Is Skilled Nursing Facility Financial Status Related to Readmission Rate Improvement?

GOAL: We examined whether higher skilled nursing facility (SNF) lagged profitability is associated with a lower 30-day all-cause all-payer risk-adjusted hospital readmission rate. Our aim was to provide insight into whether SNFs with limited financial resources are able to respond to incentives to lower their readmission rates to hospitals. METHODS: We used data from 2012-2016 to estimate a fixed effects (FE) model with a time trend. Our data included financial data from the Centers for Medicare & Medicaid Services Healthcare Cost Report Information System SNF cost reports, facility characteristics including the all-cause all-payer risk-adjusted unplanned 30-day readmission rate from the LTCFocus (Long-Term Care Focus) project at Brown University, and county-level market variables from the Area Health Resource File. We also examined the relationship for a shorter time frame (2012-2015) after stratifying the sample by system membership or ownership. PRINCIPAL FINDINGS: SNFs with an increase in the lagged operating margin showed a statistically significant, small decrease (<.01 percentage point) in the risk-adjusted readmission rate. The results were robust for different time periods and model specifications. Fixed effects model estimates for SNFs in the highest quartile of percentage of Medicaid patients (≥73.9%) had a lagged operating margin coefficient that is almost four times as large as the coefficient of the FE model with all SNFs. APPLICATION TO PRACTICE: SNFs have an important role in achieving the national priority of reducing hospital readmissions. The study findings suggest that managers of SNFs should not see low profitability as an obstacle to reducing readmission rates, which is good news given the low average profitability of SNFs. Further, reductions in profitability due to penalties incurred from the recently implemented Medicare Skilled Nursing Facility Value-Based Purchasing Program may not limit SNFs' ability to lower hospital readmission rates, at least initially. However, policymakers may need to determine whether additional resources to high Medicaid SNFs can lower readmission rates for these SNFs.

Hospital Performance in the First 6 Years of Medicare's Value-Based Purchasing Program.

The Medicare value-based purchasing (VBP) program, ongoing since 2013, uses financial bonuses and penalties to incentivize hospital quality improvements. Previous research has identified characteristics of penalized hospitals, but has not examined characteristics of hospitals with improvements in VBP program performance or consistent good performance. We identify five different trajectories of program performance (improvement, decline, consistent good or poor performance, mixed). A total of 11% of hospitals were penalized every year of the program, 24% improved their VBP program performance, 14% of hospitals consistently earned a bonus, while 18% performed well in the program's early years but experienced declines in performance. In 2013, organizational and community characteristics were associated with higher odds of improving relative to performing poorly every year. Few variables under managers' control were associated with program improvement, though accountable care organization participation was in some models. We find changes in VBP program metrics may have contributed to improvement in some hospitals' program scores.

Flash-Like Albuminuria in Acute Kidney Injury Caused by Puumala Hantavirus Infection.

Transient proteinuria and acute kidney injury (AKI) are characteristics of Puumala virus (PUUV) infection. Albuminuria peaks around the fifth day and associates with AKI severity. To evaluate albuminuria disappearance rate, we quantified albumin excretion at different time points after the fever onset. The study included 141 consecutive patients hospitalized due to acute PUUV infection in Tampere University Hospital, Finland. Timed overnight albumin excretion (cU-Alb) was measured during the acute phase in 133 patients, once or twice during the convalescent phase within three months in 94 patients, and at six months in 36 patients. During hospitalization, 30% of the patients had moderately increased albuminuria (cU-Alb 20-200 µg/min), while 57% presented with severely increased albuminuria (cU-Alb >200 µg/min). Median cU-Alb was 311 µg/min (range 2.2-6460) ≤7 days after fever onset, 235 µg/min (range 6.8-5479) at 8-13 days and 2.8 µg/min (range 0.5-18.2) at 14-20 days. After that, only one of the measurements showed albuminuria (35.4 µg/min at day 44). At six months, the median cU-Alb was 2.0 µg/min (range 0.6-14.5). Albuminuria makes a flash-like appearance in PUUV infection and returns rapidly to normal levels within 2-3 weeks after fever onset. In the case of AKI, this is a unique phenomenon.

Meeting report: Eleventh International Conference on Hantaviruses.

