Cross-setting Comparison of Risk Factors for Pressure Injuries Acquired in Post-Acute Care.

GENERAL PURPOSE: To provide information on the association between risk factors and the development of new or worsened stage 2 to 4 pressure injuries (PIs) in patients in long-term care hospitals (LTCHs), inpatient rehabilitation facilities (IRFs), and skilled nursing facilities (SNFs). TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant will:1. Compare the unadjusted PI incidence in SNF, IRF, and LTCH populations.2. Explain the extent to which the clinical risk factors of functional limitation (bed mobility), bowel incontinence, diabetes/peripheral vascular disease/peripheral arterial disease, and low body mass index are associated with new or worsened stage 2 to 4 PIs across the SNF, IRF, and LTCH populations.3. Compare the incidence of new or worsened stage 2 to 4 PI development in SNF, IRF, and LTCH populations associated with high body mass index, urinary incontinence, dual urinary and bowel incontinence, and advanced age.

Use of electronic health record data to examine administrations of pro re nata analgesics during hip fracture post-acute care.

PURPOSE: Medications prescribed to older adults in US skilled nursing facilities (SNF) and administrations of pro re nata (PRN) "as needed" medications are unobservable in Medicare insurance claims. There is an ongoing deficit in our understanding of medication use during post-acute care. Using SNF electronic health record (EHR) datasets, including medication orders and barcode medication administration records, we described patterns of PRN analgesic prescribing and administrations among SNF residents with hip fracture. METHODS: Eligible participants resided in SNFs owned by 11 chains, had a diagnosis of hip fracture between January 1, 2018 to August 2, 2021, and received at least one administration of an analgesic medication in the 100 days after the hip fracture. We described the scheduling of analgesics, the proportion of available PRN doses administered, and the proportion of days with at least one PRN analgesic administration. RESULTS: Among 24 038 residents, 57.3% had orders for PRN acetaminophen, 67.4% PRN opioids, 4.2% PRN non-steroidal anti-inflammatory drugs, and 18.6% PRN combination products. The median proportion of available PRN doses administered per drug was 3%-50% and the median proportion of days where one or more doses of an ordered PRN analgesic was administered was 25%-75%. Results differed by analgesic class and the number of administrations ordered per day. CONCLUSIONS: EHRs can be leveraged to ascertain precise analgesic exposures during SNF stays. Future pharmacoepidemiology studies should consider linking SNF EHRs to insurance claims to construct a longitudinal history of medication use and healthcare utilization prior to and during episodes of SNF care.

A National Survey of Pediatric Post-Acute Care Facilities.

OBJECTIVES: To identify and geolocate pediatric post-acute care (PAC) facilities in the United States. DESIGN: Cross-sectional survey using both online resources and telephone inquiry. SETTING: All 50 U.S. states surveyed from June 2022 to May 2023. Care sites identified via state regulatory agencies and the Centers for Medicare & Medicaid Services. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Number, size, and type of facility, scope of practice, and type of care provided. One thousand three hundred fifty-five facilities were surveyed; of these, 18.6% (252/1355) were pediatric-specific units or adult facilities accepting some pediatric patients. There were 109 pediatric-specific facilities identified within 39 U.S. states. Of these, 38 were freestanding with all accepting children with tracheostomies, 97.4% (37/38) accepting those requiring mechanical ventilation via tracheostomy, and 81.6% (31/38) accepting those requiring parenteral nutrition. The remaining 71 facilities were adult facilities with embedded pediatric units or children's hospitals with 88.7% (63/71), 54.9% (39/71), and 54.9% (39/71), accepting tracheostomies, mechanical ventilation via tracheostomy, and parenteral nutrition, respectively. Eleven states lacked any pediatric-specific PAC units or facilities. CONCLUSIONS: The distribution of pediatric PAC is sparse and uneven across the United States. We present an interactive map and database describing these facilities. These data offer a starting point for exploring the consequences of pediatric PAC supply.

Interdisciplinary videoconference model for identifying potential adverse transition of care events following hospital discharge to postacute care.

