An Exploratory Analysis of Tamsulosin for Overactive Bladder (OAB) in Men With Varying Voiding Symptom Burden.

OBJECTIVE: To evaluate tamsulosin (α-blocker therapy) for male overactive bladder (OAB) and to examine if indicators of concomitant benign prostatic hyperplasia are associated with OAB symptom improvement. MATERIALS AND METHODS: This was a planned, exploratory analysis of a 4-week, α-blocker (tamsulosin 0.4 mg) run-in phase of the Male Overactive Bladder Trial in Veterans (MOTIVE). Participants with urinary urgency and urinary frequency (> 8 voids/24 hours) completed bladder diaries, answered symptom questionnaires (AUA-7 SI), and had post-void residual and noninvasive uroflowmetry measurement. RESULTS: A total of 116 male Veterans aged 42-88 years with OAB participated. There were statistically significant reductions in voiding frequency (11.3 > 10.0 voids/24 hours, P < .0001), urgency scores (mean 2.5-2.2 points, P < .0001), and nightly nocturia (2.1 > 1.8, P < .001). Only baseline AUA-7 SI total and voiding subscale categories (mild, moderate, severe) were associated with significant reduction in AUA-7 SI total score. For continuous variables, only AUA-7 SI baseline total score was associated with AUA-7 SI storage symptom changes. No other baseline measures were associated with changes in urgency, frequency, or nocturia. CONCLUSION: Initiation of short course tamsulosin therapy in men was associated with statistical reduction in OAB symptoms. Baseline post-void residual, uroflow rate, and the voiding symptom subscore of the AUA-7 SI were not predictive of OAB symptom improvement with tamsulosin. These findings merits further exploration.

COVID-19 in Nursing Homes: Calming the Perfect Storm.

The pandemic of viral infection with the severe acute respiratory syndrome coronavirus-2 that causes COVID-19 disease has put the nursing home industry in crisis. The combination of a vulnerable population that manifests nonspecific and atypical presentations of COVID-19, staffing shortages due to viral infection, inadequate resources for and availability of rapid, accurate testing and personal protective equipment, and lack of effective treatments for COVID-19 among nursing home residents have created a "perfect storm" in our country's nursing homes. This perfect storm will continue as society begins to reopen, resulting in more infections among nursing home staff and clinicians who acquire the virus outside of work, remain asymptomatic, and unknowingly perpetuate the spread of the virus in their workplaces. Because of the elements of the perfect storm, nursing homes are like a tinderbox, and it only takes one person to start a fire that could cause many deaths in a single facility. Several public health interventions and health policy strategies, adequate resources, and focused clinical quality improvement initiatives can help calm the storm. The saddest part of this perfect storm is that many years of inaction on the part of policy makers contributed to its impact. We now have an opportunity to improve nursing homes to protect residents and their caregivers ahead of the next storm. It is time to reimagine how we pay for and regulate nursing home care to achieve this goal. J Am Geriatr Soc 68:2153-2162, 2020.

Quality Clinical Care in Nursing Facilities.

Despite improvements in selected nursing facility (NF) quality measures such as reduction in antipsychotic use; local, state, and national initiatives; and regulatory incentives, the quality of clinical care delivered in this setting remains inconsistent. Herein, recommendations for overcoming barriers to achieving consistent, high-quality clinical outcomes in long-term (LTC) and post-acute care are provided to address inadequate workforce, suboptimal culture and interprofessional teamwork, insufficiently evidence-based processes of care, and poor adoption and fidelity of technology and integrated clinical decision support. With high staff attrition rates in NFs, mechanisms to measure and close knowledge gaps as well as opportunities for practice simulations should be available to educate and ensure adoption of clinical quality standards on clinician hiring and on an ongoing basis. Multipronged, integrated approaches are needed to further the quest for sustainment of high clinical quality in NF care. In addition to setting a tone for attainment of clinical quality, leadership should champion adoption of practice standards, quality initiatives, and evidence-based guidelines. Maintaining an optimal ratio of hours per resident per day of nurses and nurse aides can improve quality outcomes and staff satisfaction. Clinicians must consistently and effectively apply care processes that include recognition, problem definition, diagnosis, goal identification, intervention, and monitoring resident progress. In order to do so they must have rapid, easy access to necessary tools, including evidence-based standards, algorithms, care plans, during the care delivery process. Embedding such tools into workflow of electronic health records has the potential to improve quality outcomes. On a national and international level, quality standards should be developed by interprofessional LTC experts committed to applying the highest levels of clinical evidence to improve the care of older persons. The standards should be realistic and practical, and basic principles of implementation science must be used to achieve the desired outcomes.