The 2019 11th International Conference on Hantaviruses (ICH 2019) was organized by the International Society for Hantaviruses (ISH), and held on September 1-4, 2019, at the Irish College, in Leuven, Belgium. These ICHs have been held every three years since 1989. ICH 2019 was attended by 158 participants from 33 countries. The current report summarizes research presented on all aspects of hantavirology: ecology; pathogenesis and immune responses; virus phylogeny, replication and morphogenesis; epidemiology; vaccines, therapeutics and prevention; and clinical aspects and diagnosis.

Wild Rats, Laboratory Rats, Pet Rats: Global Seoul Hantavirus Disease Revisited.

Recent reports from Europe and the USA described Seoul orthohantavirus infection in pet rats and their breeders/owners, suggesting the potential emergence of a "new" public health problem. Wild and laboratory rat-induced Seoul infections have, however, been described since the early eighties, due to the omnipresence of the rodent reservoir, the brown rat Rattus norvegicus. Recent studies showed no fundamental differences between the pathogenicity and phylogeny of pet rat-induced Seoul orthohantaviruses and their formerly described wild or laboratory rat counterparts. The paucity of diagnosed Seoul virus-induced disease in the West is in striking contrast to the thousands of cases recorded since the 1980s in the Far East, particularly in China. This review of four continents (Asia, Europe, America, and Africa) puts this "emerging infection" into a historical perspective, concluding there is an urgent need for greater medical awareness of Seoul virus-induced human pathology in many parts of the world Given the mostly milder and atypical clinical presentation, sometimes even with preserved normal kidney function, the importance of simple but repeated urine examination is stressed, since initial but transient proteinuria and microhematuria are rarely lacking.

Clinical Characteristics of Ratborne Seoul Hantavirus Disease.

Although Seoul orthohantavirus is the only globally spread hantavirus pathogen, few confirmed human infections with this virus have been reported in Western countries, suggesting lower medical awareness of the milder, transient, and often chameleon-like symptoms of this zoonosis. We describe lesser known clinical and laboratory characteristics to help improve underreporting of this virus.

Urban-Rural Differences in Skilled Nursing Facility Rehospitalization Rates.

OBJECTIVES: To examine the association of rurality with skilled nursing facility (SNF) all-cause 30-day risk-adjusted rehospitalization rates. DESIGN: Cross-sectional study combining Center for Medicare and Medicaid Services Nursing Home Compare (CMS-NHC) website for 30-day risk-adjusted rehospitalization rates for 2014-2015 with SNF organizational and community variables. PARTICIPANTS: 12,261 non-hospital based skilled nursing facilities in the US. MEASUREMENTS: We estimated a multiple linear regression model of percentage all-cause unplanned risk-adjusted rehospitalization rate within 30 days after a hospital discharge and admission to the SNF averaged over the third and fourth quarters of 2014 and the first and second quarters of 2015. The model uses robust standard errors. RESULTS: After controlling for community- and SNF-level resources, the risk-adjusted rehospitalization rates for SNFs are lowest in rural areas and large rural towns followed by SNFs in suburban and then urban areas. CONCLUSION: The rural culture that includes a strong sense of connectedness among residents may contribute to lower SNF rehospitalization rates. Our results suggest that rural SNFs may avoid future reimbursement penalties and decreased admissions from patients discharged from hospitals because of their lower rehospitalizaton rates. However, because this is the first study to address this topic, additional research is needed.

Glomerular Proteinuria Predicts the Severity of Acute Kidney Injury in Puumala Hantavirus-Induced Tubulointerstitial Nephritis.

