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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.
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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.
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Intercambio de Información en Salud , Medicare , Readmisión del Paciente , Readmisión del Paciente/estadística & datos numéricos , Humanos , Estados Unidos , Medicare/estadística & datos numéricos , Medicare/economía , Masculino , Femenino , Anciano , Intercambio de Información en Salud/estadística & datos numéricos , Anciano de 80 o más Años , Planes de Aranceles por Servicios/estadística & datos numéricosRESUMEN
BACKGROUND: The Center for Disease Control and Prevention's Stopping Elderly Accidents, Deaths, and Injuries (STEADI) initiative offers health care providers tools and resources to assist with fall risk screening and multifactorial fall risk assessment and interventions. Its effectiveness has never been evaluated in a randomized trial. OBJECTIVE: This study aims to describe the protocol for the STEADI Options Randomized Quality Improvement Trial (RQIT), which was designed to evaluate the impact on falls and all-cause health expenditures of a telemedicine-based form of STEADI implemented among older adults aged 65 years and older, within a primary care setting. METHODS: STEADI Options was a pragmatic RQIT implemented within a health system comparing a telemedicine version of the STEADI fall risk assessment to the standard of care (SOC). Before screening, we randomized all eligible patients in participating clinics into the STEADI arm or SOC arm based on their scheduled provider. All received the Stay Independent screener (SIS) to determine fall risk. Patients were considered at risk for falls if they scored 4 or more on the SIS or answered affirmatively to any 1 of the 3 key questions within the SIS. Patients screened at risk for falls and randomized to the STEADI arm were offered a registered nurse (RN)-led STEADI assessment through telemedicine; the RN provided assessment results and recommendations to the providers, who were advised to discuss fall-prevention strategies with their patients. Patients screened at risk for falls and randomized to the SOC arm were asked to participate in study data collection only. Data on recruitment, STEADI assessments, use of recommended prevention services, medications, and fall occurrences were collected using electronic health records and patient surveys. Using staff time diaries and administrative records, the study prospectively collected data on STEADI implementation costs and all-cause outpatient and inpatient charges incurred over the year following enrollment. RESULTS: The study enrolled 720 patients (n=307, 42.6% STEADI arm; n=353, 49% SOC arm; and n=60, 8.3% discontinued arm) from September 2020 to December 2021. Follow-up data collection was completed in January 2023. As of February 2024, data analysis is complete, and results are expected to be published by the end of 2025. CONCLUSIONS: The STEADI RQIT evaluates the impact of a telemedicine-based, STEADI-based fall risk assessment on falls and all-cause health expenditures and can provide information on the intervention's effectiveness and cost-effectiveness. TRIAL REGISTRATION: ClinicalTrials.gov NCT05390736, http://clinicaltrials.gov/ct2/show/NCT05390736. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/54395.
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Clinical dashboards are an emerging and fast-evolving technology used to support frontline clinicians' practice. Understanding end users' perceived engagement with clinical dashboards is essential to co-design, implementation, and adoption. There is a lack of literature exploring the integration of dashboards into clinical workflow. This rapid review explores clinical end users' perceived engagement with dashboards that support workflow. We conducted a literature search in PubMed and CINAHL. Four articles met our eligibility criteria. Findings reveal variations in taxonomy and measures used to evaluate clinicians' perceived engagement. There are also a variety of reported barriers and facilitators to adoption. Standardized frameworks and vocabulary are needed to facilitate a common understanding of clinical end users' perceived engagement with dashboards.
