Is Electronic Information Exchange Associated With Lower 30-Day Readmission Charges Among Medicare Beneficiaries?

OBJECTIVE: Fragmented readmissions, when admission and readmission occur at different hospitals, are associated with increased charges compared with nonfragmented readmissions. We assessed if hospital participation in health information exchange (HIE) was associated with differences in total charges in fragmented readmissions. DATA SOURCE: Medicare Fee-for-Service Data, 2018. STUDY DESIGN: We used generalized linear models with hospital referral region and readmission month fixed effects to assess relationships between information sharing (same HIE, different HIEs, and no HIE available) and total charges of 30-day readmissions among fragmented readmissions; analyses were adjusted for patient-level clinical/demographic characteristics and hospital-level characteristics. DATA EXTRACTION METHODS: We included beneficiaries with a hospitalization for acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, syncope, urinary tract infection, dehydration, or behavioral issues with a 30-day readmission for any reason. PRINCIPAL FINDINGS: In all, 279,729 admission-readmission pairs were included, 27% of which were fragmented (n=75,438); average charges of fragmented readmissions were $64,897-$71,606. Compared with fragmented readmissions where no HIE was available, the average marginal effects of same-HIE and different-HIE admission-readmission pairs were -$2329.55 (95% CI: -7333.73, 2674.62) and -$3905.20 (95% CI: -7592.85, -307.54), respectively. While the average marginal effects of different-HIE pairs were lower than those for no-HIE fragmented readmissions, the average marginal effects of same-HIE and different-HIE pairs were not significantly different from each other. CONCLUSIONS: There were no statistical differences in charges between fragmented readmissions to hospitals that share an HIE or that do not share an HIE compared with hospitals with no HIE available.

A Confirmatory Factor Analysis of the NIH Emotions Toolbox Among People Living with HIV and Who May Use Methamphetamine.

The National Institutes of Health Toolbox Emotion Battery (NIHTB-EB) was developed to provide researchers and clinicians with a concise tool for measuring emotional health. The NIHTB-EB has been validated and normed in English and Spanish-speaking populations in the United States. However, its application in certain groups, such as people living with HIV (PWH) and who may use methamphetamine has not been tested. This paper evaluates the factor structure in a sample of people without HIV and PWH who may or may not use methamphetamine. The sample included 773 adults ages 18 to 87. The factorial structure of the NIHTB-EB was examined using confirmatory factor analysis (CFA) in the full sample and among four subgroups based on HIV status and methamphetamine use. The CFA confirmed a three-factor structure that mirrors the previously validated structure with latent factors measuring negative affect, social relationships, and psychological well-being for three subgroups. While each latent factor was confirmed in all groups, we could not confirm, with confidence, the full battery in the smallest subgroup (HIV-seronegative participants who use methamphetamine). The three-factor NIHTB-EB is appropriate for use among PWH who may use methamphetamine, but further examination with larger samples is warranted.

Evaluation of a Photo Captioning Cognitive Empathy Intervention for Dementia Caregivers.

OBJECTIVES: The goal of this study was to develop and evaluate an intervention aimed at increasing cognitive empathy, improving mental health, and reducing inflammation in dementia caregivers, and to examine the relevant neural and psychological mechanisms. METHODS: Twenty dementia caregivers completed an intervention that involved taking 3-5 daily photographs of their person living with dementia (PLWD) over a period of 10 days and captioning those photos with descriptive text capturing the inner voice of the PLWD. Both before and after the intervention, participants completed questionnaires, provided a blood sample for measures of inflammation, and completed a neuroimaging session to measure their neural response to viewing photographs of their PLWD and others. RESULTS: 87% of enrolled caregivers completed the intervention. Caregivers experienced pre- to post-intervention increases in cognitive empathy (i.e. Perspective-Taking) and decreases in both burden and anxiety. These changes were paralleled by an increased neural response to photographs of their PLWD within brain regions implicated in cognitive empathy. CONCLUSION: These findings warrant a larger replication study that includes a control condition and follows participants to establish the duration of the intervention effects. CLINICAL IMPLICATIONS: Cognitive empathy interventions may improve caregiver mental health and are worthy of further investigation.

Correction to: Complementary and Alternative Medicine Among Persons living with HIV in the Era of Combined Antiretroviral Treatment.

In the original publication of the article, the given and family name of the fourth author was not correct. The name has been corrected with this erratum.

Complementary and Alternative Medicine Among Persons living with HIV in the Era of Combined Antiretroviral Treatment.