BACKGROUND: Puumala virus (PUUV)-induced hemorrhagic fever with renal syndrome is common in many European countries. The typical renal histologic lesion is acute tubulointerstitial nephritis. We examined the type and kinetics of urine protein excretion and prognostic significance of proteinuria for the severity of acute kidney injury (AKI) in acute PUUV infection. METHODS: The amount of dipstick albuminuria at hospital admission was analyzed in 205 patients with acute PUUV infection. Dipstick albuminuria at admission was graded into 3 categories: 0-1+, 2+, and 3+. In 70 patients, 24-h urinary excretion of protein, overnight urinary excretion of albumin, immunoglobulin (Ig) G, and α1-microglobulin also were measured over 3 consecutive days during the hospital stay. RESULTS: Maximum median daily proteinuria, overnight albuminuria, and IgG excretion were observed over 5 days, while that of creatinine values was observed 9 days after the onset of the disease. The medians of maximum plasma creatinine levels during hospital stay were different in the 3 categories of dipstick albuminuria: 0-1+: 98 µmol/L (58-1,499), 2+: 139 µmol/L (71-829), and 3+: 363 µmol/L (51-1,285; p < 0.001). Dipstick albuminuria ≥2+ at admission could be detected in 89% of the patients who subsequently developed severe AKI. Glomerular proteinuria, but not tubular proteinuria (α1-microglobulin), correlated with the severity of the emerging AKI. CONCLUSION: In acute PUUV infection, maximum median proteinuria values preceded the most severe phase of AKI by a few days. A highly useful finding for clinical work was that a quick and simple albuminuria dipstick test at hospital admission predicted the severity of the upcoming AKI.

Meeting report: Tenth International Conference on Hantaviruses.

The 10th International Conference on Hantaviruses, organized by the International Society on Hantaviruses, was held from May 31-June 3, 2016 at Colorado State University, Fort Collins, CO, USA. These conferences have been held every three years since 1980. The current report summarizes research presented on all aspects of hantavirology: ecology and epidemiology, virus replication, phylogeny, pathogenesis, immune response, clinical studies, vaccines and therapeutics.

Large-scale impact of climate change vs. land-use change on future biome shifts in Latin America.

Climate change and land-use change are two major drivers of biome shifts causing habitat and biodiversity loss. What is missing is a continental-scale future projection of the estimated relative impacts of both drivers on biome shifts over the course of this century. Here, we provide such a projection for the biodiverse region of Latin America under four socio-economic development scenarios. We find that across all scenarios 5-6% of the total area will undergo biome shifts that can be attributed to climate change until 2099. The relative impact of climate change on biome shifts may overtake land-use change even under an optimistic climate scenario, if land-use expansion is halted by the mid-century. We suggest that constraining land-use change and preserving the remaining natural vegetation early during this century creates opportunities to mitigate climate-change impacts during the second half of this century. Our results may guide the evaluation of socio-economic scenarios in terms of their potential for biome conservation under global change.

Community Acquired Severe Acute Kidney Injury Caused by Hantavirus-Induced Hemorrhagic Fever with Renal Syndrome Has a Favorable Outcome.

BACKGROUND: Puumala hantavirus (PUUV) induces an acute tubulointerstitial nephritis and acute kidney injury (AKI). Our aim was to evaluate the prognosis of severe AKI associated with PUUV infection. METHODS: We examined 556 patients who were treated at Tampere University Hospital during 1982-2013 for acute, serologically confirmed PUUV infection. Plasma creatinine was measured during hospitalization, convalescence, and 1, 2, and 5 years after the acute infection. RESULTS: Plasma creatinine concentration was elevated (>100 µmol/l) in 459 (83%) patients, while altogether 189 patients (34%) had severe AKI defined as Kidney Disease: Improving Global Outcomes (KDIGO) stage 3, that is, plasma creatinine ≥353.6 µmol/l (4.0 mg/dl) or need of dialysis. There were no fatal cases during the hospitalization or the following 3 months. Fatality rate during the years following PUUV infection did not differ between patients who had suffered from severe AKI versus those without severe AKI. Post-hospitalization plasma creatinine values were available for 188 (34%) patients. One month after the acute infection, patients with prior severe AKI had higher median plasma creatinine concentration (82 µmol/l, range 54-184) than patients without severe AKI (74 µmol/l, range 55-109, p = 0.005). After 1 year, no significant difference existed in median plasma creatinine concentrations between patients with (71 µmol/l, range 36-123) and without prior severe AKI (72 µmol/l, range 34-116, p = 0.711). After 5 years all but 1 patient had normal creatinine levels. CONCLUSIONS: In contrast to the worldwide well-accepted KDIGO criteria, severe AKI associated with PUUV infection is not associated with excess fatality but has a very good prognosis, both in the short and long terms.

Does Assisted Living Capacity Influence Case Mix at Nursing Homes?