Discharge from hospitals to postacute care settings is a vulnerable time for many older adults, when they may be at increased risk for errors occurring in their care. We developed the Extension for Community Healthcare Outcomes-Care Transitions (ECHO-CT) programme in an effort to mitigate these risks through a mulitdisciplinary, educational, case-based teleconference between hospital and skilled nursing facility providers. The programme was implemented in both academic and community hospitals. Through weekly sessions, patients discharged from the hospital were discussed, clinical concerns addressed, errors in care identified and plans were made for remediation. A total of 1432 discussions occurred for 1326 patients. The aim of this study was to identify errors occurring in the postdischarge period and factors that predict an increased risk of experiencing an error. In 435 discussions, an issue was identified that required further discussion (known as a transition of care event), and the majority of these were related to medications. In 14.7% of all discussions, a medical error, defined as 'any preventable event that may cause or lead to inappropriate medical care or patient harm', was identified. We found that errors were more likely to occur for patients discharged from surgical services or the emergency department (as compared with medical services) and were less likely to occur for patients who were discharged in the morning. This study shows that a number of errors may be detected in the postdischarge period, and the ECHO-CT programme provides a mechanism for identifying and mitigating these events. Furthermore, it suggests that discharging service and time of day may be associated with risk of error in the discharge period, thereby suggesting potential areas of focus for future interventions.

Patterns and predictors of ten-year mortality after discharge from community-based post-acute care for acquired brain injury: A retrospective cohort study (ABI-RESTaRT), Western Australia, 1991-2017.

BACKGROUND: Survivors of acquired brain injury (ABI) are left with long-term disability and an increased risk of mortality years post-injury. OBJECTIVE: To examine 10-year mortality in adults with ABI after discharge from post-acute care and identify modifiable risk factors to reduce long-term mortality risk. METHODS: Retrospective cohort study of 586 adults with traumatic (TBI) or non-traumatic brain injury (NTBI), or neurologic condition, consecutively discharged from a post-acute rehabilitation service in Western Australia from 1-Mar-1991 to 31-Dec-2017. Data sources included rehabilitation records, and linked mortality, hospital, and emergency department data. Survival status at 10 years post-discharge was determined. All-cause and cause-specific age- and sex-adjusted standardised mortality ratios (SMR) by ABI diagnosis were calculated using Australian population reference data. Risk factors were examined using multilevel cox proportional hazards regression. RESULTS: Compared with the Australian population, 10-year all-cause mortality was significantly elevated for all diagnosis cohorts, with the first 12 months the highest risk period. Accidents or intentional self-harm deaths were elevated in TBI (13.2, 95%CI 5.4; 12.1). Neurodegenerative disease deaths were elevated in Neurologic (21.9, 95%CI 13.0; 30.9) and Stroke (19.8; 95%CI 2.4; 27.2) cohorts. Stroke (20.8; 95%CI 7.9; 33.8) and circulatory disease deaths (6.2; 95%CI 2.3; 9.9) were also elevated in Stroke. Psychiatric comorbidity was the strongest risk factor followed by older age, geographical remoteness, and cardiac, vascular, genitourinary and renal comorbidity. Clinically significant improvement in functional independence and psychosocial functioning significantly reduced mortality risk. CONCLUSIONS: Individuals with ABI have an elevated risk of mortality years post-injury. Comorbidity management, continuity of care, and rehabilitation are important to reduce long-term mortality risk.

Post-acute care transitions during COVID-19: Racial, ethnic, and socioeconomic differences in older adults with Alzheimer's disease and related dementia.

BACKGROUND: Differences in the post-acute care (PAC) destinations among racial, ethnic, and socioeconomic groups have been documented before the COVID-19 pandemic. Yet, the pandemic's impact on these differences remains unknown. We examined the impact of the COVID-19 pandemic on PAC destinations and its variation by individual race, ethnicity, and socioeconomic status among community-dwelling older adults with Alzheimer's disease and related dementia (ADRD). METHODS: We linked 2019-2021 national data (Medicare claims, Minimum Data Set, Master Beneficiary Summary File) and several publicly available datasets, including Provider of Services File, Area Deprivation Index, Area Health Resource File, and COVID-19 infection data. PAC discharge destinations included skilled nursing facilities (SNFs), home health agencies (HHA), and homes without services. Key variables of interest included individual race, ethnicity, and Medicare-Medicaid dual status. The analytic cohort included 830,656 community-dwelling Medicare fee-for-service beneficiaries with ADRD who were hospitalized between 2019 and 2021. Regression models with hospital random effects and state-fixed effects were estimated, stratified by the time periods, and adjusted for the individual, hospital, and county-level covariates. RESULTS: SNF discharges decreased while home and HHA discharges increased during the pandemic. The trend was more prominent among racial and ethnic minoritized groups and even more so among dual-eligible beneficiaries. For instance, the reduction in the probabilities of SNF admissions between the pre-pandemic period and the 2nd year of COVID was 4.6 (White non-duals), 18.5 (White duals), 8.7 (Black non-duals), and 20.1 (Black duals) percentage-point, respectively. We also found that non-duals were more likely to replace SNF with HHA services, while duals were more likely to be discharged home without HHA. CONCLUSIONS: The COVID-19 pandemic significantly impacted PAC destinations for individuals with ADRD, especially among socioeconomically disadvantaged and racial and ethnic minoritized populations. Future research is needed to understand if and how these transitions may have affected health outcomes.

