diagnosis of ADRD, including the growing population of Medicare Advantage beneficiaries.

Impact of higher payments for rural home health episodes on rehospitalizations.

PURPOSE: Home health agencies delivering care in rural counties face unique challenges when providing care to older adults; long travel times between each visit can limit the number of patients seen each day. In 2010, Medicare began paying home health (HH) providers 3% more to serve rural beneficiaries without evaluating the policy's impact on patient outcomes. METHODS: Using 100% Medicare data on postacute HH episodes from 2007 to 2014, we estimated the impact of higher payments on beneficiaries outcomes using difference-in-differences analysis, comparing rehospitalizations between rural and urban postacute HH episodes before and after 2010. FINDINGS: Our sample included 5.6 million postacute HH episodes (18% rural). In the preperiod, the 30- and 60-day rehospitalization rates for urban HH episodes were 11.30% and 18.23% compared to 11.38% and 18.39% for rural HH episodes. After 2010, 30- and 60-day rehospitalization rates declined, 10.08% and 16.49% for urban HH episodes and 9.87% and 16.08% for rural HH episodes, respectively. The difference-in-difference estimate was 0.29 percentage points (P = .005) and 0.57 percentage points (P < .001) for 30- and 60-day rehospitalization, respectively. CONCLUSIONS: Increasing payments resulted in a statistically significant reduction in rehospitalizations for rural postacute HH episodes. The add-on payment is set to sunset in 2022 and its impact on access and quality to HH for rural older adults should be reconsidered.

State Regulations and Assisted Living Residents' Potentially Burdensome Transitions at the End of Life.

Background: Potentially burdensome transitions at the end of life (e.g., repeated hospitalizations toward the end of life and/or health care transitions in the last three days of life) are common among residential care/assisted living (RC/AL) residents, and are associated with lower quality of end-of-life care reported by bereaved family members. We examined the association between state RC/AL regulations relevant to end-of-life care delivery and the likelihood of residents experiencing potentially burdensome transitions. Methods: Retrospective cohort study combining RC/AL registries of states' regulations with Medicare claims data for residents in large RC/ALs (i.e., 25+ beds) in the United States on the 120th day before death (N = 129,153), 2017-2019. Independent variables were state RC/AL regulations relevant to end-of-life care, including third-party services, staffing, and medication management. Analyses included: (1) separate logistic regression models for each RC/AL regulation, adjusting for sociodemographic covariates; (2) separate logistic regression models with a Medicare fee-for-service (FFS) subgroup to control for comorbidities, and (3) multivariable regression analysis, including all regulations in both the overall sample and the Medicare FFS subgroup. Results: We found a lack of associations between potentially burdensome transitions and regulations regarding third-party services and staffing. There were small associations found between regulations related to medication management (i.e., requiring regular medication reviews, permitting direct care workers for injections, requiring/not requiring licensed nursing staff for injections) and potentially burdensome transitions. Conclusions: In this cross-sectional study, the associations of RC/AL regulations with potentially burdensome transitions were either small or not statistically significant, calling for more studies to explain the wide variation observed in end-of-life outcomes among RC/AL residents.

Association Between State Regulations Supportive of Third-party Services and Likelihood of Assisted Living Residents in the US Dying in Place.