Assisted living facilities (ALFs) have grown over the past few decades. If they attract residents with lower care needs away from nursing homes (NHs), NHs may be left with higher case mix residents. We study the relationship between ALF bed market capacity and NH case mix in a state (Virginia) where ALF bed capacity stabilized after a period of growth. Similarly, NH capacity and use had been stable. While it is interesting to study markets in flux, for planning purposes, it is also important to examine what happens after periods of turbulence and adaptation. Our findings show some substitution of ALF for NH care, but the relationship is not linear with ALF market capacity. Communities need to consider the interplay of ALFs and NHs in planning for long-term care services and supports. Policies supporting ALFs may enable care needs to be met in a lower cost setting than the NH.

Comment on Jameson et al.: Prevalence of antibodies against hantaviruses in serum and saliva of adults living or working on farms in Yorkshire, United Kingdom.

This British hantavirus IgG prevalence study, aimed at 119 asymptomatic farmers in England, and using indirect immunofluorescence assay (IFA) as screening technique, concluded that rat-transmitted Seoul virus (SEOV) might be the main suspect as hantaviral pathogen in the UK. Exactly the same conclusion, using the same IFA screening technique, resulted from a 1994 serosurvey in the same country, and in 627 clinical cases plus 100 healthy controls. SEOV-positive study subjects were also mainly farmers with heavy rat-exposure, but residing in Northern-Ireland, a region where all other known rodent reservoirs for pathogenic hantaviruses are known to be absent, except the wild rat. A rodent capture action in and around the farms of eight seropositives confirmed SEOV seropositivity in 21.6% of 51 rats. All SEOV seropositives were patients, hospitalized with an acute feverish condition, a majority of which having the clinical picture of hantavirus-induced nephropathy, known as hemorrhagic fever with renal syndrome (HFRS). Leptospirosis, often mimicking perfectly HFRS, was serologically excluded. Thus, SEOV was established as a human hantaviral pathogen in the UK and in Europe 20 years ago.

The experiences of Massachusetts hospitals as statewide health insurance reform was implemented.

Hospitals treat many uninsured patients and shoulder substantial amounts of uncompensated care. Health reform as implemented in Massachusetts, then, would be expected to bode well for hospitals as many people obtain coverage from private and public programs. We examined changes in Massachusetts hospital payer mix, unreimbursed costs of care for the uninsured and those in means-tested public programs, and overall financial condition for the period 2004 to 2010. Despite increases in coverage, unreimbursed costs for the uninsured and those in means-tested government programs did not decrease appreciably for Massachusetts hospitals over the study period. Major safety-net hospitals, which play a substantial role in serving the uninsured and Medicaid, had some initial easing of this burden but their financial situation weakened through 2010. The U.S. economic recession and Massachusetts budget pressures, which in part resulted from reform implementation, likely offset advantages hospitals experienced from reductions in the uninsured. Our analysis suggests that state actions in Massachusetts to change payment programs that the two major safety net hospitals relied on to support indigent care contributed to their financial difficulties.

Hemorrhagic Fever with Renal Syndrome in the New, and Hantavirus Pulmonary Syndrome in the Old World: paradi(se)gm lost or regained?

Since the first clinical description in 1994 of the so-called "Hantavirus Pulmonary Syndrome" (HPS) as a "newly recognized disease", hantavirus infections have always been characterized as presenting in two distinct syndromes, the so-called "Hemorrhagic Fever with Renal Syndrome" (HFRS) in the Old World, with the kidney as main target organ, in contrast to HPS in the New World, with the lung as main target organ. However, European literature mentions already since 1934 a mostly milder local HFRS form, aptly named "nephropathia epidemica" (NE), and caused by the prototype European hantavirus species Puumala virus (PUUV). Several NE reports dating from the 1980s and early 1990s described already non-cardiogenic HPS-like lung involvement, prior to any kidney involvement, and increasing evidence is now mounting that a considerable clinical overlap exists between HPS and HFRS. Moreover, growing immunologic insights point to common pathologic mechanisms, leading to capillary hyperpermeability, the cardinal feature of all hantavirus infections, both of the New and Old World. It is now perhaps time to reconsider the paradigm of two "different" syndromes caused by viruses of the same Hantavirus genus in the same Bunyaviridae family, and to agree on a common, more logical disease denomination, such as simply and briefly "Hantavirus fever".