Complementary and alternative medicine (CAM), often pursued independent of prescribing clinicians, may interact with traditional treatments, yet CAM use has not been well characterized among people living with HIV (PLWH) in the combined antiretroviral therapy (ART) era. We analyzed data from the Veterans Aging Cohort Study (October 2012-April 2015) to characterize CAM use in PLWH on ART. CAM users were more likely to have lived longer with HIV, report more bothersome symptoms, be prescribed more benzodiazepines and opioids, and consume less nicotine and alcohol. Given its high prevalence, clinicians should routinely assess for CAM use and its impact among PLWH.

Emergency Medical Services Provider Experiences of Hospice Care.

BACKGROUND: Growing numbers of emergency medical services (EMS) providers respond to patients who receive hospice care. The objective of this investigation was to assess the knowledge, attitudes, and experiences of EMS providers in the care of patients enrolled in hospice care. METHODS: We conducted a survey study of EMS providers regarding hospice care. We collected quantitative and qualitative data on EMS provider's knowledge, attitudes, and experiences in responding to the care needs of patients in hospice care. We used Chi-squared tests to compare EMS provider's responses by credential (Emergency Medical Technician [EMT] vs. Paramedic) and years of experience (0-5 vs. 5+). We conducted a thematic analysis to examine open-ended responses to qualitative questions. RESULTS: Of the 182 EMS providers who completed the survey (100% response rate), 84.1% had cared for a hospice patient one or more times. Respondents included 86 (47.3%) EMTs with Intermediate and Advanced training and 96 (52.7%) Paramedics. Respondent's years of experience ranged from 0-10+ years, with 99 (54.3%) providers having 0-5 years of experience and 83 (45.7%) providers having 5+ years of experience. There were no significant differences between EMTs and Paramedics in their knowledge of the care of these patients, nor were there significant differences (p < 0.05) between those with 0-5 and 5+ years of experience. Furthermore, 53 (29.1%) EMS providers reported receiving formal education on the care of hospice patients. A total of 36% respondents felt that patients in hospice care required a DNR order. In EMS providers' open-ended responses on challenges in responding to the care needs of hospice patients, common themes were family-related challenges, and the need for more education. CONCLUSION: While the majority of EMS providers have responded to patients enrolled in hospice care, few providers received formal training on how to care for this population. EMS providers have expressed a need for a formal curriculum on the care of the patient receiving hospice.

Using social exchange theory to understand non-terminal palliative care referral practices for Parkinson's disease patients.

BACKGROUND: A palliative approach is recommended in the care of Parkinson's disease patients; however, many patients only receive this care in the form of hospice at the end of life. Physician attitudes about palliative care have been shown to influence referrals for patients with chronic disease, and negative physician perceptions may affect early palliative referrals for Parkinson's disease patients. AIM: To use Social Exchange Theory to examine the association between neurologist-perceived costs and benefits of palliative care referral for Parkinson's disease patients and their reported referral practices. DESIGN: A cross-sectional survey study of neurologists. SETTING/PARTICIPANTS: A total of 62 neurologists recruited from the National Parkinson Foundation, the Medical Association of Georgia, and the American Academy of Neurology's clinician database. RESULTS: Participants reported significantly stronger endorsement of the rewards ( M = 3.34, SD = 0.37) of palliative care referrals than the costs ( M = 2.13, SD = 0.30; t(61) = -16.10, p < 0.0001). A Poisson regression found that perceived costs, perceived rewards, physician type, and the number of complementary clinicians in practice were significant predictors of palliative care referral. CONCLUSION: Physicians may be more likely to refer patients to non-terminal palliative care if (1) they work in interdisciplinary settings and/or (2) previous personal or patient experience with palliative care was positive. They may be less likely to refer if (1) they fear a loss of autonomy in patient care, (2) they are unaware of available programs, and/or (3) they believe they address palliative needs. Initiatives to educate neurologists on the benefits and availability of non-terminal palliative services could improve patient access to this care.

Exposing the Backstage: Critical Reflections on a Longitudinal Qualitative Study of Residents' Care Networks in Assisted Living.

In this article, we analyze the research experiences associated with a longitudinal qualitative study of residents' care networks in assisted living. Using data from researcher meetings, field notes, and memos, we critically examine our design and decision making and accompanying methodological implications. We focus on one complete wave of data collection involving 28 residents and 114 care network members in four diverse settings followed for 2 years. We identify study features that make our research innovative, but that also represent significant challenges. They include the focus and topic; settings and participants; scope and design complexity; nature, modes, frequency, and duration of data collection; and analytic approach. Each feature has methodological implications, including benefits and challenges pertaining to recruitment, retention, data collection, quality, and management, research team work, researcher roles, ethics, and dissemination. Our analysis demonstrates the value of our approach and of reflecting on and sharing methodological processes for cumulative knowledge building.