Nursing home closures and access to post-acute care and long-term care services in rural areas.

PURPOSE: Nursing home closures have raised concerns about access to post-acute care (PAC) and long-term care (LTC) services. We estimate the additional distance rural residents had to travel to access PAC and LTC services because of nursing home closures. METHODS: We identify nursing home closures and the availability of PAC and LTC services in nursing homes, home health agencies, and hospitals with swing beds using the Medicare Provider of Services file (2008-2018). Using distances between ZIP codes, we summarize distances to the closest provider of PAC and LTC services for rural and urban ZIP codes with nursing home closures from 2008 to 2018 and no nursing homes in 2018. FINDINGS: Compared to urban ZIP codes, rural ZIP codes experiencing nursing home closure had higher distances to the closest nursing home providing PAC (6.4 vs. 0.94 miles; p < 0.05) and LTC services (7.2 vs. 1.1 miles; p < 0.05), and these differences remain even after accounting for the availability of home health agencies and hospitals with swing beds. Distances to the closest providers with PAC and LTC services were even higher for rural ZIP codes with no nursing homes in 2018. About 6.1%-15.7% of rural ZIP codes with a nursing home closure or with no nursing homes had no PAC or LTC providers within 25 miles. CONCLUSIONS: Nursing home closures increased distances to nursing homes, home health agencies, and hospitals with swing beds for rural residents. Access to PAC and LTC services is a concern, especially for rural areas with no nursing homes.

Trends in Receipt of Help at Home After Hospital Discharge Among Older Adults in the US.

Importance: With declining use of institutional postacute care, more patients are going directly home after hospital discharge. The consequences on the amount of help needed at home after discharge are unknown. Objective: To estimate trends in the frequency and duration of receipt of help with activities of daily living (ADLs) among older adults discharged home. Design, Setting, and Participants: Repeated cross-sectional study of a national sample of community-dwelling older adults who returned home after hospital discharge from 2011 to 2017. Participants included respondents to National Health and Aging Trends Study (NHATS), an annual population-based, nationally representative survey of Medicare beneficiaries, who were 69 years or older and were discharged from an acute care hospital to home during the years of the study. A nationally representative sample was estimated using NHATS' analytic weights. Unweighted frequencies and weighted and unweighted percentages are reported. The analysis was conducted from September 2020 to October 2021. Exposures: Discharge from an acute care hospitalization. Main Outcomes and Measures: Receipt of help with ADLs during the 3 months after hospital discharge. Results: Of the 3591 survey participants who were discharged home from an acute care hospital during the study period, 53.3% were female, 54.8% were married or living with a partner, and the mean (SD) age was 78.5 (7.0) years. Of these, 1710 (44.1%) reported receiving help within 3 months of discharge. Compared with people not receiving help, those receiving help were older (mean [SD] years, 79.7 [7.5] years vs 77.6 [6.3] years), had worse self-rated health at baseline (47.1% with fair or poor health vs 26.5%) and were more likely to have dementia (21.8% vs 5.5%). The percentage of respondents who reported receiving help increased during the study period from 38.1% of hospital discharges in 2011 to 51.5% in 2017. For those who were independent in their ADLs before hospitalization, the percentage receiving help after discharge more than doubled over the study period increasing from 9.3% receiving help in 2011 to 31.8% in 2017. Among patients who did not receive Medicare-reimbursed home health, the percentage receiving help also increased from 22.1% to 28.1%. Among those who received help after discharge, the need for help slowly declined to prehospitalization levels over the ensuing 9 months. Conclusions and Relevance: In this cross-sectional study, older adults' receipt of help at home after hospital discharge increased from 2011 to 2017, including patients relying on non-Medicare funded sources of care. As payers steer patients away from inpatient postacute care facilities, policymakers will need to pay attention to this shifting burden of care.