Degree of Implementation of the Interventions to Reduce Acute Care Transfers (INTERACT) Quality Improvement Program Associated with Number of Hospitalizations.

OBJECTIVES: To determine whether degree of implementation of the Interventions to Reduce Acute Care Transfers (INTERACT) program is associated with number of hospitalizations and emergency department (ED) visits of skilled nursing facility (SNF) residents. DESIGN: Secondary analysis from a randomized controlled trial. SETTING: SNFs from across the United States (N=264). PARTICIPANTS: Two hundred of the SNFs from the randomized trial that provided baseline and intervention data on INTERACT use. INTERVENTIONS: During a 12-month period, intervention SNFs received remote training and support for INTERACT implementation; control SNFs did not, although most control facilities were using various components of the INTERACT program before and during the trial on their own. MEASUREMENTS: INTERACT use data were based on monthly self-reports for SNFs randomized to the intervention group and pre- and postintervention surveys for control SNFs. Primary outcomes were rates of all-cause hospitalizations, potentially avoidable hospitalizations (PAHs), ED visits without admission, and 30-day hospital readmissions. RESULTS: The 65 SNFs (32 intervention, 33 control) that reported increases in INTERACT use had reductions in all-cause hospitalizations (0.427 per 1,000 resident-days; 11.2% relative reduction from baseline, p<.001) and PAHs (0.221 per 1,000 resident-days; 18.9% relative reduction, p<.001). The 34 SNFs (12 intervention, 22 control) that reported consistently low or moderate INTERACT use had statistically insignificant changes in hospitalizations and ED visit rates. CONCLUSION: Increased reported use of core INTERACT tools was associated with significantly greater reductions in all-cause hospitalizations and PAHs in both intervention and control SNFs, suggesting that motivation and incentives to reduce hospitalizations were more important than the training and support provided in the trial in improving outcomes. Further research is needed to better understand the most effective strategies to motivate SNFs to implement and sustain quality improvement programs such as INTERACT.

Nursing Home Regulations Redefined: Implications for Providers.

The Centers for Medicare and Medicaid Services (CMS) finalized a comprehensive update to nursing home requirements of participation in October 2016. Nearly 10,000 public comments were received regarding the proposed rule, and CMS made multiple modifications based on comments from providers, advocacy organizations, and others before issuing the final rule. The final rule describing nursing home requirements of participation modernizes nursing home regulation. It is being implemented in three phases-beginning in November 2016, November 2017, and November 2019. There are multiple provisions that have implications for clinicians caring for nursing home residents, particularly in terms of management of infections, medication prescribing and monitoring, and delegation of medical orders.

Barriers and Facilitators to Implementing a Change Initiative in Long-Term Care Using the INTERACT® Quality Improvement Program.

Implementation of major organizational change initiatives presents a challenge for long-term care leadership. Implementation of the INTERACT® (Interventions to Reduce Acute Care Transfers) quality improvement program, designed to improve the management of acute changes in condition and reduce unnecessary emergency department visits and hospitalizations of nursing home residents, serves as an example to illustrate the facilitators and barriers to major change in long-term care. As part of a larger study of the impact of INTERACT® on rates of emergency department visits and hospitalizations, staff of 71 nursing homes were called monthly to follow-up on their progress and discuss successful facilitating strategies and any challenges and barriers they encountered during the yearlong implementation period. Themes related to barriers and facilitators were identified. Six major barriers to implementation were identified: the magnitude and complexity of the change (35%), instability of facility leadership (27%), competing demands (40%), stakeholder resistance (49%), scarce resources (86%), and technical problems (31%). Six facilitating strategies were also reported: organization-wide involvement (68%), leadership support (41%), use of administrative authority (14%), adequate training (66%), persistence and oversight on the part of the champion (73%), and unfolding positive results (14%). Successful introduction of a complex change such as the INTERACT® quality improvement program in a long-term care facility requires attention to the facilitators and barriers identified in this report from those at the frontline.

