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.

Antimicrobial Prescribing in the Telehealth Setting: Framework for Stewardship During a Period of Rapid Acceleration Within Primary Care.

Antibiotic resistance is a global public health threat. The use of telehealth in primary care presents unique barriers to antimicrobial stewardship, including limited physical examination and changes to the patient-provider relationship. Since the coronavirus disease 2019 (COVID-19) pandemic, there is a need to identify novel antimicrobial stewardship strategies with an explosion in the use of telehealth within primary care. Our review proposes a tailored, sustainable approach to antimicrobial prescribing in the telehealth setting based on the Centers for Disease Control and Prevention's Core Elements of Outpatient Antibiotic Stewardship: commitment, action for policy and practice; tracking and reporting; and education and expertise. The rapid growth of telehealth for all types of primary care visits (not just antibiotic use) is outpacing knowledge associated with strategies for antimicrobial stewardship. Improving antibiotic use within primary care settings is critical as telehealth will remain a priority whether the COVID-19 pandemic recedes, particularly within patient populations with limited access to healthcare.

Risk factors for Veteran food insecurity: findings from a National US Department of Veterans Affairs Food Insecurity Screener.

OBJECTIVE: Food insecurity is associated with numerous adverse health outcomes. The US Veterans Health Administration (VHA) began universal food insecurity screening in 2017. This study examined prevalence and correlates of food insecurity among Veterans screened. DESIGN: Retrospective cross-sectional study using VHA administrative data. Multivariable logistic regression models were estimated to identify sociodemographic and medical characteristics associated with a positive food insecurity screen. SETTING: All US Veterans Administration (VA) medical centres (n 161). PARTICIPANTS: All Veterans were screened for food insecurity since screening initiation (July 2017-December 2018). RESULTS: Of 3 304 702 Veterans screened for food insecurity, 44 298 were positive on their initial screen (1·3 % of men; 2·0 % of women). Food insecurity was associated with identifying as non-Hispanic Black or Hispanic. Veterans who were non-married/partnered, low-income Veterans without VA disability-related compensation and those with housing instability had higher odds of food insecurity, as did Veterans with a BMI < 18·5, diabetes, depression and post-traumatic stress disorder. Prior military sexual trauma (MST) was associated with food insecurity among both men and women. Women screening positive, however, were eight times more likely than men to have experienced MST (48·9 % v. 5·9 %). CONCLUSIONS: Food insecurity was associated with medical and trauma-related comorbidities as well as unmet social needs including housing instability. Additionally, Veterans of colour and women were at higher risk for food insecurity. Findings can inform development of tailored interventions to address food insecurity such as more frequent screening among high-risk populations, onsite support applying for federal food assistance programs and formal partnerships with community-based resources.

Frequency and Predictors of Suboptimal Prescribing Among a Cohort of Older Male Residents with Urinary Tract Infections.

BACKGROUND: Unnecessary antibiotic treatment of suspected urinary tract infections (UTI) is common in long-term care facilities (LTCFs). However, less is known about the extent of suboptimal treatment, in terms of antibiotic choice, dose, and duration, after the decision to use antibiotics has been made. METHODS: We described the frequency of potentially suboptimal treatment among residents with an incident UTI (the first during the study with none in the year prior) in Department of Veterans Affairs (VA) community living centers (CLCs; 2013-2018). Time trends were analyzed using Joinpoint regression. Residents with UTIs receiving potentially suboptimal treatment were compared with those receiving optimal treatment, to identify resident characteristics predictive of suboptimal antibiotic treatment, using multivariable unconditional logistic regression models. RESULTS: We identified 21 938 residents with an incident UTI treated in 120 VA CLCs, of whom 96.0% were male. Potentially suboptimal antibiotic treatment was identified in 65.0% of residents and decreased 1.8% annually (P < .05). Potentially suboptimal initial drug choice was identified in 45.6% of residents, suboptimal dose frequency in 28.6%, and longer than recommended duration in 12.7%. Predictors of suboptimal antibiotic treatment included prior fluoroquinolone exposure (adjusted odds ratio, 1.38), chronic renal disease (1.19), age ≥85 years (1.17), prior skin infection (1.14), recent high white blood cell count (1.08), and genitourinary disorder (1.08). CONCLUSION: Similar to findings in non-VA facilities, potentially suboptimal treatment was common but improving in CLC residents with an incident UTI. Predictors of suboptimal antibiotic treatment should be targeted with antibiotic stewardship interventions to improve UTI treatment.

