Electronic Health Record Implementation Enhances Financial Performance in High Medicaid Nursing Homes.

Introduction: The nursing home (NH) industry operates within a two-tiered system, wherein high Medicaid NHs which disproportionately serve marginalized populations, exhibit poorer quality of care and financial performance. Utilizing the resource-based view of the firm, this study aimed to investigate the association between electronic health record (EHR) implementation and financial performance in high Medicaid NHs. A positive correlation could allow high Medicaid NHs to leverage technology to enhance efficiency and financial health, thereby establishing a business case for EHR investments. Methods: Data from 2017 to 2018 were sourced from mail surveys sent to the Director of Nursing in high Medicaid NHs (defined as having 85% or more Medicaid census, excluding facilities with over 10% private pay or 8% Medicare), and secondary sources like LTCFocus.org and Centers for Medicare & Medicaid Services cost reports. From the initial sample of 1,050 NHs, a 37% response rate was achieved (391 surveys). Propensity score inverse probability weighting was used to account for potential non-response bias. The independent variable, EHR Implementation Score (EIS), was calculated as the sum of scores across five EHR functionalities-administrative, documentation, order entry, results viewing, and clinical tools-and reflected the extent of electronic implementation. The dependent variable, total margin, represented NH financial performance. A multivariable linear regression model was used, adjusting for organizational and market-level control variables that may independently affect NH financial performance. Results: Approximately 76% of high Medicaid NHs had implemented EHR either fully or partially (n = 391). The multivariable regression model revealed that a one-unit increase in EIS was associated with a 0.12% increase in the total margin (p = 0.05, CI: -0.00-0.25). Conclusion: The findings highlight a potential business case -long-term financial returns for the initial investments required for EHR implementation. Nonetheless, policy interventions including subsidies may still be necessary to stimulate EHR implementation, particularly in high Medicaid NHs.

Waterpipe Use and Its Cardiovascular Effects: A Systematic Review and Meta-Analysis of Case-Control, Cross-Sectional, and Non-Randomized Studies.

Approximately 100 million people globally smoke cigarettes, making it a significant and quickly spreading global tobacco epidemic. Substance use disorders are frequently evaluated by non-randomized studies. Tobacco use and its impacts on the cardiovascular system were the subjects of a comprehensive search across five electronic databases: Cochrane, MEDLINE, Scopus, Embase, and PubMed. The findings demonstrated that waterpipe smokers in comparison to non-smokers have immediate elevations in heart rate and blood pressure, lower levels of high-density lipoprotein, higher levels of low-density lipoprotein, higher levels of triglycerides, higher levels of fasting blood glucose, and a higher heart rate. Users of waterpipes and cigarettes had similar average heart rates, blood pressure, and lipid levels, with the exception that waterpipe smokers had greater total cholesterol. Smoking a waterpipe has significant negative effects on the cardiovascular system comparable to cigarette smoking, and non-randomized studies proved to yield substantial evidence related to its cardiovascular effects. Such study designs can be used to evaluate substance use and its cardiovascular impact.

Organizational Characteristics and the Adoption of Electronic Health Records Among Nursing Homes in One Southern State.

Electronic health records (EHRs) can improve quality of care and patient safety, as demonstrated in a variety of health care settings. However, greater use of EHRs in nursing homes (NHs) is needed. To understand which NHs have and have not adopted EHR systems, all federally certified NHs in Arkansas (n = 223) were surveyed, with 27.9% responding. Non-responders were similar to responders on all characteristics except for staffing skill mix, with responders having a higher skill mix than non-responders. Two thirds of responding Arkansas NHs reported having an EHR system in use (69.8%), while only a few reported no plans for an EHR system (4.8%). NHs with greater resources and in competitive markets were more likely to implement EHR systems. Full implementation across all NHs may require intervention, which should be explored in future research. In addition, future investigation should consider the level of interoperability of EHR systems that are in place among NHs.

Status Epilepticus among Older Adults in the United States.