Characteristics of older adults rehospitalized within 7 and 30 days of discharge: implications for nursing practice.

Rehospitalization within 30 days consumes a significant portion of health care costs; therefore, interventions aimed at reducing the risk of rehospitalization are needed. A retrospective study was conducted examining rehospitalization rates and diagnoses according to discharge location and comparing characteristics of older adults within 7 and 30 days of discharge from a community hospital. Data on rehospitalization for Medicare fee-for-service patients (75 and older) over a 12-month period were obtained from the information technology department of a not-for-profit community hospital. A total of 6,809 patients were discharged, with 12% rehospitalized within 30 days. Skilled nursing facilities had the highest rehospitalization rates (15%), followed by home with home health care (13%) and then home with self-care (8%). The highest rehospitalization rates were in areas where nursing has a strong presence, suggesting that nurses can play an important role in the development of interventions aimed at reducing rehospitalizations.

Potentially avoidable hospitalizations of dually eligible Medicare and Medicaid beneficiaries from nursing facility and Home- and Community-Based Services waiver programs.

OBJECTIVES: Beneficiaries dually eligible for Medicare and Medicaid are of increasing interest because of their clinical complexity and high costs. The objective of this study was to examine the incidence, costs, and factors associated with potentially avoidable hospitalizations (PAH) in this population. DESIGN: Retrospective study of hospitalizations. SETTING: Hospitalizations from nursing facilities (NF) including Medicare and Medicaid-covered stays, and Medicaid Home and Community-Based Services (HCBS) waiver programs. PARTICIPANTS: Dually eligible individuals who received Medicare skilled nursing facility (SNF) or Medicaid NF services or HCBS waiver services in 2005. INTERVENTIONS: None. MEASUREMENTS: Potentially avoidable hospitalizations were defined by an expert panel that identified conditions and associated Diagnostic Related Groups (DRGs) which can often be prevented or safely and effectively managed without hospitalization. RESULTS: More than one-third of the population was hospitalized at least once, totaling almost 1 million hospitalizations. The admitting DRG for 382,846 (39%) admissions were identified as PAH. PAH rates varied considerably among states, and blacks had a higher rate and costs for PAH than whites. Five conditions (pneumonia, congestive heart failure, urinary tract infections, dehydration, and chronic obstructive pulmonary disease/asthma) were responsible for 78% of the PAH. The total Medicare costs for these hospitalizations were $3 billion, but only $463 million for Medicaid. A sensitivity analysis, assuming that 20%-60% of these hospitalizations could be prevented, revealed that between 77,000 and 260,000 hospitalizations and between $625 million and $1.9 billion in expenditures could be avoided annually in this population. CONCLUSION: Potentially avoidable hospitalizations are common and costly in the dually eligible population. New initiatives are needed to reduce PAH in this population as they are costly and can adversely affect function and quality of life.

Frequency and diagnoses associated with 7- and 30-day readmission of skilled nursing facility patients to a nonteaching community hospital.