Importance: Older adults are increasingly residing in assisted living residences during their last year of life. The regulations guiding these residential care settings differ between and within the states in the US, resulting in diverse policies that may support residents who wish to die in place. Objective: To examine the association between state regulations and the likelihood of assisted living residents dying in place. The study hypothesis was that regulations supporting third-party services, such as hospice, increase the likelihood of assisted living residents dying in place. Design, Setting, and Participants: This retrospective cohort study combined data about assisted living residences in the US from state registries with an inventory of state regulations and administrative claims data. The study participants comprised 168 526 decedents who were Medicare beneficiaries, resided in 8315 large, assisted living residences (with ≥25 beds) across 301 hospital referral regions during the last 12 months of their lives, and died between 2017 and 2019. Descriptive analyses were performed at the state level, and 3-level multilevel models were estimated to examine the association between supportive third-party regulations and dying in place in assisted living residences. The data were analyzed from September 2021 to August 2022. Exposures: Supportive (vs "silent," ie, not explicitly mentioned in regulatory texts) state regulations regarding hospice care, private care aides, and home health services, as applicable to licensed/registered assisted living residences across the US. Main Outcomes and Measures: Presence in assisted living residences on the date of death. Results: The median (IQR) age of the 168 526 decedents included in the study was 90 (84-94) years. Of these, 110 143 (65.4%) were female and 158 491 (94.0%) were non-Hispanic White. Substantial variation in the percentage of assisted living residents dying in place was evident across states, from 18.0% (New York) to 73.7% (Utah). Supportive hospice and home health regulations were associated with a higher odds of residents dying in place (adjusted odds ratio [AOR], 1.38; 95% CI, 1.24-1.54; P < .001; and AOR, 1.21; 95% CI, 1.10-1.34; P < .001, respectively). In addition, hospice regulations remained significant in fully adjusted models (AOR, 1.46; 95% CI, 1.25-1.71). Conclusions and Relevance: The findings of this cohort study suggest that a higher percentage of assisted living residents died in place in US states with regulations supportive of third-party services. In addition, assisted living residents in licensed settings with regulations supportive of hospice regulations were especially likely to die in place.

Pain Impacting Quality of Life in Persons with Dementia Dying in the Nursing Home by Alternative Medicare Payment Model.

Background: Medicare alternative payment models were created to improve health care value by controlling costs and improving care quality. Objective: To determine if prevalence of pain affecting quality of life (QoL) differs by Medicare payment model among nursing home (NH) decedents with dementia at the end of life. Setting/Subjects: NH decedents in 2017/2018 in the United States with dementia who self-reported pain on a Minimum Data Set assessment in the last 30 days of life. Measurements: Main outcome was pain impacting QoL (i.e., affecting day-to-day activities or sleep). Multivariable logistic analysis examined the association between payment model (traditional Medicare [TM], Medicare Advantage [MA], or accountable care organizations [ACOs]) and pain impacting QoL after controlling for potential confounders. Results: There were 115,757 NH residents with dementia who self-reported pain in the last 30 days of life. Of those, 17.8% (n = 20,585) reported having pain the last five days from assessment, which varied by Medicare payment model (17.7% in TM, 17.5% in MA, and 19.1% in ACOs; p < 0.001). Among decedents reporting pain, 23.6% of ACO decedents reported pain affecting QoL compared to 22.1% in MA and 21.6% in TM (p = 0.09). After adjustment, decedents in ACOs compared to TM had greater predicted probability of pain affecting QoL (absolute marginal difference 0.017, 95% CI 0.00-0.035, p = 0.05), and persons in MA did not differ from persons in TM (absolute marginal difference 0.005, 95% CI -0.008 to 0.019, p = 0.41). Conclusions and Implications: Among dementia decedents dying with pain, pain impacted QoL in more than one in five persons. All payment models can improve pain management.

Dementia diagnosis in the hospital and outcomes among patients with advanced dementia documented in the Minimum Data Set.

BACKGROUND: Individuals with dementia do not always have a diagnosis of dementia noted on their hospital claims. Whether this lack of documentation is associated with patient outcomes is unknown. We examined the association between a dementia diagnosis listed on a hospital claim and patient outcomes among individuals with a Minimum Data Set (MDS) assessment. METHODS: A retrospective cohort study was conducted using administrative claims data and nursing home MDS assessments. Hospitalized patients aged 66 and older with advanced dementia noted on an MDS assessment completed within 120 days prior to their first hospitalization in 2017 were included. Advanced dementia was defined based on an MDS diagnosis of dementia, dependency in four or more activities of daily living, and a Cognitive Function Scale score indicative of moderate to severe impairment. Multilevel regression with a random intercept at the hospital level was used to examine the relationship between documentation of dementia in inpatient hospital Medicare claims and the following patient outcomes after adjusting for patient and hospital characteristics: invasive mechanical ventilation (IMV) use, intensive care unit or coronary care unit (ICU/CCU) use, 30-day mortality, and hospital length of stay (LOS). RESULTS: In 2017, among 120,989 patients with advanced dementia and a nursing home stay, 90.57% had a dementia diagnosis on their hospital claims. In adjusted models, documentation of a dementia diagnosis was associated with lower use of the ICU/CCU (adjusted odds ratio [AOR]: 0.78 [95% confidence interval 0.74, 0.81]), use of IMV (AOR: 0.50 [0.47, 0.54]), and 30-day mortality (AOR: 0.81 [0.77, 0.85]). Patients with a dementia diagnosis had a shorter LOS. CONCLUSIONS: Among patients with advanced dementia, those whose dementia diagnosis was documented on their inpatient hospital Medicare claim experienced lower use of ICU/CCU, use of IMV, lower 30-day mortality, and shorter LOS than those whose diagnosis was not documented.