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Sistemas de Tablero , Determinación de la Elegibilidad , PubMed , Tecnología , Flujo de TrabajoRESUMEN
BACKGROUND: The EQUIPPED (Enhancing Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department) medication safety program is an evidence-informed quality improvement initiative to reduce potentially inappropriate medications (PIMs) prescribed by Emergency Department (ED) providers to adults aged 65 and older at discharge. We aimed to scale-up this successful program using (1) a traditional implementation model at an ED with a novel electronic medical record and (2) a new hub-and-spoke implementation model at three new EDs within a health system that had previously implemented EQUIPPED (hub). We hypothesized that implementation speed would increase under the hub-and-spoke model without cost to PIM reduction or site engagement. METHODS: We evaluated the effect of the EQUIPPED program on PIMs for each ED, comparing their 12-month baseline to 12-month post-implementation period prescribing data, number of months to implement EQUIPPED, and facilitators and barriers to implementation. RESULTS: The proportion of PIMs at all four sites declined significantly from pre- to post-EQUIPPED: at traditional site 1 from 8.9% (8.1-9.6) to 3.6% (3.6-9.6) (p < 0.001); at spread site 1 from 12.2% (11.2-13.2) to 7.1% (6.1-8.1) (p < 0.001); at spread site 2 from 11.3% (10.1-12.6) to 7.9% (6.4-8.8) (p = 0.045); and at spread site 3 from 16.2% (14.9-17.4) to 11.7% (10.3-13.0) (p < 0.001). Time to implement was equivalent at all sites across both models. Interview data, reflecting a wide scope of responsibilities for the champion at the traditional site and a narrow scope at the spoke sites, indicated disproportionate barriers to engagement at the spoke sites. CONCLUSIONS: EQUIPPED was successfully implemented under both implementation models at four new sites during the COVID-19 pandemic, indicating the feasibility of adapting EQUIPPED to complex, real-world conditions. The hub-and-spoke model offers an effective way to scale-up EQUIPPED though a speed or quality advantage could not be shown.
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Servicio de Urgencia en Hospital , Prescripción Inadecuada , Mejoramiento de la Calidad , Humanos , Anciano , Servicio de Urgencia en Hospital/organización & administración , Prescripción Inadecuada/prevención & control , Masculino , Lista de Medicamentos Potencialmente Inapropiados , Femenino , Registros Electrónicos de Salud , Alta del Paciente , COVID-19/epidemiología , Seguridad del PacienteRESUMEN
OBJECTIVES: In this pragmatic clinical trial, the primary objective is to increase access to behavioral treatment of urinary incontinence (UI) for women Veterans by comparing the effectiveness of two virtual care delivery modalities. METHODS: Veterans Affairs (VA) clinical sites in AL, GA, NC will virtually randomize 286 women Veterans with UI (ie, stress, urge, or mixed). We will compare the effectiveness of our mHealth UI application (MyHealtheBladder) to a single VA Video Connect (VVC) session delivered by trained UI providers. Women without improvement after 8 weeks will receive an optimization VVC visit using a sequential, multiple assignment, randomized trial (SMART) design. The primary outcome is UI symptom improvement at 12-weeks with or without optimization; secondary outcomes include improvements in lower urinary tract symptoms, adherence, retention rates, perceptions of improvement, and visit-related miles saved. Sample size needed to identify a 2.5-point change (range 0-21) in the International Consultation on Incontinence Questionnaire - Urinary Incontinence Short Form (ICIQ-UI SF) from baseline to 12-weeks post-randomization is 200 participants. Allowing for an attrition rate of 25%, 286 participants are required. KEY RESULTS: Study team initiated remote recruitment on April 2020. Recruitment is on target with a 75% retention rate. We expect completion in fall of 2023 (clinicaltrials.govNCT04237753). DISCUSSION/CONCLUSION: Engaging women Veterans with virtual modalities for initial UI treatment may increase access to UI care while also improving symptoms. After assessing efficacy, adherence, and retention, the next step is to implement the most effective option for remote delivery of evidence-based behavioral UI treatment for women Veterans. TRIAL REGISTRATION: ClinicalTrials.gov number NCT04237753.
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BACKGROUND: Urgency urinary incontinence (UUI) occurs in >40% of older women. Our objective was to examine the relationship of total and free plasma 25-hydroxyvitamin D (25(OH)D) and UUI to evaluate vitamin D status as a novel target for prevention of UUI. METHODS: We conducted a nested case control study using the Nurses' Health Study (NHS) and NHS II. Using stored plasma samples from 2000, we measured total 25(OH)D, free 25(OH)D, and intact parathyroid hormone (PTH) levels and examined their relationship to incident UUI from 2000 to 2013. Plasma biomarker levels were categorized as quartiles. Multivariable-adjusted odds ratios of UUI were estimated by conditional logistic regression models (with matching by age) across categories of each biomarker and covariates. RESULTS: The analytic sample included 398 cases of incident UUI and 398 matched controls with a mean age of 50 years. We found a strong correlation of plasma levels of total 25(OH)D with free 25(OH)D (r=0.5). Plasma total 25(OH)D and free 25(OH)D concentrations were negatively correlated with PTH (r=-0.08 AND -0.09, respectively). Overall, we found no evidence that levels of total plasma 25(OH)D, free 25(OH)D, or PTH were related to incident UUI after adjustment for obesity, physical activity, cigarette smoking, menopausal status, hypertension, and type 2 diabetes. CONCLUSIONS: Free plasma 25(OH)D by quartile, as well as total plasma 25(OH)D, was not associated with incident UUI in women. We found that plasma total and free 25(OH)D were highly correlated with each other and inversely correlated with PTH. Plasma free 25(OH)D did not provide additional predictive value in determining risk of UUI.