Challenges and Lessons Learned for Acute Inpatient Rehabilitation of Persons With COVID-19: Clinical Presentation, Assessment, Needs, and Services Utilization.

OBJECTIVE: The aim of the study was to present: (1) physiatric care delivery amid the SARS-CoV-2 pandemic, (2) challenges, (3) data from the first cohort of post-COVID-19 inpatient rehabilitation facility patients, and (4) lessons learned by a research consortium of New York and New Jersey rehabilitation institutions. DESIGN: For this clinical descriptive retrospective study, data were extracted from post-COVID-19 patient records treated at a research consortium of New York and New Jersey rehabilitation inpatient rehabilitation facilities (May 1-June 30, 2020) to characterize admission criteria, physical space, precautions, bed numbers, staffing, employee wellness, leadership, and family communication. For comparison, data from the Uniform Data System and eRehabData databases were analyzed. The research consortium of New York and New Jersey rehabilitation members discussed experiences and lessons learned. RESULTS: The COVID-19 patients (N = 320) were treated during the study period. Most patients were male, average age of 61.9 yrs, and 40.9% were White. The average acute care length of stay before inpatient rehabilitation facility admission was 24.5 days; mean length of stay at inpatient rehabilitation facilities was 15.2 days. The rehabilitation research consortium of New York and New Jersey rehabilitation institutions reported a greater proportion of COVID-19 patients discharged to home compared with prepandemic data. Some institutions reported higher changes in functional scores during rehabilitation admission, compared with prepandemic data. CONCLUSIONS: The COVID-19 pandemic acutely affected patient care and overall institutional operations. The research consortium of New York and New Jersey rehabilitation institutions responded dynamically to bed expansions/contractions, staff deployment, and innovations that facilitated safe and effective patient care.

An international comparison of long-term care trajectories and spending following hip fracture.

OBJECTIVE: The objectives of this study are to compare the relative use of different postacute care settings in different countries and to compare three important outcomes as follows: total expenditure, total days of care in different care settings, and overall longevity over a 1-year period following a hip fracture. DATA SOURCES: We used administrative data from hospitals, institutional and home-based long-term care (LTC), physician visits, and medications compiled by the International Collaborative on Costs, Outcomes, and Needs in Care (ICCONIC) from five countries as follows: Canada, France, Germany, the Netherlands, and Sweden. DATA EXTRACTION METHODS: Data were extracted from existing administrative data systems in each participating country. STUDY DESIGN: This is a retrospective cohort study of all individuals admitted to acute care for hip fracture. Descriptive comparisons were used to examine aggregate institutional and home-based postacute care. Care trajectories were created to track sequential care settings after acute-care discharge through institutional and community-based care in three countries where detailed information allowed. Comparisons in patient characteristics, utilization, and costs were made across these trajectories and countries. PRINCIPAL FINDINGS: Across five countries with complete LTC data, we found notable variations with Germany having the highest days of home-based services with relatively low costs, while Sweden incurred the highest overall expenditures. Comparisons of trajectories found that France had the highest use of inpatient rehabilitation. Germany was most likely to discharge hip fracture patients to home. Over 365 days, France averaged the highest number of days in institution with 104, Canada followed at 94, and Germany had just 87 days of institutional care on average. CONCLUSION: In this comparison of LTC services following a hip fracture, we found international differences in total use of institutional and noninstitutional care, longevity, and total expenditures. There exist opportunities to organize postacute care differently to maximize independence and mitigate costs.

Is Discordance Between Recommended and Actual Postacute Discharge Setting a Risk Factor for Readmission in Patients With Congestive Heart Failure?

