Do end-of-life outcomes differ by assisted living memory-care designation?

BACKGROUND: Residential care/assisted living (RC/AL) is an increasingly common place of end-of-life care for persons with Alzheimer's disease and related dementia (ADRD), who have unique care needs as their health declines. Approximately 22% of RC/ALs provide specialized memory care (memory-care RC/AL). Understanding how end-of-life outcomes differ by memory care among residents with ADRD could facilitate aging/dying in place for this population. The objective of this paper is to examine if end-of-life outcomes (i.e., mortality, hospice use, and number of days receiving hospice in the last month of life) differ between residents with ADRD who moved to memory-care RC/AL, compared with residents with ADRD who moved to RC/AL without memory care (general RC/AL). METHODS: Prospective cohort of 15,152 fee-for-service Medicare beneficiaries with ADRD who moved to large RC/AL (> = 25 beds) between 2016 and 2018. We used inverse probability treatment weighting to account for observable differences between memory-care and general RC/AL residents. Two-part models estimated the difference by memory care in the number of days receiving hospice care in the last months of life among RC/AL decedents. RESULTS: The unadjusted mortality rates were 13.4% in general RC/AL and 15.8% in memory-care RC/AL with an adjusted difference of 1.3 percentage points higher mortality among memory-care RC/AL residents (p = 0.04). Hospice use was 8% and 10.6% among general and memory-care RC/AL residents, respectively, with an adjusted difference of 1.4 percentage points (p = 0.01) higher in memory care. Two-part models showed that decedents in memory-care RC/AL spent about 1.4 more days receiving hospice care in the last month of life (p = 0.02). CONCLUSION: We find a higher mortality rate and higher rate of hospice use among memory-care RC/AL residents. These findings suggest that memory care may attract residents closer to the end of life and/or promote hospice use at the end of life.

Characteristics and End-of-Life Care Pathways of Decedents From a National Cohort of Assisted Living Residents.

BACKGROUND: Assisted living (AL) is an increasingly common, place of care for dying persons. However, it remains unclear to what extent residents are able to age in place or if AL represents an additional transition before death. OBJECTIVES: Examine the sociodemographic characteristics, comorbidities, health care utilization, and end-of-life care pathways of AL residents before death. RESEARCH DESIGN: A national cohort study of fee-for-service Medicare beneficiaries residing in large AL communities (25+ beds) during the month of January 2017 with 3 years of follow-up, using administrative claims data. SUBJECTS: 268,812 AL residents. MEASURES: Sociodemographic characteristics, comorbidities, and health care utilization at the end of life. RESULTS: Between 2017 and 2019, 35.1% of the study cohort died. Decedents were more likely than the overall AL population to be 85 years old or older (76.5% vs. 59.5%), and diagnosed with Alzheimer's disease and related dementia (70.3% vs. 51.6%). Most decedents (96.2%) had some presence in AL during the last year of life, but over 1 in 5 left AL before the last month of life. Among those in AL on day 30 before death, nearly half (46.4%) died in place without any health care transition, while 13.2% had 3 or more transfers before dying. CONCLUSIONS: AL is an important place of care for dying persons, especially for those with dementia. These findings indicate a need to assess existing policies and processes guiding the care of the frail and vulnerable population of dying AL residents.

Hospice Aide Visits among Nursing Home Residents During the Early Months of the COVID-19 Pandemic.

OBJECTIVE: Hospice aides are vital in delivering care to patients and family members at the end of life. The COVID-19 pandemic resulted in disruptions in hospice care delivery, especially in long-term care settings. We aim to provide a description of hospice aide visits among nursing home residents enrolled in hospice during the first 9 months of 2020, as compared with the same months in 2019. DESIGN: Observational cohort study. SETTING AND PARTICIPANTS: 153,109 and 152,077 long-stay nursing home residents enrolled in hospice in 2019 and 2020, respectively. METHODS: On a monthly basis, we reported estimated probabilities of not having visits from hospice aides and adjusted visit minutes among those who had hospice aide visits for the 2019 and 2020 cohort, respectively. The regression models accounted for resident sociodemographic and clinical characteristics and nursing home fixed effects. The analyses were conducted at the national and state level, separately. RESULTS: More than half of residents did not have any visits from hospice aides in 2020 from April and onward. Among residents who had hospice aide visits, the 2020 cohort had reduced visits in March and onward, with the greatest difference being 155 minutes less in April (95% CI: -163.4, -146.5). State-level analyses suggested that multiple factors besides community spread or state policies might contribute to the reduced presence of hospice aides. CONCLUSIONS AND IMPLICATIONS: Our findings highlight the toll of the pandemic on hospice care delivery in nursing homes and the need for hospice care to be better incorporated into emergency preparedness planning.