From Empathy to Action: Design Thinking as a Catalyst for Community-Based Participatory Research in Dementia Caregiving.

This article delves into the understudied realm of investigating the potential benefits of integrating design thinking into community-based participatory research within the context of culturally diverse dementia caregivers. Following the Double-Diamond process model, we conducted a series of workshops with 15 family caregivers of dementia patients from three distinct communities (multi-racial, Black, and Latino ethnicity) to gain insights into their daily experiences and co-create interventions that could address their pressing challenges. The research question for this study aimed to explore the potential benefits of design thinking in community-based research on dementia caregiving. Our findings contribute to the health design community by demonstrating the potential of design thinking to 1) uncover common and distinct challenges in diverse communities, 2) translate findings into actionable solutions, and 3) design tailored interventions that are responsive to the context-specific needs of the community. Our study leads us to conclude that the integration of design thinking as a catalyst in community-based participatory research has the potential to amplify the identification of nuanced and previously unexamined challenges through empathetic exploration, and to propose innovative interventions that are more amenable to uptake and acceptance within the community.

Resident and Caregiver Dyads Talk About Death and Dying in Assisted Living: A Typology of Communication Behaviors.

BACKGROUND: In the U.S., assisted living (AL) is increasingly a site of death, and anxiety about dying has been identified in long-term care residents and their caregivers. Communication about death and dying is associated with better quality of life and care at end of life (EOL). OBJECTIVE: To understand communication behaviors used by AL residents and their informal caregivers (i.e., family members or friends) related to death and dying, and address communication needs or opportunities applicable to EOL care in AL. DESIGN: A thematic analysis of in-depth interviews and fieldnotes from a subsample of data from a 5-year NIA-funded study. SETTING/SUBJECTS: Participants included 15 resident-caregiver dyads from three diverse AL communities in Atlanta, Georgia in the U.S. MEASUREMENTS: Interview transcripts were coded for communication behavior. Concordances and discordances within dyads were examined. RESULTS: We identified a typology of four dyadic communication behaviors: Talking (i.e., both partners were talking with each other about death), Blocking (i.e., one partner wanted to talk about death but the other did not), Avoiding (i.e., each partner perceived that the other did not want to communicate about death), and Unable (i.e., dyads could not communicate about death because of interpersonal barriers). CONCLUSIONS: Older residents in AL often want to talk about death but are blocked from doing so by an informal caregiver. Caregivers and AL residents may benefit from training in death communication. Recommendations for improving advance care planning and promoting better EOL communication includes timing these conversations before the opportunity is lost.

Proactive Care-Seeking Strategies Among Adults Aging Solo With Early Dementia: A Qualitative Study.

OBJECTIVES: People living with dementia need increasing care over time, but 1 in 3 adults with cognitive impairment lives alone. The goal of this study was to explore the self-identified strengths and resources for future care needs of adults aging solo with early dementia. METHODS: Semistructured interviews with 15 adults not living with a partner and with no children in the same state, who self-identified as having early dementia or mild cognitive impairment; hybrid inductive/deductive reflexive thematic analysis using a successful aging framework. RESULTS: Participants placed a high value on maintaining independence and expressed concerns about preserving selfhood and becoming a burden to others. These values influenced how participants appraised financial and social resources available to address future care needs and strategies to preempt or respond to needs such as transportation, help with finances, or activities of daily living. DISCUSSION: Adults without close family are heterogeneous and have variable resources available to address care needs associated with dementia progression. Common values of retaining independence and minimizing burden to others may be helpful in motivating adults aging solo to undertake planning and help-seeking early.

Latent class analysis of perceived stigma among older adults receiving medications for opioid use disorder.