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INTRODUCTION: Urinary incontinence (UI) is a common and disruptive symptom of Parkinson's disease (PD). This study aimed to identify neural correlates associated with UI among PD patients with UI (UI-PD) compared to those PD patients without UI (nonUI-PD) with the expectation of demonstrating increased functional connectivity (FC) between areas in the striatum and limbic system and decreased FC in executive areas. METHODS: rsfMRI and T1w data (n = 119) were retrieved from the Parkinson's Progression Markers Initiative (PPMI). Resting-state FC analyses assessed temporal covariance with anterior cingulate gyrus, precuneus, and putamen seed regions. RESULTS: The UI-PD group (n = 32, 16 females) showed significantly greater positive FC between the bilateral putamen seed and the right caudate and right thalamus (p < 0.01), relative to individuals with PD but who did not have UI (n = 87, 18 females). The UI-PD group showed greater negative FC between the anterior cingulate seed and right angular gyrus (p < 0.01) relative to nonUI-PD. CONCLUSION: Individuals with PD and UI display stronger FC within neural circuits likely affected by PD such as between the putamen and caudate, as well as within those associated with brain bladder control, compared to persons with PD and without UI. Clinical application based on this study's results can provide greater discernment of treatment strategies for UI-PD patients.
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Enfermedad de Parkinson , Incontinencia Urinaria , Femenino , Humanos , Enfermedad de Parkinson/complicaciones , Enfermedad de Parkinson/diagnóstico por imagen , Imagen por Resonancia Magnética/métodos , Encéfalo/diagnóstico por imagen , Mapeo Encefálico , Incontinencia Urinaria/complicacionesRESUMEN
BACKGROUND: The Enhancing Quality of Prescribing Practices for Older Veterans Discharged from the Emergency Department (EQUIPPED) program developed an audit and feedback health information technology (IT) solution with the intent to replace the in-person academic detailing service provided by the program. The EQUIPPED dashboard provides emergency department (ED) providers with a personalized view of their prescribing performance. OBJECTIVES: Here, we analyze the association between ED provider characteristics and viewership of the EQUIPPED dashboard, adding insight into strategies for addressing barriers to initial use. METHODS: We performed a retrospective analysis of EQUIPPED dashboard viewership among four Veterans Affairs (VA) EDs. We extracted quantitative data from user interaction logs to determine evidence of dashboard use. Provider characteristics and baseline potentially inappropriate medication (PIM) prescribing rate were extracted from the VA's Corporate Data Warehouse. Logistic regression was used to examine the association between dashboard use and provider characteristics. RESULTS: A total of 82 providers were invited to receive audit and feedback via the EQUIPPED dashboard. Among invited providers, 40 (48.7%) had evidence of at least 1 dashboard view during the 1-year feedback period. Adjusted analyses suggest that providers with a higher baseline PIM prescribing rate were more likely to use the dashboard (odds ratio [OR]: 1.22; 95% confidence interval [CI]: 1.01-1.47). Furthermore, providers at ED site D were more likely to use the dashboard in comparison to the other sites (OR: 9.99; 95% CI: 1.72-58.04) and reportedly had the highest site-level baseline PIM rate. CONCLUSION: Providers with lower PIM prescribing rates (i.e., <5%) receive communication from an integrated dashboard reminder system that they are "optimal prescribers" which may have discouraged initial attempts to view the dashboard. Site D had the highest baseline PIM rate, but further qualitative investigation is warranted to better understand why site D had the greatest users of the dashboard.