State Regulations and Hospice Utilization in Assisted Living During the Last Month of Life.

OBJECTIVES: To examine the association between hospice/staffing regulations in residential care or assisted living (RC/AL) and hospice utilization among a national cohort of Medicare decedents residing in RC/AL at least 1 day during the last month of life, and to describe patterns of hospice utilization. DESIGN: Retrospective cohort study of fee-for-service Medicare beneficiaries who died in 2018 and resided in an RC/AL community with ≥25 beds at least 1 day during the last month of life. SETTING/PARTICIPANTS: 23,285 decedents who spent time in 6274 RC/AL communities with 146 state license classifications. METHODS: Descriptive statistics about hospice use; logistic regression models to test the association between regulations supportive of hospice care or registered nurse (RN) staffing requirements and the odds of hospice use in RC/AL in the last month of life. RESULTS: More than half (56.4%) of the study cohort received hospice care in RC/AL at some point during the last 30 days of life, including 5.7% who received more intensive continuous home care (CHC). A larger proportion of decedents who resided in RC/ALs with supportive hospice policies received hospice (57.3% vs 52.6%), with this difference driven by more CHC hospice programs. This association remained significant after controlling for sociodemographic characteristics, comorbidities, time spent in RC/AL, and Hospital Referral Region fixed effects. Decedents in RC/ALs with explicit RN staffing requirements had significantly less CHC use (2.0% vs 6.8%). CONCLUSIONS AND IMPLICATIONS: A large proportion of RC/AL decedents received hospice care in RC/AL regardless of differing regulations. Those in licensed settings with explicitly supportive hospice regulations were significantly more likely to receive hospice care in RC/AL during the last month of life, especially CHC level of hospice care. Regulatory change in states that do not yet explicitly allow hospice care in RC/AL may potentially increase hospice utilization in this setting, although the implications for quality of care remain unclear.

Dying with dementia in Medicare Advantage, Accountable Care Organizations, or traditional Medicare.

BACKGROUND/OBJECTIVE: Medicare Advantage (MA) and Accountable Care Organizations (ACOs) operate under incentives to reduce burdensome and costly care at the end of life. We compared end-of-life care for persons with dementia who are in MA, ACOs, or traditional Medicare (TM). DESIGN, SETTING, AND PARTICIPANTS: Retrospective study of decedents with dementia enrolled in MA, attributed to an ACO, or in TM. Decedents had a nursing home stay between 91 and 180 days prior to death, two or more functional impairments, and mild to severe cognitive impairment. MEASUREMENTS: Hospitalization, invasive mechanical ventilation (IMV) use, and in-hospital death in the last 30 days of life reported in Medicare billing. RESULTS: Among 370,094 persons with dementia, 93,801 (25.4%) were in MA (mean age [SD], 86.9 [7.7], 67.6% female), 39,586 (10.7%) were ACO attributed (mean age [SD], 87.2 [7.6], 67.3% female), and 236,707 (63.9%) were in TM (mean age [SD], 87.0 [7.8], 67.6% female). The proportion hospitalized in the last 30 days of life was higher among TM enrollees (27.9%) and those ACO attributed (28.1%) than among MA enrollees (20.5%, p ≤ 0.001). After adjustment for socio-demographics, cognitive and functional impairments, comorbidities, and Hospital Referral Region, adjusted odds of hospitalization in the 30 days prior to death was 0.72 (95% confidence interval [CI] 0.70-0.74) among MA enrollees and 1.05 (95% CI 1.02-1.09) among those attributed to ACOs relative to TM enrollees. Relative to TM, the adjusted odds of death in the hospital were 0.78 (95% CI 0.75-0.81) among MA enrollees and 1.02 (95% CI 0.96-1.08) for ACO participants. Dementia decedents in MA had a lower likelihood of IMV use (adjusted odds ratio 0.80, 95% CI 0.75-0.85) compared to TM. CONCLUSIONS: Among decedents with dementia, MA enrollees but not decedents in ACOs experienced less costly and potentially burdensome care compared with those with TM. Policy changes are needed for ACOs.