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.

To compare the incidence of new or worsened pressure injuries (PIs) and associated risk factors for their development in inpatient post-acute care settings: long-term care hospitals (LTCHs), inpatient rehabilitation facilities (IRFs), and skilled nursing facilities (SNFs). The authors investigated Medicare Part A SNF resident stays and LTCH patient stays that ended between October 1, 2016 and December 31, 2016 and IRF patient stays that ended between October 1, 2016 and March 31, 2017. They calculated the incidence of new or worsened PIs using the specifications of the National Quality Forum-endorsed PI quality measure #0678: Percent of Residents or Patients with Pressure Ulcers that are New or Worsened . The incidences of new or worsened stages 2 through 4 PIs varied across settings: 1.23% in SNFs, 1.56% in IRFs, and 3.07% in LTCHs. Seven risk factors were positively and consistently associated with new or worsened PIs across settings: limited bed mobility, bowel incontinence, low body mass index, diabetes/peripheral vascular disease/peripheral arterial disease, advanced age, urinary incontinence, and dual urinary and bowel incontinence. These findings provide empirical support for the alignment of risk factors for the PI quality measures across post-acute care settings.

State Regulations and Assisted Living Residents' Potentially Burdensome Transitions at the End of Life.

Background: Potentially burdensome transitions at the end of life (e.g., repeated hospitalizations toward the end of life and/or health care transitions in the last three days of life) are common among residential care/assisted living (RC/AL) residents, and are associated with lower quality of end-of-life care reported by bereaved family members. We examined the association between state RC/AL regulations relevant to end-of-life care delivery and the likelihood of residents experiencing potentially burdensome transitions. Methods: Retrospective cohort study combining RC/AL registries of states' regulations with Medicare claims data for residents in large RC/ALs (i.e., 25+ beds) in the United States on the 120th day before death (N = 129,153), 2017-2019. Independent variables were state RC/AL regulations relevant to end-of-life care, including third-party services, staffing, and medication management. Analyses included: (1) separate logistic regression models for each RC/AL regulation, adjusting for sociodemographic covariates; (2) separate logistic regression models with a Medicare fee-for-service (FFS) subgroup to control for comorbidities, and (3) multivariable regression analysis, including all regulations in both the overall sample and the Medicare FFS subgroup. Results: We found a lack of associations between potentially burdensome transitions and regulations regarding third-party services and staffing. There were small associations found between regulations related to medication management (i.e., requiring regular medication reviews, permitting direct care workers for injections, requiring/not requiring licensed nursing staff for injections) and potentially burdensome transitions. Conclusions: In this cross-sectional study, the associations of RC/AL regulations with potentially burdensome transitions were either small or not statistically significant, calling for more studies to explain the wide variation observed in end-of-life outcomes among RC/AL residents.

Association Between State Regulations Supportive of Third-party Services and Likelihood of Assisted Living Residents in the US Dying in Place.

Importance: Older adults are increasingly residing in assisted living residences during their last year of life. The regulations guiding these residential care settings differ between and within the states in the US, resulting in diverse policies that may support residents who wish to die in place. Objective: To examine the association between state regulations and the likelihood of assisted living residents dying in place. The study hypothesis was that regulations supporting third-party services, such as hospice, increase the likelihood of assisted living residents dying in place. Design, Setting, and Participants: This retrospective cohort study combined data about assisted living residences in the US from state registries with an inventory of state regulations and administrative claims data. The study participants comprised 168 526 decedents who were Medicare beneficiaries, resided in 8315 large, assisted living residences (with ≥25 beds) across 301 hospital referral regions during the last 12 months of their lives, and died between 2017 and 2019. Descriptive analyses were performed at the state level, and 3-level multilevel models were estimated to examine the association between supportive third-party regulations and dying in place in assisted living residences. The data were analyzed from September 2021 to August 2022. Exposures: Supportive (vs "silent," ie, not explicitly mentioned in regulatory texts) state regulations regarding hospice care, private care aides, and home health services, as applicable to licensed/registered assisted living residences across the US. Main Outcomes and Measures: Presence in assisted living residences on the date of death. Results: The median (IQR) age of the 168 526 decedents included in the study was 90 (84-94) years. Of these, 110 143 (65.4%) were female and 158 491 (94.0%) were non-Hispanic White. Substantial variation in the percentage of assisted living residents dying in place was evident across states, from 18.0% (New York) to 73.7% (Utah). Supportive hospice and home health regulations were associated with a higher odds of residents dying in place (adjusted odds ratio [AOR], 1.38; 95% CI, 1.24-1.54; P < .001; and AOR, 1.21; 95% CI, 1.10-1.34; P < .001, respectively). In addition, hospice regulations remained significant in fully adjusted models (AOR, 1.46; 95% CI, 1.25-1.71). Conclusions and Relevance: The findings of this cohort study suggest that a higher percentage of assisted living residents died in place in US states with regulations supportive of third-party services. In addition, assisted living residents in licensed settings with regulations supportive of hospice regulations were especially likely to die in place.