Background Readmissions in patients with congestive heart failure are common and often preventable. Limited data suggest that patients discharged to a less intensive postacute care setting than recommended are likely to readmit. We examined whether postacute setting discordance (discharge to a less intensive postacute setting than recommended by a physical and occupational therapist) was associated with hospital readmission in patients with congestive heart failure. We also assessed sociodemographic and clinical predictors of setting discordance. Methods and Results Retrospective analysis of administrative claims and electronic health record data was conducted on 25 500 adults with a discharge diagnosis of congestive heart failure from 12 acute care hospitals in Western Pennsylvania. Generalized linear mixed models were estimated to examine the association between postacute setting discordance and 30-day hospital readmission and to identify predictors of setting discordance. The 30-day readmission and postacute setting discordance rates were high (23.7%, 20.6%). While controlling for demographic and clinical covariates, patients in discordant postacute settings were more likely to be readmitted within 30 days (adjusted odds ratio [OR], 1.12; 95% CI, 1.04-1.20). The effect was also seen in the subgroup of patients with low mobility scores (adjusted OR, 1.20; 95% CI, 1.08-1.33). Factors associated with setting discordance were lower-income, higher comorbidity burden, therapist recommendation disagreement, and midrange mobility limitations. Conclusions Postacute setting discordance was associated with an increased readmission risk in patients hospitalized with congestive heart failure. Maximizing concordance between therapist recommended and actual postacute discharge setting may decrease readmissions. Understanding factors associated with post-acute setting discordance can inform strategies to improve the quality of the discharge process.

Outcomes of post-acute care in skilled nursing facilities in Medicare beneficiaries with and without a diagnosis of dementia.

BACKGROUND: More than 600,000 Medicare beneficiaries with a diagnosis of dementia are discharged to skilled nursing facilities (SNFs) after hospitalization annually. However, it is unclear how their risks and benefits of a SNF stay compare to beneficiaries without a diagnosis of dementia. DESIGN: Retrospective analysis comparing SNF outcomes for Medicare beneficiaries with and without a diagnosis of dementia. SETTING: One hundred percent sample of Medicare beneficiaries from 2015 to 2016. PARTICIPANTS: Dementia was identified using validated diagnosis codes. In beneficiaries who had an acute hospitalization followed by SNF stay, we used propensity score matching to balance demographics, comorbidities, characteristics of the index hospital stay, prior hospital and SNF utilization, and cognitive status on SNF admission. MEASUREMENTS: Outcomes included unplanned hospital readmission, community discharge rate, and mortality during the SNF stay. Multivariate models were adjusted for hospital and SNF characteristics. RESULTS: Our sample included 2,418,853 Medicare beneficiaries discharged from hospital to SNF; 830,524 (34.3%) carried a diagnosis of dementia. Overall, 14.7% of the sample had a hospital readmission, 5.0% died, and 61.5% were successfully discharged to the community. In the propensity-matched cohort, beneficiaries with a diagnosis of dementia had a lower odds ratio of mortality (OR 0.87; 95% confidence interval [CI] 0.86-0.89), similar odds of hospital readmission (OR 0.99; 95% CI 0.98-1.00), and reduced odds of discharge to the community (OR 0.92; 95% CI 0.91-0.93). However, these findings varied by the severity of cognitive impairment on SNF admission: in beneficiaries with no impairment, those with a diagnosis of dementia had higher odds of adverse outcomes. In beneficiaries with severe impairment, beneficiaries with a diagnosis of dementia had lower odds of adverse outcomes. CONCLUSIONS: Cognitive dysfunction on SNF admission is a stronger predictor of outcomes than a diagnosis of dementia, suggesting the need to individualize decisions about the benefits and risks of SNF care in populations with cognitive impairment.

Multimorbidity and Its Relationship With Long-Term Outcomes After Critical Care Discharge: A Prospective Cohort Study.

BACKGROUND: Survivors of critical illness have poor long-term outcomes with subsequent increases in health care utilization. Less is known about the interplay between multimorbidity and long-term outcomes. RESEARCH QUESTION: How do baseline patient demographics impact mortality and health care utilization in the year after discharge from critical care? STUDY DESIGN AND METHODS: Using data from a prospectively collected cohort, we used propensity score matching to assess differences in outcomes between patients with a critical care encounter and patients admitted to the hospital without critical care. Long-term mortality was examined via nationally linked data as was hospital resource use in the year after hospital discharge. The cause of death was also examined. RESULTS: This analysis included 3,112 participants. There was no difference in long-term mortality between the critical care and hospital cohorts (adjusted hazard ratio, 1.09; 95% CI, 0.90-1.32; P = .39). Prehospitalization emotional health issues (eg, clinical diagnosis of depression) were associated with increased long-term mortality (hazard ratio, 1.49; 95% CI, 1.14-1.96; P < .004). Health care utilization was different between the two cohorts in the year after discharge with the critical care cohort experiencing a 29% increased risk of hospital readmission (OR, 1.29; 95% CI, 1.11-1.50; P = .001). INTERPRETATION: This national cohort study has demonstrated increased resource use for critical care survivors in the year after discharge but fails to replicate past findings of increased longer-term mortality. Multimorbidity, lifestyle factors, and socioeconomic status appear to influence long-term outcomes and should be the focus of future research.

