Variation in Hospital-Based Rehabilitation Services Among Patients With Ischemic Stroke in the United States.

BACKGROUND: Little is known about variation in use of rehabilitation services provided in acute care hospitals for people who have had a stroke. OBJECTIVE: The objective was to examine patient and hospital sources of variation in acute care rehabilitation services provided for stroke. DESIGN: This was a retrospective, cohort design. METHODS: The sample consisted of Medicare fee-for-service beneficiaries with ischemic stroke admitted to acute care hospitals in 2010. Medicare claims data were linked to the Provider of Services file to gather information on hospital characteristics and the American Community Survey for sociodemographic data. Chi-square tests compared patient and hospital characteristics stratified by any rehabilitation use. We used multilevel, multivariable random effect models to identify patient and hospital characteristics associated with the likelihood of receiving any rehabilitation and with the amount of therapy received in minutes. RESULTS: Among 104,295 patients, 85.2% received rehabilitation (61.5% both physical therapy and occupational therapy; 22.0% physical therapy only; and 1.7% occupational therapy only). Patients received 123 therapy minutes on average (median [SD] = 90.0 [99.2] minutes) during an average length of stay of 4.8 [3.5] days. In multivariable analyses, male sex, dual enrollment in Medicare and Medicaid, prior hospitalization, ICU stay, and feeding tube were associated with lower odds of receiving any rehabilitation services. These same variables were generally associated with fewer minutes of therapy. Patients treated by tissue plasminogen activator, in limited-teaching and nonteaching hospitals, and in hospitals with inpatient rehabilitation units, were more likely to receive more therapy minutes. LIMITATION: The findings are limited to patients with ischemic stroke. CONCLUSION: Only 61% of patients with ischemic stroke received both physical therapy and occupational therapy services in the acute setting. We identified considerable variation in the use of rehabilitation services in the acute care setting following a stroke.

Association of Physician Specialty with Hospice Referral for Hospitalized Nursing Home Patients with Advanced Dementia.

OBJECTIVES: Hospitalists hospice referral patterns have been unstudied. This study aims to examine hospice referral rates by attending type for hospitalized nursing home (NH) residents with advanced cognitive impairment (ACI) at the time of discharge between 2000 and 2010. DESIGN: Retrospective cohort study. PARTICIPANTS: Hospitalized NH residents age ≥66 drawn from the 20% sample of Medicare beneficiaries with ACI, 4 or more activities of daily living (ADL) impairments on last minimum data set (MDS) assessment completed within 120 days of admission (n = 128,989). MEASUREMENTS: Hospice referral was defined as referral to hospice within 1 day after hospital discharge. Attending physician type was determined by Part B physician billing for 100% of the billings during that admission. Continuity of care was defined as the hospital physician also billing for an outpatient visit within 120 days of that hospital admission. Number of ADL impairments, cognitive measures, pre-admission illnesses and illness severity were derived from the MDS. RESULTS: Of the 105,329 hospitalized patients with ACI that survived to discharge (72.3% white, 30.6% male), the hospice referral rate at the time of hospital discharge increased from 2.8% in 2000 to 11.2% in 2010. Using a multivariate, hospital fixed effects model examining changes in the distribution of inpatient attending physicians, hospitalists compared to generalist physicians were more likely to refer these patients to hospice at discharge (AOR 1.17, 95% CI 1.09-1.26). Continuity of physician care from the outpatient setting to the hospital was associated with lower hospice referral (AOR 0.78, 95% CI 0.73-0.85). CONCLUSION: Hospice referrals for NH-dwelling persons with ACI admitted to the hospital increased between 2000 and 2011 and disproportionately so when the attending physician was a hospitalist.

Comprehensive clinical assessment of home-based older persons within New Zealand: an epidemiological profile of a national cross-section.