Trends in Noninvasive and Invasive Mechanical Ventilation Among Medicare Beneficiaries at the End of Life.

Importance: End-of-life care is costly, and decedents often experience overtreatment or low-quality care. Noninvasive ventilation (NIV) may be a palliative approach to avoid invasive mechanical ventilation (IMV) among select patients who are hospitalized at the end of life. Objective: To examine the trends in NIV and IMV use among decedents with a hospitalization in the last 30 days of life. Design, Setting, and Participants: This population-based cohort study used a 20% random sample of Medicare fee-for-service beneficiaries who had an acute care hospitalization in the last 30 days of life and died between January 1, 2000, and December 31, 2017. Sociodemographic, diagnosis, and comorbidity data were obtained from Medicare claims data. Data analysis was performed from September 2019 to July 2020. Exposures: Use of NIV or IMV. Main Outcomes and Measures: Validated International Classification of Diseases, Ninth Revision, Clinical Modification or International Statistical Classification of Diseases, Tenth Revision, Clinical Modification procedure codes were reviewed to identify use of NIV, IMV, both NIV and IMV, or none. Four subcohorts of Medicare beneficiaries were identified using primary admitting diagnosis codes (chronic obstructive pulmonary disease [COPD], congested heart failure [CHF], cancer, and dementia). Measures of end-of-life care included in-hospital death (acute care setting), hospice enrollment at death, and hospice enrollment in the last 3 days of life. Random-effects logistic regression examined NIV and IMV use adjusted for sociodemographic characteristics, admitting diagnosis, and comorbidities. Results: A total of 2 470 435 Medicare beneficiaries (1 353 798 women [54.8%]; mean [SD] age, 82.2 [8.2] years) were hospitalized within 30 days of death. Compared with 2000, the adjusted odds ratio (AOR) for the increase in NIV use was 2.63 (95% CI, 2.46-2.82; % receipt: 0.8% vs 2.0%) for 2005 and 11.84 (95% CI, 11.11-12.61; % receipt: 0.8% vs 7.1%) for 2017. Compared with 2000, the AOR for the increase in IMV use was 1.04 (95% CI, 1.02-1.06; % receipt: 15.0% vs 15.2%) for 2005 and 1.63 (95% CI, 1.59-1.66; % receipt: 15.0% vs 18.2%) for 2017. In subanalyses comparing 2017 with 2000, similar trends found increased NIV among patients with CHF (% receipt: 1.4% vs 14.2%; AOR, 14.14 [95% CI, 11.77-16.98]) and COPD (% receipt: 2.7% vs 14.5%; AOR, 8.22 [95% CI, 6.42-10.52]), with reciprocal stabilization in IMV use among patients with CHF (% receipt: 11.1% vs 7.8%; AOR, 1.07 [95% CI, 0.95-1.19]) and COPD (% receipt: 17.4% vs 13.2%; AOR, 1.03 [95% CI, 0.88-1.21]). The AOR for increased NIV use was 10.82 (95% CI, 8.16-14.34; % receipt: 0.4% vs 3.5%) among decedents with cancer and 9.62 (95% CI, 7.61-12.15; % receipt: 0.6% vs 5.2%) among decedents with dementia. The AOR for increased IMV use was 1.40 (95% CI, 1.26-1.55; % receipt: 6.2% vs 7.6%) among decedents with cancer and 1.28 (95% CI, 1.17-1.41; % receipt: 5.7% vs 6.2%) among decedents with dementia. Among decedents with NIV vs IMV use, lower rates of in-hospital death (50.3% [95% CI, 49.3%-51.3%] vs 76.7% [95% CI, 75.9%-77.5%]) and hospice enrollment in the last 3 days of life (57.7% [95% CI, 56.2%-59.3%] vs 63.0% [95% CI, 60.9%-65.1%]) were observed along with higher rates of hospice enrollment (41.3% [95% CI, 40.4%-42.3%] vs 20.0% [95% CI, 19.2%-20.7%]). Conclusions and Relevance: This study found that the use of NIV rapidly increased from 2000 through 2017 among Medicare beneficiaries at the end of life, especially among persons with cancer and dementia. The findings suggest that trials to evaluate the outcomes of NIV are warranted to inform discussions about the goals of this therapy between clinicians and patients and their health care proxies.