Longer length of post-acute care stay causes greater functional improvements in poststroke patients.

ABSTRACT: Post-acute care (PAC) is a type of transitional care for poststroke patients after the acute medical stage; it offers a relatively intensive rehabilitative program. Under Taiwan's National Health Insurance guidelines, the only patients who can transfer to PAC institutions are those who have had an acute stroke in the previous month, are in a relatively stable medical condition, and have the potential for improvement after aggressive rehabilitation. Poststroke patients receive physical, occupational, and speech therapy in PAC facility. However, few studies have evaluated the effects of PAC in poststroke patients since PAC's initiation in Taiwan. Thus, this study aims to investigate whether the length of stay in a PAC institution correlates with patients' improvements.This retrospective and single-center study in Taiwan enrolled 193 poststroke patients who had received acute care at Chi-Mei Medical Center, Taiwan, at any period between 2014 and 2017. Data on their length of stay in the PAC institution were collected. Poststroke patients' functional ability-such as activities of daily living (ADL) function and swallowing ability-as well as their corresponding scales were assessed on the first and last day of PAC stay. Statistical analysis was conducted by SPSS version 21.0 .The average duration of PAC stay was 35.01 ±â€Š16.373 days. Duration of PAC stay was significantly positively correlated with the Barthel index (P < .001), Berg balance test score (P < .001), gait speed (P = .002), and upper sensory function and upper motor function within the Fugl-Meyer Assessment (both P < .001).Poststroke patients with longer stay in a PAC institution had superior ADL function, balance and coordination, walking speed, and upper-limb dexterity and sensory function.

Evaluation of the Reliability of Medicare Spending Per Beneficiary for Post-Acute Care.

BACKGROUND: A measure of episode spending, such as Medicare Spending Per Beneficiary (MSPB) is increasingly used to evaluate provider performance. Yet if the measure is unreliable, as is often true for low-volume providers, it cannot distinguish "good" from "poor" performance. OBJECTIVE: The objective of this study was to evaluate the reliability of a uniformly calculated MSPB measure for post-acute care (PAC) and the tradeoffs involved in setting a minimum case count threshold. DATA: Medicare claims for 15 million PAC episodes from April 2013 to March 2015. RESEARCH DESIGN: Given the overlap in patients treated in PAC settings, we developed a uniformly calculated MSPB measure for PAC providers that measures spending during the PAC stay and the following 30 days. We examine variation in the MSPB-PAC measure and characterize the measure's reliability and its relationship to provider case counts. RESULTS: Applied to our MSPB-PAC measure, a minimum threshold of 20 Medicare episodes as currently used by the Centers for Medicare & Medicaid Services (CMS) would not establish reasonably reliable measures and could result in drawing unduly erroneous conclusions about provider performance. The measures for home health agencies were considerably less stable and reliable than for institutional PAC providers. CONCLUSIONS: CMS should consider adopting a more stringent reliability standard for setting minimum case counts for MSPB-PAC and other measures. Its current threshold (R-statistic=0.4) reflects more random variation than differences in actual provider performance. To include as many providers as possible, CMS should consider pooling data over multiple years to avoid drawing incorrect conclusions about low-volume providers.

Institutional Postacute Care Use May Help Reduce Readmissions for Ischemic Stroke Patients.

OBJECTIVES: Readmissions for Medicare patients initially admitted for stroke are common and costly. Rehabilitation in an institutional postacute care (PAC) setting is an evidence-based component of recovery for stroke. Under current Medicare payment reforms, care coordination across hospitals and PAC providers is key to improving quality and efficiency of care. We examined the causal impact of institutional PAC use on 30-day readmission rates for Medicare fee-for-service patients initially admitted for ischemic stroke. DATA SOURCES: The 2010-2016 Medicare Provider Analysis and Review files. RESEARCH DESIGN: We used the method of instrumental variable (IV) analysis to control for unobserved differences in the types of patients admitted to each PAC facility. We chose the distance from the patient's residence to the closest institutional PAC provider and the number of PAC providers of each type within a county where the patient resides as IVs. PRINCIPAL FINDINGS: In the naive model, an increase in institutional PAC use was significantly associated with an increase in 30-day readmission by 0.03 percentage points. However, using IV analysis to control for endogeneity bias, an increase in institutional PAC use was associated with a decrease in 30-day readmission rate by 0.19 percentage points. Our findings indicate that reducing institutional PAC use among patients typically requiring rehabilitation in institutional settings for recovery may potentially lead to adverse postdischarge outcomes that require rehospitalization. Thus, payment incentives to reduce institutional PAC use should be balanced with postdischarge outcomes among ischemic stroke patients.