Poor clinical outcomes associated with suboptimal antibiotic treatment among older long-term care facility residents with urinary tract infection: a retrospective cohort study.

BACKGROUND: Antibiotic use is associated with several antibiotic-related harms in vulnerable, older long-term care (LTC) residents. Suboptimal antibiotic use may also be associated with harms but has not yet been investigated. The aim of this work was to compare rates of poor clinical outcomes among LTC residents with UTI receiving suboptimal versus optimal antibiotic treatment. METHODS: We conducted a retrospective cohort study among residents with an incident urinary tract infection (UTI) treated in Veterans Affairs LTC units (2013-2018). Potentially suboptimal antibiotic treatment was defined as use of a suboptimal initial antibiotic drug choice, dose frequency, and/or excessive treatment duration. The primary outcome was time to a composite measure of poor clinical outcome, defined as UTI recurrence, acute care hospitalization/emergency department visit, adverse drug event, Clostridioides difficile infection (CDI), or death within 30 days of antibiotic discontinuation. Shared frailty Cox proportional hazard regression models were used to compare the time-to-event between suboptimal and optimal treatment. RESULTS: Among 19,701 LTC residents with an incident UTI, 64.6% received potentially suboptimal antibiotic treatment and 35.4% experienced a poor clinical outcome. In adjusted analyses, potentially suboptimal antibiotic treatment was associated with a small increased hazard of poor clinical outcome (aHR 1.06, 95% CI 1.01-1.11) as compared with optimal treatment, driven by an increased hazard of CDI (aHR 1.94, 95% CI 1.54-2.44). CONCLUSION: In this national cohort study, suboptimal antibiotic treatment was associated with a 6% increased risk of the composite measure of poor clinical outcomes, in particular, a 94% increased risk of CDI. Beyond the decision to use antibiotics, clinicians should also consider the potential harms of suboptimal treatment choices with regards to drug type, dose frequency, and duration used.

A New Data Resource to Examine Meals on Wheels Clients' Health Care Utilization and Costs.

BACKGROUND: Access to social services (eg, nutrition) can impact older adults' health care utilization and health outcomes. However, data documenting the relationship between receiving services and objective measures of health care utilization remain limited. OBJECTIVES: To link Meals on Wheels (MOW) program data to Medicare claims to enable examination of clients' health and health care utilization and to highlight the utility of this linked dataset. RESEARCH DESIGN: Using probabilistic linking techniques, we matched MOW client data to Medicare enrollment and claims data. Descriptive information is presented on clients' health and health care utilization before and after receiving services from MOW. SUBJECTS: In total, 29,501 clients were from 13 MOW programs. MEASURES: Clients' demographics, chronic conditions, and hospitalization, emergency department (ED), and nursing home (NH) utilization rates. RESULTS: We obtained a one-to-one link for 25,279 clients. Among these, 14,019 were Medicare fee-for-service (FFS) beneficiaries and met inclusion criteria for additional analyses. MOW clients had high rates of chronic conditions (eg, almost 90% of FFS clients were diagnosed with hypertension, compared with 63% of FFS beneficiaries in their communities). In the 6 months before receiving MOW services, 31.6% of clients were hospitalized, 24.9% were admitted to the ED and 13% received care in a NH. In the 6 months after receiving meals, 24.2% were hospitalized, 19.3% were admitted to the ED, and 9.5% received care in a NH. CONCLUSIONS: Linking MOW data to Medicare claims has the potential to shed additional light on the relationships among social services, health status, health care use, and benefits to clients' well-being.

Facilitators and Barriers to Antibiotic Stewardship: A Qualitative Study of Pharmacists' Perspectives.