The Black and White of Invasive Mechanical Ventilation in Advanced Dementia.

BACKGROUND/OBJECTIVES: Over the past decade, feeding tube use in nursing home residents with advanced dementia has declined by 50% among white and black patients. Little is known about whether a similar reduction has occurred in other invasive interventions, such as mechanical ventilation. DESIGN: Retrospective cohort study. SETTING: Acute-care hospitals in the United States. PARTICIPANTS: Medicare beneficiaries with advanced dementia who previously resided in a nursing home and were hospitalized between 2001 and 2014 with pneumonia and/or septicemia and of either black or white race. MEASUREMENT: Invasive mechanical ventilation (IMV), as identified by International Classification of Diseases (ICD) procedure codes. Two multivariable logistic regression models examined the association between race and the likelihood of receiving IMV, adjusting for patients' demographics, physical function, and comorbidities. A hospital fixed-effects model examined the association of race within a hospital, whereas a random-effects logistic model was used to estimate the between-hospital variation in the probability of receiving IMV and examine the overall association of race and use of IMV. RESULTS: Between 2001 and 2014, 289,017 patients with advanced dementia were hospitalized for pneumonia or septicemia. Use of IMV increased from 3.7% to 12.1% in white patients and from 8.6% to 21.8% in blacks. Among those ventilated, 1-year mortality rates remained high, at 82.7% for whites and 84.2% for blacks dying in 2013. Compared with whites, blacks had a higher odds of receiving IMV in the fixed-effects (within-hospital) model (adjusted odds ratio (AOR) = 1.34; 95% confidence interval (CI) = 1.29-1.39) and in the random-effects (between-hospital) model (AOR = 1.46; 95% CI = 1.40-1.51). CONCLUSION: IMV use in patients with advanced dementia has increased substantially, with black patients having a larger increase than whites, based, in part, on the hospitals where black patients receive care.

Hospital Readmission Rates in Medicare Advantage and Traditional Medicare: A Retrospective Population-Based Analysis.

Background: Medicare's Hospital Readmissions Reduction Program reports risk-standardized readmission rates for traditional Medicare but not Medicare Advantage beneficiaries. Objective: To compare readmission rates between Medicare Advantage and traditional Medicare. Design: Retrospective cohort study linking the Medicare Provider Analysis and Review (MedPAR) file with the Healthcare Effectiveness Data and Information Set (HEDIS). Setting: 4748 U.S. acute care hospitals. Patients: Patients aged 65 years or older hospitalized for acute myocardial infarction (AMI) (n = 841 613), congestive heart failure (CHF) (n = 1 458 652), or pneumonia (n = 2 020 365) between 2011 and 2014. Measurements: 30-day readmissions. Results: Among admissions for AMI, CHF, and pneumonia identified in MedPAR, 29.2%, 38.0%, and 37.2%, respectively, did not have a corresponding record in HEDIS. Of these, 18.9% for AMI, 23.7% for CHF, and 18.3% for pneumonia resulted in a readmission that was identified in MedPAR. However, among index admissions appearing in HEDIS, 14.4% for AMI, 18.4% for CHF, and 13.9% for pneumonia resulted in a readmission. Patients in Medicare Advantage had lower unadjusted readmission rates than those in traditional Medicare for all 3 conditions (16.6% vs. 17.1% for AMI, 21.4% vs. 21.7% for CHF, and 16.3% vs. 16.4% for pneumonia). However, after standardization, patients in Medicare Advantage had higher readmission rates than patients in traditional Medicare for AMI (17.2% vs. 16.9%; difference, 0.3 percentage point [95% CI, 0.1 to 0.5 percentage point]), CHF (21.7% vs. 21.4%; difference, 0.3 percentage point [CI, 0.2 to 0.5 percentage point]), and pneumonia (16.5% vs. 16.0%; difference, 0.5 percentage point [95% CI, 0.4 to 0.6 percentage point]). Rate differences increased between 2011 and 2014. Limitation: Potential unobserved differences between populations. Conclusion: The HEDIS data underreported hospital admissions for 3 common medical conditions, and readmission rates were higher among patients with underreported admissions. Medicare Advantage beneficiaries had higher risk-adjusted 30-day readmission rates than traditional Medicare beneficiaries. Primary Funding Source: National Institute on Aging.