OBJECTIVES: To determine the frequency and diagnoses associated with 7- and 30-day acute hospital readmissions of patients discharged to a skilled nursing facility (SNF) from an acute hospital. DESIGN: A quality improvement project focusing on 30-day hospital readmissions, using retrospective data derived from the hospital's electronic data repository. SETTING: A 350-bed nonteaching community hospital in southeast Florida. MEASUREMENTS: Data were collected on all discharges of Medicare fee-for-service patients age 75 and older for a 17-month period in 2007 and 2008. The primary source of data was the hospital's electronic data repository. Seven and 30-day hospital readmission rates were calculated for all discharges to SNFs. Index hospital and readmission diagnoses were determined by hospital coders and categorized by the physician coauthors. RESULTS: Among 10,777 discharges of patients age 75 and older, 3254 (30%) were discharged to an SNF, and of these, 584 (18%) were readmitted to the hospital within 30 days; 191 (33%) of these readmissions occurred within 7 days. The index diagnostic categories with the highest readmission rates were genitourinary disorders (30%) and cardiovascular disorders (25%). Specific diagnoses associated with the highest readmission rates included congestive heart failure (CHF) (31%), urinary tract infection (28%), renal failure (27%), and pneumonia and chronic obstructive pulmonary disease (23% each). Infections and cardiovascular disorders were the primary diagnoses for 63% of the hospital readmissions (36% and 27% respectively). The most frequent readmission primary diagnosis was the same as the index admission primary diagnosis in less than half the cases. CONCLUSION: In this community hospital population, close to 1 in 5 discharges to an SNF resulted in a hospital readmission within 30 days. CHF, renal failure, UTI, pneumonia, and COPD were common index hospital and readmission diagnoses. Care paths and guidelines are available for these conditions that should be helpful to SNFs in initiatives designed to improve transitional care and reduce potentially avoidable hospital readmissions, as well as their associated morbidity and cost.

The modified total body rotation test: a rapid, reliable assessment of physical function in older adults.

OBJECTIVES: To describe a quick, modified measure of total body rotation with performance rankings for elderly persons and to highlight the importance of total body rotational ability for overall physical performance. DESIGN: Scores were collected during the same testing session and were compared with other measures using a Pearson correlation. SETTING: Community-based senior centers. PARTICIPANTS: One hundred forty-five participants aged 79.6±7.2 were recruited using flyers distributed at health fairs, senior centers, and lifelong learning programs. MEASUREMENTS: The modified total body rotation test (MTBR), the back-scratch test, the modified sit-and-reach test, the 30-second chair-stand test, the Short Physical Performance Battery, and the short version of the Continuous-Scale Physical Functional Performance Test. RESULTS: The MBTR significantly correlated to all standard measures of physical performance. Norms are reported for all participants, and reliability analyses were conducted using data from 18 participants. Data were divided into quintiles to create cutoffs for physical performance rankings that can be used when reporting results to the general public. CONCLUSION: Many evaluations measure isolated components of physical performance, but few examine whole body movements that allow all components necessary for independence and function to work in harmony as needed considering the task and the individual's movement strategy. The current study offers the MTBR as a quick, easy, and cost-effective evaluation method to quantify the degree of impairment or injury and the rate of improvement with treatment or training.

Potentially avoidable hospitalizations of nursing home residents: frequency, causes, and costs: [see editorial comments by Drs. Jean F. Wyman and William R. Hazzard, pp 760-761].

OBJECTIVES: To examine the frequency and reasons for potentially avoidable hospitalizations of nursing home (NH) residents. DESIGN: Medical records were reviewed as a component of a project designed to develop and pilot test clinical practice tools for reducing potentially avoidable hospitalization. SETTING: NHs in Georgia. PARTICIPANTS: In 10 NHs with high and 10 with low hospitalization rates, 10 hospitalizations were randomly selected, including long- and short-stay residents. MEASUREMENTS: Ratings using a structured review by expert NH clinicians. RESULTS: Of the 200 hospitalizations, 134 (67.0%) were rated as potentially avoidable. Panel members cited lack of on-site availability of primary care clinicians, inability to obtain timely laboratory tests and intravenous fluids, problems with quality of care in assessing acute changes, and uncertain benefits of hospitalization as causes of these potentially avoidable hospitalizations. CONCLUSION: In this sample of NH residents, experienced long-term care clinicians commonly rated hospitalizations as potentially avoidable. Support for NH infrastructure, clinical practice and communication tools for health professionals, increased attention to reducing the frequency of medically futile care, and financial and other incentives for NHs and their affiliated hospitals are needed to improve care, reduce avoidable hospitalizations, and avoid unnecessary healthcare expenditures in this population.