Background: The Veterans Affairs (VA) is a leader in the implementation and advancement of antibiotic stewardship programs throughout the nation. The Centers for Disease Control and Prevention (CDC) has also led national antibiotic stewardship efforts and has outlined core elements to improve antibiotic use in hospitals, long-term care, and outpatient settings. Many facilities still face challenges to the implementation and maintenance of successful programs, particularly in nonacute care settings. The objective of this study was to identify barriers and facilitators to antibiotic stewardship within the VA medical centers through qualitative interviews with pharmacists. Methods: Eight semi-structured telephone interviews were conducted with pharmacists from 6 VA medical centers within VA New England Healthcare System. Pharmacist respondents were either pharmacy champions (for medical centers with established programs) or pharmacists with responsibilities in making antibiotic recommendations (locations without established programs). All interviews were audio recorded and transcribed verbatim. NVivo 8 was used for data coding and analysis. Results: Pharmacists from all 8 medical centers were contacted for interviews and pharmacists from 6 medical centers agreed to interviews (75% VA New England medical center participation). Three main themes regarding antibiotic stewardship were identified from the interviews with pharmacists. Respondents described the importance of (1) a supportive organizational culture, (2) protected time for antibiotic stewardship, and (3) a cohesive organizational structure in the success of antibiotic stewardship programs. Conclusions: Our findings support the CDC core elements for antibiotic stewardship, in particular the importance of leadership commitment in the creation of a culture that supports antibiotic stewardship and in ensuring staff are given sufficient time for antibiotic stewardship efforts. Although a strong supportive culture has been built, strategies focused on fostering increased protected time for antibiotic stewardship and a cohesive organizational structure may be helpful in advancing and sustaining successful antibiotic stewardship programs that improve patient outcomes.

Vancomycin Plus Piperacillin-Tazobactam and Acute Kidney Injury in Adults: A Systematic Review and Meta-Analysis.

OBJECTIVES: The objective of this systematic review and meta-analysis was to assess acute kidney injury with combination therapy of vancomycin plus piperacillin-tazobactam, in general, adult patients and in critically ill adults. Rates of acute kidney injury, time to acute kidney injury, and odds of acute kidney injury were compared with vancomycin monotherapy, vancomycin plus cefepime or carbapenem, or piperacillin-tazobactam monotherapy. DATA SOURCES: Studies were identified by searching Pubmed, Embase, Web of Science, and Cochrane from inception to April 2017. Abstracts from selected conference proceedings were manually searched. STUDY SELECTION: Articles not in English, pediatric studies, and case reports were excluded. DATA EXTRACTION: Two authors independently extracted data on study methods, rates of acute kidney injury, and time to acute kidney injury. Effect estimates and 95% CIs were calculated using the random effects model in RevMan 5.3. DATA SYNTHESIS: Literature search identified 15 published studies and 17 conference abstracts with at least 24,799 patients. The overall occurrence rate of acute kidney injury was 16.7%, with 22.2% for vancomycin plus piperacillin-tazobactam and 12.9% for comparators. This yielded an overall number needed to harm of 11. Time to acute kidney injury was faster for vancomycin plus piperacillin-tazobactam than vancomycin plus cefepime or carbapenem, but not significantly (mean difference, -1.30; 95% CI, -3.00 to 0.41 d). The odds of acute kidney injury with vancomycin plus piperacillin-tazobactam were increased versus vancomycin monotherapy (odds ratio, 3.40; 95% CI, 2.57-4.50), versus vancomycin plus cefepime or carbapenem (odds ratio, 2.68; 95% CI, 1.83-3.91), and versus piperacillin-tazobactam monotherapy (odds ratio, 2.70; 95% CI, 1.97-3.69). In a small subanalysis of 968 critically ill patients, the odds of acute kidney injury were increased versus vancomycin monotherapy (odds ratio, 9.62; 95% CI, 4.48-20.68), but not significantly different for vancomycin plus cefepime or carbapenem (odds ratio, 1.43; 95% CI, 0.83-2.47) or piperacillin-tazobactam monotherapy (odds ratio, 1.35; 95% CI, 0.86-2.11). CONCLUSIONS: The combination of vancomycin plus piperacillin-tazobactam increased the odds of acute kidney injury over vancomycin monotherapy, vancomycin plus cefepime or carbapenem, and piperacillin-tazobactam monotherapy. Limited data in critically ill patients suggest the odds of acute kidney injury are increased versus vancomycin monotherapy, and mitigated versus the other comparators. Further research in the critically ill population is needed.