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Comunicación , Servicio de Urgencia en Hospital , Humanos , Retroalimentación , Estudios Retrospectivos , Alta del PacienteRESUMEN
Importance: When an older adult is hospitalized, where they are discharged is of utmost importance. Fragmented readmissions, defined as readmissions to a different hospital than a patient was previously discharged from, may increase the risk of a nonhome discharge for older adults. However, this risk may be mitigated via electronic information exchange between the admission and readmission hospitals. Objective: To determine the association of fragmented hospital readmissions and electronic information sharing with discharge destination among Medicare beneficiaries. Design, Setting, and Participants: This cohort study retrospectively examined data from Medicare beneficiaries hospitalized for acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, syncope, urinary tract infection, dehydration, or behavioral issues in 2018 and their 30-day readmission for any reason. The data analysis was completed between November 1, 2021, and October 31, 2022. Exposures: Same hospital vs fragmented readmissions and presence of the same health information exchange (HIE) at the admission and readmission hospitals vs no information shared between the admission and readmission hospitals. Main Outcomes and Measures: The main outcome was discharge destination following the readmission, including home, home with home health, skilled nursing facility (SNF), hospice, leaving against medical advice, or dying. Outcomes were examined for beneficiaries with and without Alzheimer disease using logistic regressions. Results: The cohort included 275â¯189 admission-readmission pairs, representing 268â¯768 unique patients (mean [SD] age, 78.9 [9.0] years; 54.1% female and 45.9% male; 12.2% Black, 82.1% White, and 5.7% other race and ethnicity). Of the 31.6% fragmented readmissions in the cohort, 14.3% occurred at hospitals that shared an HIE with the admission hospital. Beneficiaries with same hospital/nonfragmented readmissions tended to be older (mean [SD] age, 78.9 [9.0] vs 77.9 [8.8] for fragmented with same HIE and 78.3 [8.7] years for fragmented without HIE; P < .001). Fragmented readmissions were associated with 10% higher odds of discharge to an SNF (adjusted odds ratio [AOR], 1.10; 95% CI, 1.07-1.12) and 22% lower odds of discharge home with home health (AOR, 0.78; 95% CI, 0.76-0.80) compared with same hospital/nonfragmented readmissions. When the admission and readmission hospital shared an HIE, beneficiaries had 9% to 15% higher odds of discharge home with home health (patients without Alzheimer disease: AOR, 1.09 [95% CI, 1.04-1.16]; patients with Alzheimer disease: AOR, 1.15 [95% CI, 1.01-1.32]) compared with fragmented readmissions where information sharing was not available. Conclusions and Relevance: In this cohort study of Medicare beneficiaries with 30-day readmissions, whether a readmission is fragmented was associated with discharge destination. Among fragmented readmissions, shared HIE across admission and readmission hospitals was associated with higher odds of discharge home with home health. Efforts to study the utility of HIE for care coordination for older adults should be pursued.
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Enfermedad de Alzheimer , Hospitales para Enfermos Terminales , Humanos , Masculino , Femenino , Anciano , Estados Unidos , Alta del Paciente , Readmisión del Paciente , Estudios de Cohortes , Estudios Retrospectivos , MedicareRESUMEN
Whether initiation of statins could increase survival free of dementia and disability in adults aged ≥75 years is unknown. PREVENTABLE, a double-blind, placebo-controlled randomized pragmatic clinical trial, will compare high-intensity statin therapy (atorvastatin 40 mg) with placebo in 20,000 community-dwelling adults aged ≥75 years without cardiovascular disease, disability, or dementia at baseline. Exclusion criteria include statin use in the prior year or for >5 years and inability to take a statin. Potential participants are identified using computable phenotypes derived from the electronic health record and local referrals from the community. Participants will undergo baseline cognitive testing, with physical testing and a blinded lipid panel if feasible. Cognitive testing and disability screening will be conducted annually. Multiple data sources will be queried for cardiovascular events, dementia, and disability; survival is site-reported and supplemented by a National Death Index search. The primary outcome is survival free of new dementia or persisting disability. Co-secondary outcomes are a composite of cardiovascular death, hospitalization for unstable angina or myocardial infarction, heart failure, stroke, or coronary revascularization; and a composite of mild cognitive impairment or dementia. Ancillary studies will offer mechanistic insights into the effects of statins on key outcomes. Biorepository samples are obtained and stored for future study. These results will inform the benefit of statins for increasing survival free of dementia and disability among older adults. This is a pioneering pragmatic study testing important questions with low participant burden to align with the needs of the growing population of older adults.