State Regulations and Hospice Utilization in Assisted Living During the Last Month of Life.

OBJECTIVES: To examine the association between hospice/staffing regulations in residential care or assisted living (RC/AL) and hospice utilization among a national cohort of Medicare decedents residing in RC/AL at least 1 day during the last month of life, and to describe patterns of hospice utilization. DESIGN: Retrospective cohort study of fee-for-service Medicare beneficiaries who died in 2018 and resided in an RC/AL community with ≥25 beds at least 1 day during the last month of life. SETTING/PARTICIPANTS: 23,285 decedents who spent time in 6274 RC/AL communities with 146 state license classifications. METHODS: Descriptive statistics about hospice use; logistic regression models to test the association between regulations supportive of hospice care or registered nurse (RN) staffing requirements and the odds of hospice use in RC/AL in the last month of life. RESULTS: More than half (56.4%) of the study cohort received hospice care in RC/AL at some point during the last 30 days of life, including 5.7% who received more intensive continuous home care (CHC). A larger proportion of decedents who resided in RC/ALs with supportive hospice policies received hospice (57.3% vs 52.6%), with this difference driven by more CHC hospice programs. This association remained significant after controlling for sociodemographic characteristics, comorbidities, time spent in RC/AL, and Hospital Referral Region fixed effects. Decedents in RC/ALs with explicit RN staffing requirements had significantly less CHC use (2.0% vs 6.8%). CONCLUSIONS AND IMPLICATIONS: A large proportion of RC/AL decedents received hospice care in RC/AL regardless of differing regulations. Those in licensed settings with explicitly supportive hospice regulations were significantly more likely to receive hospice care in RC/AL during the last month of life, especially CHC level of hospice care. Regulatory change in states that do not yet explicitly allow hospice care in RC/AL may potentially increase hospice utilization in this setting, although the implications for quality of care remain unclear.

Increasing the adoption of ambulatory hysteroscopy in Australia - cost comparisons and patient satisfaction.

We present the findings of a prospective cohort study in a single tertiary hospital to review the patient experience and economic benefit of ambulatory hysteroscopy (AH). Data were collected between May 2017 and February 2020. Patient satisfaction was measured with qualitative survey. Hospital level financial data were obtained over two financial years (2017/18 and 2018/19) to identify seasonal variation. The primary outcome was patient satisfaction and the secondary outcome was cost of AH compared to hysteroscopy under GA. Three hundred and twenty-nine patients underwent AH. Two hundred and ninety-eight responses (91%) were collected. Ninety-five percent of procedures were successful. Median pain score was five out of 10. Despite pain, 94% of patients would undergo AH again and 97% would recommend it. The average hospital cost for AH was $259 compared with $3098 for hysteroscopy under GA. These findings support AH as a safe, well-tolerated and economically viable alternative to hysteroscopy under GA.Impact StatementWhat is already known on this subject? Hysteroscopy is traditionally performed in an operating theatre under general anaesthesia (GA). Technological advancements allow for the procedure to be performed in an outpatient setting. Despite advantages of ambulatory hysteroscopy (AH), GA hysteroscopy is still the predominant intervention in Australia.What the results of this study add? Patient satisfaction in AH was assessed. The median pain score was five out of 10. Despite pain, 94% of patients would undergo AH again and 97% would recommend it.What the implications are of these findings for clinical practice and/or further research? AH is a well-tolerated alternative to hysteroscopy under GA with significant cost benefits to the hospital and high patient satisfaction. Further research should focus on direct comparison of the two procedure approaches using randomised controlled trials.