Development and Validation of the Nursing Home Minimum Data Set 3.0 Mortality Risk Score (MRS3).

Background: To develop a score to predict mortality using the Minimum Data Set 3.0 (MDS 3.0) that can be readily calculated from items collected during nursing home (NH) residents' admission assessments. Participants: We developed a training cohort of Medicare beneficiaries newly admitted to United States NHs during 2012 (N = 1,426,815) and a testing cohort from 2013 (N = 1,160,964). Methods: Data came from the MDS 3.0 assessments linked to the Medicare Beneficiary Summary File. Using the training dataset, we developed a composite MDS 3.0 Mortality Risk Score (MRS3) consisting of 17 clinical items and patients' age groups based on their relation to 30-day mortality. We assessed the calibration and discrimination of the MRS3 in predicting 30- and 60-day mortality and compared its performance to the Charlson Comorbidity Index and the clinician's assessment of 6-month prognosis measured at admission. Results: The 30- and 60-day mortality rates for the testing population were 2.8% and 5.6%, respectively. Results from logistic regression models suggest that the MRS3 performed well in predicting death within 30 and 60 days (C-Statistics of 0.744 [95% confidence limit (CL) = 0.741, 0.747] and 0.709 [95% CL = 0.706, 0.711], respectively). The MRS3 was a superior predictor of mortality compared to the Charlson Comorbidity Index (C-statistics of 0.611 [95% CL = 0.607, 0.615] and 0.608 [95% CL = 0.605, 0.610]) and the clinicians' assessments of patients' 6-month prognoses (C-statistics of 0.543 [95% CL = 0.542, 0.545] and 0.528 [95% CL = 0.527, 0.529]). Conclusions: The MRS3 is a good predictor of mortality and can be useful in guiding decision-making, informing plans of care, and adjusting for patients' risk of mortality.

A New Data Resource to Examine Meals on Wheels Clients' Health Care Utilization and Costs.

BACKGROUND: Access to social services (eg, nutrition) can impact older adults' health care utilization and health outcomes. However, data documenting the relationship between receiving services and objective measures of health care utilization remain limited. OBJECTIVES: To link Meals on Wheels (MOW) program data to Medicare claims to enable examination of clients' health and health care utilization and to highlight the utility of this linked dataset. RESEARCH DESIGN: Using probabilistic linking techniques, we matched MOW client data to Medicare enrollment and claims data. Descriptive information is presented on clients' health and health care utilization before and after receiving services from MOW. SUBJECTS: In total, 29,501 clients were from 13 MOW programs. MEASURES: Clients' demographics, chronic conditions, and hospitalization, emergency department (ED), and nursing home (NH) utilization rates. RESULTS: We obtained a one-to-one link for 25,279 clients. Among these, 14,019 were Medicare fee-for-service (FFS) beneficiaries and met inclusion criteria for additional analyses. MOW clients had high rates of chronic conditions (eg, almost 90% of FFS clients were diagnosed with hypertension, compared with 63% of FFS beneficiaries in their communities). In the 6 months before receiving MOW services, 31.6% of clients were hospitalized, 24.9% were admitted to the ED and 13% received care in a NH. In the 6 months after receiving meals, 24.2% were hospitalized, 19.3% were admitted to the ED, and 9.5% received care in a NH. CONCLUSIONS: Linking MOW data to Medicare claims has the potential to shed additional light on the relationships among social services, health status, health care use, and benefits to clients' well-being.