OBJECTIVE: Since 2012, all community care recipients in New Zealand have undergone a standardised needs assessment using the Home Care International Residential Assessment Instrument (interRAI-HC). This study describes the national interRAI-HC population, assesses its data quality and evaluates its ability to be matched. METHODS: The interRAI-HC instrument elicits information on 236 questions over 20 domains; conducted by 1,800+ trained health professionals. Assessments between 1 July 2012 and 30 June 2014 are reported here. Stratified by age, demographic characteristics were compared to 2013 Census estimates and selected health profiles described. Deterministic matching to the Ministry of Health's mortality database was undertaken. RESULTS: Overall, 51,232 interRAI-HC assessments were conducted, with 47,714 (93.1%) research consent from 47,236 unique individuals; including 2,675 Maori and 1,609 Pacific people. Apart from height and weight, data validity and reliability were high. A 99.8% match to mortality data was achieved. CONCLUSIONS: The interRAI-HC research database is large and ethnically diverse, with high consent rates. Its generally good psychometric properties and ability to be matched enhances its research utility. IMPLICATIONS: This national database provides a remarkable opportunity for researchers to better understand older persons' health and health care, so as to better sustain older people in their own homes.

An Examination of the First 30 Days After Patients are Discharged to the Community From Hip Fracture Postacute Care.

BACKGROUND: Postacute care (PAC) rehabilitation aims to maximize independence and facilitate a safe community transition. Yet little is known about PAC patients' success in staying home after discharge or differences on this outcome across PAC providers. OBJECTIVES: Examine the percentage of PAC patients who remain in the community at least 30 days after discharge (ie, successful community discharge) after hip fracture rehabilitation and describe differences among PAC facilities based on this outcome. RESEARCH DESIGN: Retrospective observational study. SUBJECTS: Community-dwelling, Medicare fee-for-service beneficiaries 75 years of age and above who experienced their first hip fracture between 1999 and 2007 (n=880,779). PAC facilities admitting hip fracture patients in 2006. MEASURES: Successful community discharge, sites of readmission after PAC discharge. RESULTS: Between 1999 and 2007, 57% of patients achieved successful community discharge. Black were less likely (adjusted odds ratios=0.84; 95% confidence interval, 0.82-0.86) than similar whites to achieve successful community discharge. Among all who reentered the community (n=581,095), 14% remained in the community <30 days. Acute hospitals (67.5%) and institutional PAC (16.8%) were the most common sites of reentry. The median proportion of successful community discharge among facilities was 49% (interquartile range, 33%-66%). Lowest-quartile facilities admitted older (85.9 vs. 84.1 y of age), sicker patients (eg, higher rates of hospital complications 6.0% vs. 4.6%), but admitted fewer annually (7.1 vs. 19.3), compared with the highest quartile. CONCLUSIONS: Reentry into the health care system after PAC community discharge is common. Because of the distinct care needs of the PAC population there is a need for a quality measure that complements the current 30-day hospital readmission outcome and captures the objectives of PAC rehabilitation.

Intensive care utilization among nursing home residents with advanced cognitive and severe functional impairment.

BACKGROUND: Dementia is a progressive terminal illness which requires decisions around aggressiveness of care. OBJECTIVE: The study objective was to examine the rate of intensive care unit (ICU) utilization and its regional variation among persons with both advanced cognitive and severe functional impairment. METHODS: We utilized the Minimum Data Set (MDS) to identify a cohort of decedents between 2000 and 2007 who (1) were in a nursing home (NH) 120 days prior to death and (2) had an MDS assessment indicating advanced cognitive and functional impairment as identified by cognitive performance scale (CPS) ≥5 and total dependence or extensive assistance in seven activities of daily living (ADLs). ICU utilization in the last 30 days of life was determined from Medicare claims files. A multivariate logistic regression model examined the likelihood of ICU admission in 2007 versus 2000 adjusting for sociodemographics, orders to limit life sustaining treatment, and health status. RESULTS: Among 474,829 Medicare NH residents with advanced cognitive impairment followed during 2000-2007, we observed an increase in ICU utilization from 6.1% in 2000 to 9.5% in 2007. After adjustment for sociodemographic characteristics, orders to limit life sustaining treatment, and measures of health status, the likelihood of a resident being admitted to an ICU was higher in 2007 compared to 2000 (adjusted odds ratio [OR] 1.71, 95% CI 1.60-1.81). Additionally, substantial regional variation was noted in ICU utilization, from 0.82% in Montana to 22% in the District of Columbia. CONCLUSIONS: Even among patients with advanced cognitive and functional impairment, ICU utilization in the last 30 days increased and varied by geographic region.

Decision making and outcomes of a hospice patient hospitalized with a hip fracture.