First Year of Skilled Nursing Facility Value-based Purchasing Program Penalizes Facilities With Poorer Financial Performance.

BACKGROUND: The Skilled Nursing Facility Value-based Purchasing Program (SNF-VBP) incentivizes facilities to coordinate care, improve quality, and lower hospital readmissions. However, SNF-VBP may unintentionally punish facilities with lower profit margins struggling to invest resources to lower readmissions. OBJECTIVE: The objective of this study was to estimate the SNF-VBP penalty amounts by skilled nursing facility (SNF) profit margin quintiles and examine whether facilities with lower profit margins are more likely to be penalized by SNF-VBP. RESEARCH DESIGN: We combined the first round of SNF-VBP performance data with SNF profit margins and characteristics data. Our outcome variables included estimated penalty amount and a binary measure for whether facilities were penalized by the SNF-VBP. We categorized SNFs into 5 profit margin quintiles and examined the relationship between profit margins and SNF-VBP performance using descriptive and regression analysis. RESULTS: The average profit margins for SNFs in the lowest profit margin quintile was -14.4% compared with the average profit margin of 11.1% for SNFs in the highest profit margin quintile. In adjusted regressions, SNFs in the lowest profit margin quintile had 17% higher odds of being penalized under SNF-VBP compared with facilities in the highest profit margin quintile. The average penalty for SNFs in the lowest profit margin quintile was $22,312. CONCLUSIONS: SNFs in the lowest profit margins are more likely to be penalized by the SNF-VBP, and these losses can exacerbate quality problems in SNFs with lower quality. Alternative approaches to measuring and rewarding SNFs under SNF-VBP or programs to assist struggling SNFs is warranted, particularly considering the coronavirus disease 2019 pandemic, which requires resources for prevention and management.

Laparoscopic gynaecological surgery in the context of maintaining normal intracranial pressure.

A nulliparous patient in her early 20s was referred to a fertility specialist for fertility preservation, before commencing chemo-radiation therapy for a recently diagnosed malignant brain tumour. Two weeks prior, she had presented with seizures and undergone emergency craniotomy and tumour resection. Taking into consideration of the tight time frame and her comorbidities, several measures were undertaken to minimise the potential increase in intracranial pressure that may lead to cerebral oedema during laparoscopy. Preoperatively, the anaesthetist administered 8 mg dexamethasone as prophylaxis. Intraoperatively, the degree of head-down tilt was minimised to 10, which was just adequate to displace bowel cranially for visualisation of pelvic structures. Finally, a shorter operative time was achieved by ensuring the most senior surgeon performed the operation, and the procedure itself was altered from the standard approach of ovarian harvesting to unilateral oophorectomy. The patient made a quick recovery and was discharged home day 1 postoperatively.

A Rising Tide Lifts "Related" Boats-Post-Acute Care Quality Improvement is Associated with Improvement in Long-Term Care Quality in Nursing Homes.

OBJECTIVES: To examine the relationship between post-acute care (PAC) quality improvement and long-term care (LTC) quality changes. DESIGN: Observational study using national nursing home data from Nursing Home Compare linked to Brown University's LTCFocus data. SETTING AND PARTICIPANTS: Free-standing nursing homes serving PAC and LTC residents in the United States. METHODS: This study used pooled cross-sectional analysis with nursing home-level data from 2005 to 2010 (12,150 unique nursing homes). We used fixed effects models to examine the association between a 1-year change in PAC quality and a 1-year change in LTC quality, with a specific focus on related care domains. RESULTS: Strong and positive associations were found between related PAC and LTC care domains, particularly between the PAC and LTC influenza vaccination care domains (ß = 0.30, P < .001) and the PAC and LTC pneumococcal vaccination care domains (ß = 0.55, P < .001). Meanwhile, model results showed PAC quality changes essentially had no associations with unrelated LTC care domains. CONCLUSIONS AND IMPLICATIONS: This is the first study that examines the association of changes in quality between 2 overlapping but different care domains (ie, PAC and LTC) using multiple quality measures. Our findings indicate that nursing homes can manage concurrent quality improvement in PAC and LTC, particularly on care domains that are related. More research is needed to examine the mechanism that enables such concurrent quality improvement.