RATIONALE: Public stigma surrounds individuals who use medication for their recovery from a substance use disorder. However, we know little about subgroups of individuals with varying levels of perceived stigma and how these levels may be associated with physical and mental health-related quality of life (HRQOL) and social support. METHODS: We used latent class analysis to define subgroups of people aged 50-72 years of age (N = 104) who were enrolled in eight medication for opioid use disorder (MOUD) programs to explore subgroupings and correlates of group membership. RESULTS: We found evidence for three distinct classes of individuals and named the classes 1) the high stigma class, 2) the embarrassed class, and 3) the low stigma class. We found that people in the high-stigma class reported more rejection, more abstinence-based support group involvement, and reduced mental HRQOL. CONCLUSIONS: Results suggest reducing stigma among people on MOUD may help to boost mental HRQOL and improve social support receipt. The results are consistent with iatrogenic effects of AA/NA support groups such that these treatment modalities may increase stigma due to their focus on abstinence-only treatment for substance use disorders.

Barriers to Community Service Use Among Persons With Dementia and Their Care Partners: A Focus on Consumers of a Novel Statewide Dementia Care Program.

Although the importance of access to, and utilization of, home and community-based services (HCBS) is a well-documented aspect of informal care and the ability to age in place among people living with dementia, these resources are underutilized, especially in the initial stages of the disease. In 2017, the Georgia Memory Net was established as a novel private-public partnership to extend dementia screening, diagnosis, care planning, and direct HCBS connections for people with memory concerns throughout the State of Georgia. We aimed to identify barriers and facilitators to HCBS utilization following a dementia diagnosis and subsequent referral for services. Data were collected through in-depth interviews with 7 Georgia Memory Net patients and 19 care partners (unconnected dyads) and analyzed using thematic analysis. We found that even with a direct handoff, many people do not use HCBS and face barriers to accessing services. We offer several recommendations based on these findings.

"How do You Take that Much Time for One Person's Life?" Experiences of Dementia Caregivers Who are Not Immediate Family.

One in three people with Alzheimer's or other dementias lives alone, without a spouse/partner or nearby children (i.e., is aging solo), yet most dementia caregiving research has focused solely on spouses or children. This study examined the experiences of friends, neighbors, siblings, and others providing unpaid care for someone with dementia. We conducted semi-structured interviews with 14 caregivers (100% female; age 54-85, mean 71; 93% white, 7% black; 29% friend, 29% sibling or in-law, 21% neighbor, 21% church congregant). Participants balanced three priorities: the person living with dementia's quality of life, the person's safety and well-being, and the caregiver's resources. Caregivers described tensions when these priorities conflicted, such as the person with dementia's goal to live alone versus risks to their physical safety. These findings and future research can inform policies and programs to support non-family dementia caregiving.

"Just Join Them": Improv and Dementia Care.

Improvisational (improv) theatre skill development holds promise for improving the dementia capability of care partners. In this report, we present analysis of data from an ongoing study on meaningful engagement and quality of life among assisted living (AL) residents with dementia. Using ethnographic methods, we collected data from persons with dementia (n = 59) and their care partners (n = 165) in six diverse AL communities each studied for one year. Building cumulatively on past work and existing literature, we demonstrate the potential benefits of training care partners to use improv skills. We discuss implications, including the need for intervention research.

Fragmented Readmissions From a Nursing Facility in Medicare Beneficiaries.

Over one-third of Medicare beneficiaries discharged to nursing facilities require readmission. When those readmissions are to a different hospital than the original admission, or "fragmented readmissions," they carry increased risks of mortality and subsequent readmissions. This study examines whether Medicare beneficiaries readmitted from a nursing facility are more likely to have a fragmented readmission than beneficiaries readmitted from home among a 2018 cohort of Medicare beneficiaries, and examined whether this association was affected by a diagnosis of Alzheimer's Disease (AD). In fully adjusted models, readmissions from a nursing facility were 19% more likely to be fragmented (AOR 1.19, 95% CI 1.16, 1.22); this association was not affected by a diagnosis of AD. These results suggest that readmission from nursing facilities may contribute to care fragmentation for older adults, underscoring it as a potentially modifiable pre-hospital risk factor for fragmented readmissions.

"Call 911 - That's my [Advance Care] Plan": Factors that Inform Advance Care Planning Conversation Readiness Among Aging Persons Living With HIV.

Antiretroviral therapy has dramatically increased the lifespan of people living with HIV (PLWH), but advance care planning (ACP) and hospice services are underutilized in this population. The purpose of this study was to understand barriers and facilitators to ACP among this group. PLWH (n = 25) were recruited from an HIV Clinic at a Veterans Affairs (VA) Medical Center in Atlanta, GA to represent a range of sociodemographic characteristics and experiences. Semi-structured interviews were analyzed using thematic analysis. More than half of participants (64%) indicated not engaging in ACP. We identified four key barriers to ACP: (1) a self-image among PLWH as "survivors" (and a reluctance to think about ACP); (2) a history of mistrust and mistreatment; (3) weak social ties and a desire to avoid disclosure of HIV status; and (4) a value for self-reliance. Findings have important implications for interventions to overcome these barriers.