CONTEXT: Hospice patients are at risk for falls and hip fracture with little clinical information to guide clinical decision making. OBJECTIVES: To examine whether surgery is done and survival of hip fracture surgery among persons receiving hospice services. METHODS: This was an observational cohort study from 1999 to 2007 of Medicare hospice beneficiaries aged 75 years and older with incident hip fracture. We studied outcomes among hospice beneficiaries who did and did not have surgical fracture repair. Main outcomes included the trends in the proportion of those undergoing surgery, the site of death, and six-month survival. RESULTS: Between 1999 and 2007, approximately 1% (n=14,400) of patients aged 75 years and older admitted with a diagnosis of their first hip fracture were receiving hospice services in the 30 days before that admission and 83.4% underwent surgery. Among patients on hospice at the time of the hip fracture, 8.8% died during the initial hospitalization and an additional two-thirds died within the first six months on hospice. The median survival from hospital admission was 25.9 days for those forgoing surgery compared with 117 days for those who had surgery, adjusted for age, race, and other covariates (P<0.001). CONCLUSION: Despite being on hospice services, the majority underwent surgery with improved survival. Sixty-six percent of all individuals on hospice at the time of the fracture died in the first six months, with the majority returning to hospice services.

The residential history file: studying nursing home residents' long-term care histories(*).

OBJECTIVE: To construct a data tool, the Residential History File (RHF), that summarizes information from Medicare claims and nursing home (NH) Minimum Data Set (MDS) assessments to track people through health care locations, including non-Medicare-paid NH stays. DATA SOURCES: Online Survey of Certification and Reporting (OSCAR) data for 202 free-standing NHs, Medicare Denominator, claims (parts A and B), and MDS assessments for 60,984 people who were present in one of these NHs in 2006. METHODS: The algorithm creating the RHF is outlined and the RHF for the study data are used to describe place of death. The identification of residents in NHs is compared with the reports in OSCAR and part B claims. PRINCIPAL FINDINGS: The RHF correctly identified 84.8 percent of part B claims with place-of-service in NH, and it identified 18.3 less residents on average than reported in the OSCAR on the day of the survey. The RHF indicated that 17.5 percent non-Medicare NH decedents were transferred to the hospital to die versus 45.6 percent skilled nursing facility decedents. CONCLUSIONS: The population-based design of the RHF makes it possible to conduct policy-relevant research to examine the variation in the rate and type of health care transitions across the United States.

Hospitalization of nursing home residents: the effects of states' Medicaid payment and bed-hold policies.

OBJECTIVE: Hospitalizations of nursing home residents are costly and expose residents to iatrogenic disease and social and psychological harm. Economic constraints imposed by payers of care, predominantly Medicaid policies, are hypothesized to impact hospitalizations. DATA SOURCES/STUDY SETTING: Federally mandated resident assessments were merged with Medicare claims and eligibility files to determine hospitalizations and death within 150 days of baseline assessment. Nursing home and market characteristics were obtained from the Online Survey Certification and Reporting, and the Area Resource File, respectively. States' average daily Medicaid nursing home payments and bed-hold policies were obtained independently. STUDY DESIGN: Prospective cohort study of 570,614 older (> or =65-year-old), non-MCO (Medicare Managed Care), long-stay (> or =90 days) residents in 8,997 urban, freestanding nursing homes assessed between April and June 2000, using multilevel models to test the impact of state policies on hospitalizations controlling for resident, nursing home, and market characteristics. PRINCIPAL FINDINGS: Overall, 99,379 (17.4 percent) residents were hospitalized with rates varying from 8.4 percent in Utah to 24.9 percent in Louisiana. Higher Medicaid per diem was associated with lower odds of hospitalizations (5 percent lower for each $10 above average $103.5, confidence intervals [CI] 0.91-0.99). Hospitalization odds were higher by 36 percent in states with bed-hold policies (CI: 1.12-1.63). CONCLUSIONS: State Medicaid bed-hold policy and per-diem payment have important implications for nursing home hospitalizations, which are predominantly financed by Medicare. This study emphasizes the importance of properly aligning state Medicaid and federal Medicare policies in regards to the subsidy of acute, maintenance, and preventive care in the nursing home setting.

The employment of nurse practitioners and physician assistants in U.S. nursing homes.