When only one embryo is available, is it better to transfer on Day 3 or to grow on?

RESEARCH QUESTION: In patients with only one embryo on Day 3 post-IVF treatment, does transferring the embryo into the uterine environment achieve a higher pregnancy rate than growing the embryo on with a plan to transfer at Day 4-6? DESIGN: This was a retrospective cohort study conducted in patients with only one viable embryo on Day 3 post-IVF treatment. Data were extracted from a standardized IVF database and included 1384 women who fulfilled this study's selection criteria. Outcomes of these embryos were followed up and stratified into two groups: embryos transferred on Day 3 and those grown on to Day 4-6. Pregnancy rate (biochemical and clinical) and live birth rates were analysed with logistic regression and adjusted using a parsimonious model for baseline patient characteristics. RESULTS: Biochemical pregnancy (16.7% versus 9.5%, odds ratio [OR] 1.9, P = 0.001), clinical pregnancy (14.7% versus 6.8%, OR 2.35, P < 0.001) and live birth rates (9.7% versus 4.4%, OR 2.37, P = 0.002) were significantly higher in the Day 3 group than those in the group grown on to Day 4-6. These differences were still significant after adjusting for potential confounders (adjusted OR 2.60, 3.71, 4.08, respectively, P < 0.001). CONCLUSIONS: These findings support Day 3 cleavage-stage embryo transfer instead of growing on to Day 4-6 for blastocyst-stage transfer when only a single embryo is available.

Fewer Bonuses, More Penalties At Skilled Nursing Facilities Serving Vulnerable Populations.

The first round of incentives and penalties under the Medicare Skilled Nursing Facility Value-Based Purchasing Program were distributed October 1, 2018. Our results show that facilities serving vulnerable groups were less likely to receive bonus payments and more likely to be penalized.

Multitasking in Nursing Homes: Differences Between For-Profit and Nonprofit Quality Outcomes.

BACKGROUND AND OBJECTIVES: Nursing homes (NHs) in the United States face increasing pressures to admit Medicare postacute patients, given higher payments relative to Medicaid. Changes in the proportion of residents who are postacute may initiate shifts in care practices, resource allocations, and priorities. Our study sought to determine whether increases in Medicare short-stay census have an impact on quality of care for long-stay residents. RESEARCH DESIGN AND METHODS: This study used panel data (2005-2010) from publicly-available sources (Nursing Home Compare, Area Health Resource File, LTCFocus.org) to examine the relationship between a 1-year change in NH Medicare census and 14 measures of long-stay quality among NHs that experienced a meaningful increase in Medicare census during the study period (N = 7,932). We conducted analyses on the overall sample and stratified by for- and nonprofit ownership. RESULTS: Of the 14 long-stay quality measures examined, only one was shown to have a significant association with Medicare census: increased Medicare census was associated with improved performance on the proportion of residents with pressure ulcers. Stratified analyses showed increased Medicare census was associated with a significant decline in performance on 3 of 14 long-stay quality measures among nonprofit, but not for-profit, facilities. DISCUSSION AND IMPLICATIONS: Our findings suggest that most NHs that experience an increase in Medicare census maintain long-stay quality. However, this may be more difficult to do for some, particularly nonprofits. As pressure to focus on postacute care mount in the current payment innovation environment, our findings suggest that most NHs will be able to maintain stable quality.

A National-Level Analysis of the Relationship Between Nursing Home Satisfaction and Quality.

Little research has explored the relationship between consumer satisfaction and quality in nursing homes (NHs) beyond the few states mandating satisfaction surveys. We examine this relationship through data from 1,765 NHs in the 50 states and District of Columbia using My InnerView resident or family satisfaction instruments in 2013 and 2014, merged with Certification and Survey Provider Enhanced Reporting, LTCfocus, and NH Compare (NHC) data. Family and resident satisfaction correlated modestly; both correlated weakly and negatively with any quality-of-care (QoC) and any quality-of-life deficiencies and positively with NHC five-star ratings; this latter positive association persisted after covariate adjustment; the negative relationship between QoC deficiencies and family satisfaction also remained. Overall, models explained relatively small proportions of satisfaction variance; correlates of satisfaction varied between residents and families. Findings suggest that satisfaction is a unique dimension of quality and that resident and family satisfaction represent different constructs.