A Methodology to Identify a Cohort of Medicare Beneficiaries Residing in Large Assisted Living Facilities Using Administrative Data.

BACKGROUND: Assisted living is a popular option for housing and long-term care. OBJECTIVE: To develop and test a methodology to identify Medicare beneficiaries residing in assisted living facilities (ALFs). RESEARCH DESIGN: We compiled a finder file of 9-digit ZIP codes representing large ALFs (25+ beds) by matching Outcome and Assessment Information Set (OASIS) assessments and Medicare Part B Claims to the Medicare enrollment records and addresses of 11,751 ALFs. Using this finder file, we identified 738,567 beneficiaries residing in validated ALF ZIP codes in 2007-2009. We compared characteristics of this cohort to those of ALF residents in the National Survey of Residential Care Facilities (n=3009), a sample of community-dwelling Medicare beneficiaries (n=33,025,690), and long-stay nursing home residents (n=1,287,572). DATA SOURCES: A national list of licensed ALFs, Medicare enrollment records, and administrative health care databases. RESULTS: The ALF cohort we identified had good construct validity based on their demographic characteristics, health, and health care utilization when compared with ALF residents in the National Survey of Residential Care Facilities, community-dwelling Medicare beneficiaries, and long-stay nursing home residents. CONCLUSIONS: Our finder file of 9-digit ZIP codes enables identification of ALF residents using administrative data. This approach will allow researchers to examine questions related to the quality of care, health care utilization, and outcomes of residents in this growing sector of long-term care.

Constructing a Measure of Private-pay Nursing Home Days.

BACKGROUND: Nursing home (NH) care is financed through multiple sources. Although Medicaid is the predominant payer for NH care, over 20% of residents pay out-of-pocket for their care. Despite this large percentage, an accepted measure of private-pay NH occupancy has not been established and little is known about the types of facilities and the long-term care markets that cater to this population. OBJECTIVES: To describe 2 novel measures of private-pay utilization in the NH setting, including the proportion of privately financed residents and resident days, and examine their construct validity. DESIGN: Retrospective descriptive analysis of US NHs in 2007-2009. MEASURES: We used Medicare claims, Medicare Enrollment records, and the Minimum Data Set to create measures of private-pay resident prevalence and proportion of privately financed NH days. We compared our estimates of private-pay utilization to payer data collected in the NH annual certification survey and evaluated the relationships of our measures with facility characteristics. RESULTS: Our measures of private-pay resident prevalence and private-pay days are highly correlated (r=0.83, P<0.001 and r=0.83, P<0.001, respectively) with the rate of "other payer" reported in the annual certification survey. We also observed a significantly higher proportion of private-pay residents and days in higher quality facilities. CONCLUSIONS: This new methodology provides estimates of private-pay resident prevalence and resident days. These measures were correlated with estimates using other data sources and validated against measures of facility quality. These data set the stage for additional work to examine questions related to NH payment, quality of care, and responses to changes in the long-term care market.

Antimicrobial Resistance of Escherichia coli Urinary Isolates in the Veterans Affairs Health Care System.

We reviewed data for almost 300,000 clinical Escherichia coli urinary isolates (collected in 2009 through 2013) from 127 inpatient and outpatient facilities, to assess antibiotic resistance among Veterans Affairs health care system patients using Clinical and Laboratory Standards Institute and Centers for Disease Control and Prevention National Healthcare Safety Network definitions or guidance. Rates of resistance to amoxicillin or ampicillin/ß-lactamase inhibitors were approximately 40% and rates of resistance to fluoroquinolones and trimethoprim-sulfamethoxazole approached 30%. Rates of resistance to nitrofurantoin, antipseudomonal penicillin/ß-lactamase inhibitors, and carbapenems remained less than 10%. The percentage of isolates that were considered multidrug resistant varied (4% to 37%), depending on the definitions used.

The Minimum Data Set 3.0 Cognitive Function Scale.