PURPOSE: Nursing facilities with nurse practitioners or physician assistants (NPs or PAs) have been reported to provide better care to residents. Assuming that freestanding nursing homes in urban areas that employ these professionals are making an investment in medical infrastructure, we test the hypotheses that facilities in states with higher Medicaid rates, and those in more competitive markets and markets with higher managed care penetration, are more likely to employ NPs or PAs. DESIGN AND METHODS: The Online Survey Certification and Reporting System (OSCAR) database, Area Resource File, and information from surveys of state policies from 1993 to 2002 are used to study the employment of NPs or PAs, using a cross-sectional time-series generalized estimating equation model with surveys nested within facilities, testing several market and state-policy effects while controlling for facility and market characteristics. RESULTS: Throughout the 1990s the proportion of nursing facilities with NPs or PAs doubled, from less than 10% to over 20%. Facilities in states in the upper quartile of Medicaid reimbursement rates were 10% more likely to employ NPs or PAs. Facilities in more competitive markets, and in markets with higher managed care penetration, were more likely to employ NPs or PAs (adjusted odds ratio = 1.27, 1.20 respectively). IMPLICATIONS: More generous state Medicaid nursing home reimbursement and higher competition may advance the investment in medical infrastructure, which in turn may positively affect the quality of care provided to nursing home residents.

Nurse staffing patterns and quality of care in nursing homes.

Using the structure-process-outcome framework and the resource-based view of the firm, this study considers both direct and indirect effects of registered nurse staffing patterns on the quality of patient care outcomes. Consistent with theory, registered nurse staffing patterns were found to affect quality of patient care both directly and indirectly through their positive effect on the processes of delivering care.

Nursing home costs and quality of care: is there a tradeoff?

Nursing homes are facing increased environmental pressures to improve quality of care. However, this increased emphasis on quality comes at a time when nursing homes are facing revenue constraints as a result of the repeal of the Boren amendment, increased reimbursement based on prospective payment systems and widespread cuts to state Medicaid funding. This represents a strong financial incentive to control costs and there are concerns that these cost-containment measures may lead to a lower quality of care in nursing homes. In this article, the scientific literature on the cost-quality relationship in the nursing home industry is reviewed.

Does quality of care lead to better financial performance?: the case of the nursing home industry.

The study describes the relationship between quality of care and financial performance (operating profit margin) as it pertains to the nursing home industry. We found that nursing homes that produce better outcomes and process of care were able to achieve lower patient care costs and report better financial performance.

The relationship between quality of care and financial performance in nursing homes.

Changes in the reimbursement structure of the Medicaid and Medicare programs have caused nursing homes to face severe revenue restraints. In the hopes of alleviating the effect of payment cutbacks on their financial performance, nursing homes have been instituting quality improvement initiatives. The goal of this study was to examine the relationships of quality of care with revenues, private-pay market share, and costs in the nursing home industry, and how these dynamics interplay to affect financial performance. This goal was achieved by using secondary data consisting of: (1) the Minimum Data Set Plus (MDS+); (2) the Health Care Information Analyst (HCIA) nursing home data set; and (3) the On-line Survey Certification of Automated Records (OSCAR) data set. Structural equation modeling (SEM) using maximum likelihood estimation was used to examine the total, direct, and indirect effects of the variables. Findings indicate that nursing homes that produce high quality care are able to achieve lower resident costs and in the process, report better financial performance than those facilities producing lower quality care. On the other hand, quality of care provided was not significantly associated with the revenues or private-pay market share of the nursing home. Overall, the total effects of quality to financial performance were positive (.055).

The role of hospice care in the nursing home setting.

The last days of life for a substantial proportion of dying older adults are spent in nursing homes. Considering this, the provision of Medicare hospice care in nursing homes would appear to be an equitable use of Medicare expenditures as well as a valid investment in improving the quality of life for dying nursing home residents. However, government concerns regarding possible abuse of the hospice benefit in nursing homes, as well as suggestion that the payment for the benefit in nursing homes may be excessive, has perhaps slowed the adoption of hospice services into the nursing home setting. Currently, access to hospice care in nursing homes is inequitable across facilities, and across geographic areas. In nursing homes where hospice is available and present, however, recent research documents superior outcomes for residents enrolled in hospice, and perhaps for nonhospice residents. Still, more research is needed, particularly research focusing on the government costs associated with the provision of hospice care in nursing homes. If subsequent research continues to support the "added value" of hospice care in nursing homes and at the same or less total costs, the issue of foremost concern becomes how equitable access to Medicare hospice care in nursing homes can be achieved. Access may be increased to some extent by changing government policies, and conflicting regulations and interpretive guidelines, so they support and encourage the nursing home/hospice collaboration.