OBJECTIVE: This study aimed to identify temporal time trends and risk factors associated with mortality for hospitalized older adults with status epilepticus (SE). DESIGN: A retrospective study was performed. SETTING: Hospitalized patients were identified utilizing an administrative database-The Nationwide Inpatient Sample database from 1998 through September 2015. PATIENTS: Patients were older adults 65 years and older with SE. INTERVENTIONS: No interventions were undertaken. MEASUREMENTS AND MAIN RESULTS: Demographic, temporal trends, clinical characteristics, and outcome data were abstracted. The results indicated that hospitalized elderly Americans with SE increased over the 11-year study period. Univariate and multivariate analyses were performed to evaluate risk factors associated with mortality in the study cohort. From the weighted sample, 130,109 subjects were included. Overall mortality was 19%. For age subgroups, the mortality was highest for the >85 years age group (24.1%) compared to the 65-75 years (19%) and 75-85 years (23%) age groups. Among investigated etiologies, the three most common causes of SE were acute ischemic stroke (11.2% of total) followed by non-traumatic brain hemorrhage (5.4%) and malignant brain lesions (4.9%). The highest mortality by etiology was noted for acute traumatic brain injury (TBI) (31.5%), non-traumatic brain hemorrhage (31%), and acute ischemic stroke (AIS) (30.1%). Multivariate analysis indicated that non-survivors when compared to survivors were more like to have the following characteristics: older age group, acute TBI, brain neoplasms, non-traumatic brain hemorrhage, AIS and central nervous system (CNS) infections, and utilization of mechanical ventilation. Associated conditions significantly increasing risk of mortality were sodium imbalance, cardiac arrest, anoxic brain injury, pneumonia, and sepsis. Comorbidities associated with increased risk of mortality included valvular heart disease, renal failure, liver disease, and neoplasms. CONCLUSIONS: The number of hospitalized elderly Americans with SE increased over the 11-year study period. Overall mortality was 19%, with even higher mortality among various patient subsets. Several demographic and co-morbid factors are associated with increased mortality in this age group.

Bariatric Procedures in Older Adults in the United States: Analysis of a Multicenter Database.

Background: Bariatric procedures help reduce obesity-related comorbidities and thus improve survival. Clinical characteristics and outcomes after bariatric procedures in older adults were investigated. Methods: A multi-institutional Nationwide Inpatient Sample (NIS) database was queried from years 2005 through 2012. Older adults >60 years of age with procedure codes for bariatric procedures and a diagnosis of obesity/morbid obesity were selected to compare clinical characteristics/outcomes between those undergoing closed versus open procedures and identify risk factors associated with in-hospital mortality and increased hospital length of stay (LOS). Results: Over the study period, 79,122 bariatric procedures were performed. Those undergoing open procedures compared to closed procedures had a higher in-hospital mortality (0.8% vs. 0.2%) and a longer hospital LOS (4.8 days vs. 2.2 days). Risk factors significantly associated with in-hospital mortality were open procedures, the Western region, and the Elixhauser comorbidity index. Risk factors associated with increased LOS were Medicaid insurance type, an open procedure, a higher Elixhauser comorbidity score, a required skilled nursing facility (SNF) discharge, and died in hospital. Conclusion: Closed bariatric procedures are increasingly being preferred in older adults, with a four-fold lower mortality compared to open procedures. Besides choice of procedure, the presence of specific comorbidities is associated with increased mortality in older adults.

Nursing Home Quality and Financial Performance: Is There a Business Case for Quality?