BACKGROUND: The Minimum Data Set (MDS) 3.0 introduced the Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home (NH) residents. Not all residents are able to complete the BIMS and are consequently assessed by staff. We designed a Cognitive Function Scale (CFS) integrating self-report and staff-report data and present evidence of the scale's construct validity. DESIGN: A retrospective cohort study. SUBJECTS: The subjects consisted of 3 cohorts: (1) long-stay NH residents (N=941,077) and (2) new admissions (N=2,066,580) during 2011-2012, and (3) residents with the older MDS 2.0 assessment in 2010 and the newer MDS 3.0 assessment (n=688,511). MEASURES: MDS 3.0 items were used to create a single, integrated 4-category hierarchical CFS that was compared with residents' prior MDS 2.0 Cognitive Performance Scale scores and other concurrent MDS 3.0 measures of construct validity. RESULTS: The new CFS suggests that 28% of the long-stay cohort in 2011-2012 were cognitively intact, 22% were mildly impaired, 33% were moderately impaired, and 17% were severely impaired. For the admission cohort, the CFS noted 56% as cognitively intact, 23% as mildly impaired, 17% as moderately impaired, and 4% as severely impaired. The CFS corresponded closely with residents' prior MDS 2.0 Cognitive Performance Scale scores and with performance of Activities of Daily Living, and nurses' judgments of function and behavior in both the admission and long-stay cohorts. CONCLUSIONS: The new CFS is valuable to researchers as it provides a single, integrated measure of NH residents' cognitive function, regardless of the mode of assessment.

Exploring variations in recommended first-choice therapy for complicated urinary tract infections in males: Insights from outpatient settings across age, race, and ethnicity.

INTRODUCTION: There are known disparities in the treatment of infectious diseases. However, disparities in treatment of complicated urinary tract infections (UTIs) are largely uninvestigated. OBJECTIVES: We characterized UTI treatment among males in Veterans Affairs (VA) outpatient settings by age, race, and ethnicity and identified demographic characteristics predictive of recommended first-choice antibiotic therapy. METHODS: We conducted a national, retrospective cohort study of male VA patients diagnosed with a UTI and dispensed an outpatient antibiotic from January 2010 through December 2020. Recommended first-choice therapy for complicated UTI was defined as use of a recommended first-line antibiotic drug choice regardless of area of involvement (ciprofloxacin, levofloxacin, or sulfamethoxazole/trimethoprim) and a recommended duration of 7 to 10 days of therapy. Multivariable models were used to identify demographic predictors of recommended first-choice therapy (adjusted odds ratio [aOR] > 1). RESULTS: We identified a total of 157,898 males diagnosed and treated for a UTI in the outpatient setting. The average antibiotic duration was 9.4 days (±standard deviation [SD] 4.6), and 47.6% of patients were treated with ciprofloxacin, 25.1% with sulfamethoxazole/trimethoprim, 7.6% with nitrofurantoin, and 6.6% with levofloxacin. Only half of the male patients (50.6%, n = 79,928) were treated with recommended first-choice therapy (first-line drug choice and appropriate duration); 77.6% (n = 122,590) were treated with a recommended antibiotic choice and 65.9% (n = 104,070) with a recommended duration. Age 18-49 years (aOR 1.07, 95% confidence interval [CI] 1.03-1.11) versus age ≥65 years was the only demographic factor predictive of recommended first-choice therapy. CONCLUSIONS: Nearly half of the patients included in this study did not receive recommended first-choice therapies; however, racial and ethnic disparities were not identified. Underutilization of recommended first-choice antibiotic therapy in complicated UTIs continues to be an area of focus for antimicrobial stewardship programs.

Evacuation and Health Care Outcomes Among Assisted Living Residents After Hurricane Irma.