Evaluation of Nutritional Support and In-Hospital Mortality in Patients With Malnutrition.

Importance: Malnutrition affects a considerable proportion of patients in the hospital and is associated with adverse clinical outcomes. Recent trials found a survival benefit among patients receiving nutritional support. Objective: To investigate whether there is an association of nutritional support with in-hospital mortality in routine clinical practice. Design, Setting, and Participants: This cohort study was conducted from April 2013 to December 2018 among a population of patients from Swiss administrative claims data. From 114 264 hospitalizations of medical patients with malnutrition, 34 967 patients (30.6%) receiving nutritional support were 1:1 propensity score matched to patients with malnutrition in the hospital who were not receiving nutritional support. Patients in intensive care units were excluded. Data were analyzed from February 2020 to November 2020. Exposures: Receiving nutritional support, including dietary advice, oral nutritional supplementation, or enteral and parenteral nutrition. Main Outcomes and Measures: The primary outcome was all-cause in-hospital mortality. Secondary outcomes were 30-day all-cause hospital readmission and discharge to a postacute care facility. Poisson and logistic regressions were used to estimate incidence rate ratios (IRRs) and odds ratios (ORs) of outcomes. Results: After matching, the study identified 69 934 hospitalizations of patients coded as having malnutrition in the cohort (mean [SD] age, 73.8 [14.5] years; 36 776 [52.6%] women). Patients receiving nutritional support, compared with those not receiving nutritional support, had a lower in-hospital mortality rate (2525 of 34 967 patients died [7.2%] vs 3072 of 34 967 patients died [8.8%]; IRR, 0.79 [95% CI, 0.75-0.84]; P < .001) and a reduced 30-day readmission rate (IRR, 0.95 [95% CI, 0.91-0.98]; P = .002). In addition, patients receiving nutritional support were less frequently discharged to a postacute care facility (13 691 patients [42.2%] vs 14 324 patients [44.9%]; OR, 0.89 [95% CI, 0.86-0.91]; P < .001). Conclusions and Relevance: These findings suggest that nutritional support was associated with reduced mortality among patients in the medical ward with malnutrition. The results support data found by randomized clinical trials and may help to inform patients, clinicians, and authorities regarding the usefulness of nutritional support in clinical practice.

COPD Comorbidity Profiles and 2-Year Trajectory of Acute and Postacute Care Use.

BACKGROUND: Multiple morbidity is the norm in advanced COPD and contributes to high symptom burden and worse outcomes. RESEARCH QUESTION: Can distinct comorbidity profiles be identified and validated in a community-based sample of patients with COPD from a large integrated health care system using a standard, commonly used diagnostic code-based comorbidity index and downstream 2-year health care use data? STUDY DESIGN AND METHODS: In this retrospective cohort study, we used latent class analysis (LCA) to identify comorbidity profiles in a population-based sample of 91,453 patients with a COPD diagnosis between 2011 and 2015. We included specific comorbid conditions from the Charlson Comorbidity Index (CCI) and accounted for variation in underlying prevalence of different comorbidities across the three study sites. Sociodemographic, clinical, and health-care use data were obtained from electronic health records (EHRs). Multivariate logistic regression analysis was used to compare rates of acute and postacute care use by class. RESULTS: The mean age was 71 ± 11 years, 55% of patients were women, 23% of patients were people of color, and 80% of patients were former or current smokers. LCA identified four distinct comorbidity profiles with progressively higher CCI scores: low morbidity (61%; 1.9 ± 1.4), metabolic renal (21%; 4.7 ± 1.8), cardiovascular (12%; 4.6 ± 1.9), and multimorbidity (7%; 7.5 ± 1.7). In multivariate models, during 2 years of follow-up, a significant, nonoverlapping increase was found in the odds of having any all-cause acute (hospitalizations, observation stays, and ED visits) and postacute care use across the comorbidity profiles. INTERPRETATION: Distinct comorbidity profiles can be identified in patients with COPD using standard EHR-based diagnostic codes, and these profiles are associated with subsequent acute and postacute care use. Population-based risk stratification schemes for end-to-end, comprehensive COPD management should consider integrating comorbidity profiles such as those found in this study.