This study examines the relationship between nursing home quality and financial performance to assess whether there is a business case for quality. Secondary data sources included the Online Survey Certification and Reporting (OSCAR), Certification and Survey Provider Enhanced Reporting (CASPER), Medicare Cost Reports, Minimum Data Set (MDS 2.0), Area Resource File (ARF), and LTCFocus for all free-standing, nongovernment nursing homes for 2000 to 2014. Data were analyzed using panel data linear regression with facility and year fixed effects. The dependent variable, financial performance, consisted of the operating margin. The independent variables comprised nursing home quality measures that capture the three dimensions of Donabedian's structure-process-outcomes framework: structure Registered Nurse (RN) hours per resident day, Licensed Practical Nurse (LPN) hours per resident day, Certified Nursing Assistant (CNA) hours per resident day, RN skill mix), process (facility-acquired restraints, facility-acquired catheters, pressure ulcer prevention, and restorative ambulation), and outcomes (facility-acquired contractures, facility-acquired pressure ulcers, hospitalizations per resident, rehospitalizations, and health deficiencies). Control variables included size, average acuity index, market competition, per capita income, and Medicare Advantage penetration rate. This study found that the operating margin was lower in nursing homes that reported higher LPN hours per resident day and higher RN skill mix (structure); higher use of catheters, lower pressure ulcer prevention, and lower restorative ambulation (process); and more residents with contractures, pressure ulcers, hospitalizations and health deficiencies (outcomes). The results suggest that there is a business case for quality, whereas nursing homes that have better processes and outcomes of care perform better financially.

High Medicaid Nursing Homes: Organizational and Market Factors Associated With Financial Performance.

High Medicaid nursing homes (85% and higher of Medicaid residents) operate in resource-constrained environments. High Medicaid nursing homes (on average) have lower quality and poorer financial performance. However, there is significant variation in performance among high Medicaid nursing homes. The purpose of this study is to examine the organizational and market factors that may be associated with better financial performance among high Medicaid nursing homes. Data sources included Long-Term Care Focus (LTCFocus), Centers for Medicare and Medicaid Services' (CMS) Medicare Cost Reports, CMS Nursing Home Compare, and the Area Health Resource File (AHRF) for 2009-2015. There were approximately 1108 facilities with high Medicaid per year. The dependent variables are nursing homes operating and total margin. The independent variables included size, chain affiliation, occupancy rate, percent Medicare, market competition, and county socioeconomic status. Control variables included staffing variables, resident quality, for-profit status, acuity index, percent minorities in the facility, percent Medicaid residents, metropolitan area, and Medicare Advantage penetration. Data were analyzed using generalized estimating equations with state and year fixed effects. Results suggest that organizational and market slack resources are associated with performance differentials among high Medicaid nursing homes. Higher financial performing facilities are characterized as having nurse practitioners/physician assistants, more beds, higher occupancy rate, higher Medicare and Medicaid census, and being for-profit and located in less competitive markets. Higher levels of Registered Nurse (RN) skill mix result in lower financial performance in high Medicaid nursing homes. Policy and managerial implications of the study are discussed.

Outcomes for Hospitalized Older Adults with Down Syndrome in the United States.

BACKGROUND: Patients with Down syndrome (DS) often survive into adulthood. Relatively little information is currently available regarding hospitalization outcomes among mature, older adults with DS. OBJECTIVE: To identify risk factors associated with hospital mortality rates and increased costs for hospitalized older adults with DS. METHODS: Data on hospitalized older adults with DS (≥65 years) were identified from the Nationwide Inpatient Sample database (6) from 2002 through 2012. Multivariate analyses were performed to evaluate risk factors associated with hospital mortality and hospitalization cost in these patients. RESULTS: A total of 2,134 older adults with DS were identified. A temporal increase over the 11-year period was observed in the number of older adults with DS who were hospitalized (trend p < 0.0001). However, the hospital mortality rate and post-hospital discharge to skilled nursing facilities have decreased during the same time period. Risk factors associated with increased hospital mortality included advanced age (70-79 years), female gender, admissions in the western United States, and presence of comorbid conditions (ischemic heart disease, Alzheimer's disease, and cerebrovascular accident). The mean cost was $18,241 (SD $56,105) over the 11-year period. However, no significant temporal changes in costs were noted (trend p = 0.14). CONCLUSIONS: The number of hospitalized elderly Americans with DS has increased over the 11-year period. However, hospital mortality and discharge to skilled nursing facilities have decreased during the same time period. Several demographic and co-morbid factors are associated with increased mortality. No significant differences in temporal trends in costs were noted.