Importance: Evacuation has been found to be associated with adverse outcomes among nursing home residents during hurricanes, but the outcomes for assisted living (AL) residents remain unknown. Objective: To examine the association between evacuation and health care outcomes (ie, emergency department visits, hospitalizations, mortality, and nursing home visits) among Florida AL residents exposed to Hurricane Irma. Design, Setting, and Participants: Retrospective cohort study using 2017 Medicare claims data. Participants were a cohort of Florida AL residents who were aged 65 years or older, enrolled in Medicare fee-for-service, and resided in 9-digit zip codes corresponding to US assisted living communities with 25 or more beds on September 10, 2017, the day of Hurricane Irma's landfall. Propensity score matching was used to match evacuated residents to those that sheltered-in-place based on resident and AL characteristics. Data were analyzed from September 2022 to February 2024. Exposure: Whether the AL community evacuated or sheltered-in-place before Hurricane Irma made landfall. Main Outcomes and Measures: Thirty- and 90-day emergency department visits, hospitalizations, mortality, and nursing home admissions. Results: The study cohort included 25 130 Florida AL residents (mean [SD] age 81 [9] years); 3402 (13.5%) evacuated and 21 728 (86.5%) did not evacuate. The evacuated group had 2223 women (65.3%), and the group that sheltered-in-place had 14 556 women (67.0%). In the evacuated group, 42 residents (1.2%) were Black, 93 (2.7%) were Hispanic, and 3225 (94.8%) were White. In the group that sheltered in place, 490 residents (2.3%) were Black, 707 (3.3%) were Hispanic, and 20 212 (93.0%) were White. After 1:4 propensity score matching, when compared with sheltering-in-place, evacuation was associated with a 16% greater odds of emergency department visits (adjusted odds ratio [AOR], 1.16; 95% CI, 1.01-1.33; P = .04) and 51% greater odds of nursing home visits (AOR, 1.51; 95% CI, 1.14-2.00; P = .01) within 30 days of Hurricane Irma's landfall. Hospitalization and mortality did not vary significantly by evacuation status within 30 or 90 days after the landfall date. Conclusions and Relevance: In this cohort study of Florida AL residents, there was an increased risk of nursing home and emergency department visits within 30 days of Hurricane Irma's landfall among residents from communities that evacuated before the storm when compared with residents from communities that sheltered-in-place. The stress and disruption caused by evacuation may yield poorer immediate health outcomes after a major storm for AL residents. Therefore, the potential benefits and harms of evacuating vs sheltering-in-place must be carefully considered when developing emergency planning and response.

Winter Storm Uri Reduced Availability of Daily Direct-Care Nurse Staff in Texas Nursing Homes.

We examined the effect of Winter Storm Uri on daily direct-care nurse staffing levels in 1,173 Texas nursing homes (NHs) from February 13th to 19th, 2021. We used data from Payroll-Based Journaling and the Care Compare website. Linear mixed effects models were used to estimate the linear and non-linear change in staffing. During Winter Storm Uri, Texas NHs experienced a linear decrease in daily staffing levels with subsequent non-linear increase for registered nurses (RNs; p < .001) and certified nursing assistants (CNAs; p < .001), and staffing increased linearly for licensed practical nurses (LPNs; p < .001). Compared to 1 week before the storm, Texas NHs reported lower staffing levels across all three types of staff, but most dramatically among LPNs and CNAs. In supplemental analyses, urban and lower quality NHs fared slightly poorer than rural and higher-quality NHs. Winter storms pose a particular challenge to NHs and their ability to maintain direct-care nurse staffing levels.

Antibiotic Prescribing in Outpatient Settings: Rural Patients Are More Likely to Receive Fluoroquinolones and Longer Antibiotic Courses.

Suboptimal antibiotic prescribing may be more common in patients living in rural versus urban areas due to various factors such as decreased access to care and diagnostic testing equipment. Prior work demonstrated a rural health disparity of overprescribing antibiotics and longer durations of antibiotic therapy in the United States; however, large-scale evaluations are limited. We evaluated the association of rural residence with suboptimal outpatient antibiotic use in the national Veterans Affairs (VA) system. Outpatient antibiotic dispensing was assessed for the veterans diagnosed with an upper respiratory tract infection (URI), pneumonia (PNA), urinary tract infection (UTI), or skin and soft tissue infection (SSTI) in 2010-2020. Rural-urban status was determined using rural-urban commuting area codes. Suboptimal antibiotic use was defined as (1) outpatient fluoroquinolone dispensing and (2) longer antibiotic courses (>ten days). Geographic variation in suboptimal antibiotic use was mapped. Time trends in suboptimal antibiotic use were assessed with Joinpoint regression. While controlling for confounding, the association of rurality and suboptimal antibiotic use was assessed with generalized linear mixed models with a binary distribution and logit link, accounting for clustering by region and year. Of the 1,405,642 veterans diagnosed with a URI, PNA, UTI, or SSTI and dispensed an outpatient antibiotic, 22.8% were rural-residing. In 2010-2020, in the rural- and urban-residing veterans, the proportion of dispensed fluoroquinolones declined by 9.9% and 10.6% per year, respectively. The rural-residing veterans were more likely to be prescribed fluoroquinolones (19.0% vs. 17.5%; adjusted odds ratio (aOR), 1.03; 95% confidence interval (CI), 1.02-1.04) and longer antibiotic courses (53.8% vs. 48.5%; aOR, 1.19, 95% CI, 1.18-1.20) than the urban-residing veterans. Among a large national cohort of veterans diagnosed with URIs, PNA, UTIs, and SSTIs, fluoroquinolone use and longer antibiotic courses were disproportionally more common among rural- as compared to urban-residing veterans. Outpatient antibiotic prescribing must be improved, particularly for rural-residing patients. There are many possible solutions, of which antibiotic stewardship interventions are but one.