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Demencia , Inhibidores de Hidroximetilglutaril-CoA Reductasas , Infarto del Miocardio , Accidente Cerebrovascular , Humanos , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Infarto del Miocardio/tratamiento farmacológico , Accidente Cerebrovascular/epidemiología , Demencia/prevención & control , Demencia/tratamiento farmacológico , LípidosRESUMEN
OBJECTIVE: To estimate referent values for performance on clinical mobility tests conducted amongst racially diverse adults aged 50-95 years in the Southeast US. DESIGN: This is an observational study of community-dwelling older adults from diverse racial groups who participated in observational and rehabilitative studies conducted from 2011-2019. SETTING: Rehabilitation clinics around the greater metropolitan Atlanta, Georgia, region. PARTICIPANTS: A total of 314 adults (N=314; 222 women). Individuals were predominantly Black (n=121) or White (n=164), with some participants from other racial groups (n=29). INTERVENTIONS: Clinical and demographic data were collected at individual visits for each participant. MAIN OUTCOME MEASURES: Four Square Step Test (FSST), timed Up and Go (TUG) test, dual TUG test, 6-minute walk test (6MWT), 30-second chair stand, and gait speed were all used as assessments in each cohort. RESULTS: Performance slowly declines with increasing age, with a sharp drop in the ninth decade for preferred forward, backward, and fast gait speed; backward gait cadence; 6MWT, TUG test, dual-task TUG-Cognitive, and the 360° turn test. Declines were also seen in the eighth and ninth decades in the FSST. Among White participants, there were significant overall differences across age groups except in the assessment variable, preferred gait cadence. For Black individuals, there were significant overall differences across age groups for backward gait speed, fast gait speed, TUG-Cognitive, dual task, 6MWT, FSST, and 30-second chair stand. CONCLUSIONS: These data enrich current referent values for brief, commonly used clinical tests in a diverse, older Southeast US cohort. These data include representatives of the oldest old cohort. This study will support race- and age-specific fall prevention and mobility-enhancing therapeutic application among older patients in clinical practice.
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Caminata , Blanco , Anciano de 80 o más Años , Humanos , Femenino , Anciano , Marcha , Velocidad al Caminar , Vida IndependienteRESUMEN
INTRODUCTION: Few instruments measure knowledge, attitudes, and beliefs (KAB) related to bladder health. Existing questionnaires have predominantly focused on KAB related to specific conditions such as urinary incontinence, overactive bladder, and other pelvic floor disorders. To address this literature gap, the Prevention of Lower Urinary Tract Symptoms (PLUS) research consortium developed an instrument that is being administered in the baseline assessment of the PLUS RISE FOR HEALTH longitudinal study. METHODS: The bladder health knowledge, attitudes, and beliefs (BH-KAB) instrument development process consisted of two phases, item development and evaluation. Item development was guided by a conceptual framework, review of existing KAB instruments, and a review of qualitative data from the PLUS consortium Study of Habits, Attitudes, Realities, and Experiences (SHARE). Evaluation comprised three methods to assess content validity and reduce and refine items: q-sort, e-panel survey, and cognitive interviews. RESULTS: The final 18-item BH-KAB instrument assesses self-reported bladder knowledge; perceptions of bladder function, anatomy, and related medical conditions; attitudes toward different patterns of fluid intake, voiding, and nocturia; the potential to prevent or treat urinary tract infections and incontinence; and the impact of pregnancy and pelvic muscle exercises on bladder health. CONCLUSION: The PLUS BH-KAB instrument may be used independently or in conjunction with other KAB instruments for a more comprehensive assessment of women's KAB related to bladder health. The BH-KAB instrument can inform clinical conversations, health education programming, and research examining potential determinants of bladder health, LUTS, and related behavioral habits (e.g., toileting, fluid intake, pelvic muscle exercises).