Impact of electronic information exchange on repeat imaging during 30-day readmissions among Medicare beneficiaries.

OBJECTIVES: We examined the association between electronic health information sharing and repeat imaging in readmissions among older adults with and without Alzheimer disease (AD). STUDY DESIGN: Cohort study using national Medicare data. METHODS: Among Medicare beneficiaries with 30-day readmissions in 2018, we examined repeat imaging on the same body system during the readmission. This was evaluated between fragmented and nonfragmented (same-hospital) readmissions and across categories of electronic information sharing via health information exchanges (HIEs) in fragmented readmissions: admission and readmission hospitals share the same HIE, admission and readmission hospitals participate in different HIEs, one or both do not participate in HIE, or HIE data missing. This relationship was evaluated using unadjusted and adjusted logistic regression. RESULTS: Overall, 14.3% of beneficiaries experienced repeat imaging during their readmission. Compared with nonfragmented readmissions, fragmented readmissions were associated with 5% higher odds of repeat imaging on the same body system in older adults without AD. This was not mitigated by the presence of electronic information sharing: Fragmented readmissions to hospitals that shared an HIE had 6% higher odds of repeat imaging (adjusted OR, 1.06; 95% CI, 1.00-1.13). There was no difference seen in the odds of repeat imaging for older adults with AD. CONCLUSIONS: Despite substantial investment, HIEs as currently deployed and used are not associated with decreased odds of repeat imaging in readmissions.

Turning It Over to God: African American Assisted Living Residents' End-of-Life Preferences and Advance Care Planning.

OBJECTIVES: Assisted living (AL), a popular long-term care setting for older Americans, increasingly is a site for end-of-life care. Although most residents prefer AL to be their final home, relatively little is known about end-of-life preferences and advance care planning, especially among African American residents. Our research addresses this knowledge gap. METHODS: Informed by grounded theory, we present an analysis of qualitative data collected over 2 years in a 100-bed AL community catering to African American residents. Data consisted of field notes from participant observation conducted during 310 site visits and 818 observation hours, in-depth interviews with 25 residents, and a review of their AL records. RESULTS: Residents varied in their end-of-life preferences and advance care planning, but united in the belief that God was in control. We identified "Turning it over to God" as an explanatory framework for understanding how this group negotiated end-of-life preferences and advance care planning. Individual-level resident factors (e.g., age, pain, and function) and factors reflecting broader cultural and societal influences, including health literacy and care experiences, were influential. DISCUSSION: Contradictions arose from turning it over to God, including those between care preferences, planning, and anticipated or actual end-of-life outcomes.

Interpretive Qualitative Evaluation Informs Research Participation and Advocacy Training Program for Seniors: A Pilot Study.

Background: An 8-week educational intervention co-taught by medical students and faculty was designed to foster communication between clinical researchers and populations of interest to ultimately increase participation in clinical research by older adults, including underrepresented groups. Weekly topics focused on age-related changes and health conditions, socio-contextual factors impacting aging populations, and wellness strategies. Objectives: To evaluate the successes and weaknesses of an educational intervention aimed at increasing the participation of older adults in clinical research. Design: A focus group was assembled after an 8-week educational intervention, titled DREAMS, to obtain participants' feedback on the program, following a pre-formulated interview guide. Settings: Participants were interviewed in a health center office environment in the United States of America in April of 2016. Participants: A post-intervention focus group was conducted with a group of eight older adults (mean age = 75.8 ± 11.4 years) from 51 total participants who completed the intervention. Methods: The focus group was interviewed loosely following a pre-formed question guide. Participants were encouraged to give honest feedback. The conversation was recorded, transcribed verbatim, and analyzed using thematic analyses. Results: While participants viewed most aspects of the study as a success and stated that it was a productive learning experience, most participants had suggestions for improvements in the program content and implementation. Specifically, the composition of and direction to small breakout groups should be carefully considered and planned in this population, and attention should be paid to the delivery of sensitive topic such as death and dementia. A clear main benefit of this programmatic approach is the development of a rapport amongst participants and between participants and clinical researchers. Conclusions: The results provide useful insights regarding improving participation among hard-to-reach and historically underrepresented groups of older adults in clinical research. Future iterations of this program and similar educational interventions can use these findings to better achieve the programmatic objectives.