Care-Partner Support and Hospitalization in Assisted Living During Transitional Home Health Care.

BACKGROUND/OBJECTIVES: Care-partner support affects outcomes among assisted living (AL) residents. Yet, little is known about care-partner support and its effects on hospitalization during post-acute care transitions. This study examined the variation in care-partner support and its impact on hospitalizations among AL residents receiving Medicare home health (HH) services. DESIGN: Analysis of national data from the Outcome and Assessment Information Set, Medicare claims, Area Health Resources File, and the Social Deprivation Index File. SETTING: AL facilities and Medicare HH agencies in the United States. PARTICIPANTS: 741,926 Medicare HH admissions of AL residents in 2017. MEASUREMENTS: Care-partner support during the HH admission was measured based on the type and frequency of assistance from AL staff in seven domains (i.e., activities of daily living (ADL), instrumental ADLs, medication administration, treatment, medical equipment, home safety, and transportation). Care-partner support in each domain was measured as "assistance not needed" (reference group), "Care-partner currently provides assistance," "care-partner need additional training/support to provide assistance" (i.e., inadequate care-partner support), and "care-partner unavailable/unlikely to provide assistance" (i.e., unavailable care-partner support). Outcome was time-to-hospitalization during the HH admission. RESULTS: Among the 741,926 Medicare HH admissions of AL residents, inadequate care-partner support was identified for all seven domains that ranged from 13.1% (for transportation) to 49.8% (for treatment), and care-partner support was unavailable from 0.9% (for transportation) to 11.0% (for treatment). In Cox proportional hazard models adjusted for patient covariates and geography, compared with "assistance not needed", having inadequate and unavailable care-partner support was related to increased risk of hospitalization by 8.9% (treatment (hazard ratio (HR) =1.089, P < .001)) to 41.3% (medication administration (HR =1.413, P < .001)). CONCLUSION: For AL residents receiving HH services, having less care-partner support was related to increased risk of hospitalization, particularly regarding medication administration, medical equipment, and transportation/advocacy.

How skilled are skilled facilities? Post-discharge complications after colorectal cancer surgery in the U.S.

BACKGROUND: Characteristics and indications for discharging patients to home or a specific facility type have been studied; however, critical evaluation of these facilities through analysis of post-discharge complications and readmission rates is mandatory. The aim of this study was to compare complications occurring after discharge to home, skilled, and unskilled care facilities to identify potential pitfalls. METHODS: All adult (≥18 years) patients who underwent surgery for colon or rectal cancer from 2012 to 2017 as reported in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database were included. Patients were categorized according to the discharge destination into: home, skilled care (rehabilitation center, separate acute care, skilled facility), and unskilled care (multilevel senior community, facility which is home, unskilled facility). Demographics, surgical risk factors and predischarge complications were compared between the three groups. Primary endpoints were overall, major, surgical, and medical complications occurring post-discharge, within 30 days of surgery. Further assessed were specific complications, readmission, length of stay, and 30-day mortality. RESULTS: A total of 108,617 patients were identified. Of them, 100,478 (92%) discharged to home, 7313 (7%) to skilled, and 826 (1%) to unskilled care. Of patients discharged to skilled care, 1928 (26%) discharged to rehabilitation centers, 368 (5%) to separate acute care, and 5017 (69%) to skilled facilities. Adjusted overall, major, surgical, and medical post-discharge complications were highest among patients discharged to skilled care destinations. Subgroup analysis revealed separate acute care (inter-hospital transfer) to be associated with the highest morbidity. Main reasons for readmission were primarily related to surgical site infection and intestinal obstruction among the three main destinations, whereas readmissions for systemic sepsis and medical complications were more frequent in patients admitted to skilled care. CONCLUSION: This study identified higher rates of post-discharge complications associated with skilled care destinations, despite risk adjustment. This over-morbidity is potentially related to prevailing medical complications and inter-hospital transfers. Further studies are needed to better understand those findings and to improve quality of post-acute care and related outcomes.