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Síntomas del Sistema Urinario Inferior , Vejiga Urinaria Hiperactiva , Incontinencia Urinaria , Embarazo , Humanos , Femenino , Vejiga Urinaria , Conocimientos, Actitudes y Práctica en Salud , Estudios Longitudinales , Incontinencia Urinaria/diagnóstico , Incontinencia Urinaria/prevención & control , Vejiga Urinaria Hiperactiva/diagnóstico , Vejiga Urinaria Hiperactiva/terapia , Síntomas del Sistema Urinario Inferior/diagnóstico , Síntomas del Sistema Urinario Inferior/prevención & controlRESUMEN
BACKGROUND: Although electronic health information sharing is expanding nationally, it is unclear whether electronic health information sharing improves patient outcomes, particularly for patients who are at the highest risk of communication challenges, such as older adults with Alzheimer disease. OBJECTIVE: To determine the association between hospital-level health information exchange (HIE) participation and in-hospital or postdischarge mortality among Medicare beneficiaries with Alzheimer disease or 30-day readmissions to a different hospital following an admission for one of several common conditions. METHODS: This was a cohort study of Medicare beneficiaries with Alzheimer disease who had one or more 30-day readmissions in 2018 following an initial admission for select Hospital Readmission Reduction Program conditions (acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, and pneumonia) or common reasons for hospitalization among older adults with Alzheimer disease (dehydration, syncope, urinary tract infection, or behavioral issues). Using unadjusted and adjusted logistic regression, we examined the association between electronic information sharing and in-hospital mortality during the readmission or mortality in the 30 days following the readmission. RESULTS: A total of 28,946 admission-readmission pairs were included. Beneficiaries with same-hospital readmissions were older (aged 81.1, SD 8.6 years) than beneficiaries with readmissions to different hospitals (age range 79.8-80.3 years, P<.001). Compared to admissions and readmissions to the same hospital, beneficiaries who had a readmission to a different hospital that shared an HIE with the admission hospital had 39% lower odds of dying during the readmission (adjusted odds ratio [AOR] 0.61, 95% CI 0.39-0.95). There were no differences in in-hospital mortality observed for admission-readmission pairs to different hospitals that participated in different HIEs (AOR 1.02, 95% CI 0.82-1.28) or to different hospitals where one or both hospitals did not participate in HIE (AOR 1.25, 95% CI 0.93-1.68), and there was no association between information sharing and postdischarge mortality. CONCLUSIONS: These results indicate that information sharing between unrelated hospitals via a shared HIE may be associated with lower in-hospital, but not postdischarge, mortality for older adults with Alzheimer disease. In-hospital mortality during a readmission to a different hospital was higher if the admission and readmission hospitals participated in different HIEs or if one or both hospitals did not participate in an HIE. Limitations of this analysis include that HIE participation was measured at the hospital level, rather than at the provider level. This study provides some evidence that HIEs can improve care for vulnerable populations receiving acute care from different hospitals.
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OBJECTIVES: The Enhancing the Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department (EQUIPPED) medication safety program involves three core components including provider education, clinical decision support, and audit and feedback using the American Geriatrics Society Beers Criteria to determine potentially inappropriate medications (PIMs). This study evaluated implementation of audit and feedback through a centralized informatics-based dashboard compared to academic detailing delivered one on one by an EQUIPPED champion. METHODS: In a cluster-randomized study (October 2019-September 2021), eight VA emergency department (EDs) implemented either the academic detailing (n = 4) or the dashboard (n = 4) strategy for the audit and feedback component of EQUIPPED. The primary outcome was the monthly proportion of PIMs prescribed to Veterans 65 years or older at ED discharge. Poisson regression was used to evaluate the proportion of PIMs prescribed 6 months prior to EQUIPPED implementation compared to 12 months following implementation. RESULTS: Eight VA ED sites successfully implemented the EQUIPPED program. During the 6-month baseline period, the academic detailing and dashboard sites had similar PIM prescribing rates of 8.01% for academic detailing versus 8.04% for dashboard (p = 0.90). Comparing 12 months of prescribing data after EQUIPPED implementation, the academic detailing group significantly improved PIM prescribing (7.07%) compared to the dashboard group (8.10%; odds ratio 1.14, 95% confidence interval 1.08-1.22, p ≤ 0.0001). Within the groups, two of the four academic detailing sites demonstrated statistically significant reductions in PIM prescribing. One of the four dashboard sites achieved nearly 50% relative reduction in PIM prescribing. CONCLUSIONS: Eight VA EDs successfully implemented the core components of the EQUIPPED program amid the unprecedented challenges posed by the COVID-19 pandemic. While the academic detailing approach to EQUIPPED audit and feedback was more effective at the group level to improve safe prescribing for older Veterans discharged from the ED, the trial suggests that dashboard-based audit and feedback is a reasonable strategy in resource-limited settings.
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COVID-19 , Prescripción Inadecuada , Humanos , Estados Unidos , Anciano , Mejoramiento de la Calidad , Retroalimentación , PandemiasRESUMEN
BACKGROUND: Interhospital care fragmentation, when a patient is readmitted to a different hospital than they were originally discharged from, occurs in 20%-25% of readmissions. Mode of transport to the hospital, specifically ambulance use, may be a risk factor for fragmented readmissions. Our study seeks to further understand the relationship between ambulance transport and fragmented readmissions in older adults, a population that is at increased risk for poor outcomes following fragmented readmissions. METHODS: We analyzed inpatient claims from Medicare beneficiaries in 2018 who had a hospital admission for select Hospital Readmission Reduction Program Conditions (acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, pneumonia) as well as dehydration, syncope, urinary tract infection, or behavioral issues. We evaluated the associations between ambulance transport and a fragmented readmission using logistic regression models adjusted for demographic, clinical, and hospital characteristics. RESULTS: The study included 1,186,600 30-day readmissions. Of these, 46.8% (n = 555,847) required ambulance transport. In fully adjusted models, taking an ambulance to the readmission hospital increased the odds of a fragmented readmission by 38% (95% CI 1.32, 1.44). When this association was examined by readmission major diagnostic category (MDC), the strongest associations were seen for Factors Influencing Health Status and Other Contacts with Health Services (i.e., rehabilitation, aftercare) (AOR 3.66, 95% CI 3.11, 4.32), Mental Diseases and Disorders (AOR 2.69, 95% CI 2.44, 2.97), and Multiple Significant Trauma (AOR 2.61, 95% CI 1.56, 4.35). When the model was stratified by patient origin, ambulance use remained associated with fragmented readmissions across all locations. CONCLUSIONS: Ambulance use is associated with increased odds of a fragmented readmission, though the strength of the association varies by readmission diagnosis and origin. Patient-, hospital-, and system-level interventions should be developed, implemented, and evaluated to address this modifiable risk factor.
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Ambulancias , Readmisión del Paciente , Anciano , Humanos , Estados Unidos/epidemiología , Medicare , Hospitalización , Alta del Paciente , Estudios RetrospectivosRESUMEN
PURPOSE: Our goal was to evaluate vitamin D supplementation for preventing or treating overactive bladder and urinary incontinence in men. MATERIALS AND METHODS: Ancillary study of men aged ≥55 years in VITAL (VITamin D and OmegA-3 TriaL). Randomized treatments included: vitamin D3 (cholecalciferol), marine omega-3 fatty acids, or matching placebo. Structured urinary incontinence questions measured the prevalence of overactive bladder at year 5 and urinary incontinence at years 2 and 5, along with incidence and progression of urinary incontinence from years 2 to 5. Prespecified subgroup analyses examined men with low baseline serum 25-hydroxyvitamin D (<20 ng/mL). RESULTS: Among the 11,486 men who provided data at year 2 and 10,474 at year 5, mean age was 68 years at year 2, with 23% racial/ethnic minorities. In primary analyses, vitamin D supplementation compared to placebo did not lower odds of overactive bladder at year 5 (OR 0.97, 95% CI 0.87-1.08) or weekly urinary incontinence at year 2 (OR 0.94, 95% CI 0.83-1.05) or year 5 (OR 0.98, 95% CI 0.88-1.09). We found interactions of baseline serum 25-hydroxyvitamin D level with vitamin D supplementation for overactive bladder (P value for interaction = .001), and secondarily, for any urinary incontinence at year 2 (P value for interaction = .05). Men with baseline 25-hydroxyvitamin D <20 ng/mL, who were assigned to vitamin D supplements, had lower odds of overactive bladder (OR 0.51, 95% CI 0.35-0.76) compared to placebo, yet higher odds of any urinary incontinence (OR 1.24, 95% CI 0.93-1.64). CONCLUSIONS: Overall, vitamin D supplementation did not improve overactive bladder or urinary incontinence compared to placebo. However, specific use of vitamin D in men with lower 25-hydroxyvitamin D levels had inconsistent findings.