Heat-related mortality in U.S. state and private prisons: A case-crossover analysis.

Rising temperatures and heatwaves increase mortality. Many of the subpopulations most vulnerable to heat-related mortality are in prisons, facilities that may exacerbate temperature exposures. Yet, there is scare literature on the impacts of heat among incarcerated populations. We analyzed data on mortality in U.S. state and private prisons from 2001-2019 linked to daily maximum temperature data for the months of June, July, and August. Using a case-crossover approach and distributed lag models, we estimated the association of increasing temperatures with total mortality, heart disease-related mortality, and suicides. We also examined the association with extreme heat and heatwaves (days above the 90th percentile for the prison location) and assessed effect modification by personal, facility, and regional characteristics. There were 12,836 deaths during summer months. The majority were male (96%) and housed in a state-operated prison (97%). A 10°F increase was associated with a 5.2% (95% CI: 1.5%, 9.0%) increase in total mortality and a 6.7% (95% CI: -0.6%, 14.0%) increase in heart disease mortality. The association between temperature and suicides was delayed, peaking around lag 3 (exposure at three days prior death). Two- and three-day heatwaves were associated with increased total mortality of 5.5% (95% CI: 0.3%, 10.9%) and 7.4% (95% CI: 1.6%, 13.5%), respectively. The cumulative effect (lags 1-3) of an extreme heat day was associated with a 22.8% (95% CI: 3.3%, 46.0%) increase in suicides. We found the greatest increase in mortality among people ≥ 65 years old, incarcerated less than one year, held in the Northeast region, and in urban or rural counties. These findings suggest that warm temperatures are associated with increased mortality in prisons, yet this vulnerable population's risk has largely been overlooked.

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.

The relationship between exposure to Hurricane Harvey and mortality among nursing home residents.

BACKGROUND: Nursing home (NH) residents are vulnerable to mortality after natural disasters. We examined NH residents' excess all-cause mortality associated with Hurricane Harvey, a unique disaster with long-lasting flooding effects. We also explored how mortality differed between short-stay and long-stay residents and by chronic conditions. METHODS: We conducted a retrospective observational study of Texas NH residents, comparing 30- and 90-day mortality among residents exposed to Hurricane Harvey in August 2017 to residents not exposed in the same location and time period during the previous 2 years. Data came from the Minimum Data Set Assessments and the Medicare Beneficiary Summary File. We used linear probability models to examine the association between hurricane exposure and mortality, adjusting for resident demographics, clinical acuity, and NH fixed effects. Models were stratified by short-stay and long-stay status. We also described differences in mortality by residents' chronic conditions. RESULTS: In 2017, 18,479 Texas NH residents were exposed to Hurricane Harvey. Exposure to Hurricane Harvey was not significantly associated with 30-day mortality. However, 7.6% (95% CI: 7.2, 7.9) of long-stay residents died 90 days after exposure to Harvey, compared to 6.3% (95% CI: 6.0, 6.7) during 2015. Apparently, this effect was driven by chronic obstructive pulmonary disease (COPD) as approximately 9.2% of these residents died within 90 days after Harvey landing compared to 7.2% in 2015 (p < 0.01). CONCLUSIONS: Hurricane exposure appears to have significant consequences for mortality among long-stay NH residents, which appear to materialize over the long-term (90 days post-hurricane in our study) and may not be apparent immediately (30 days post-hurricane in our study). NH residents with COPD may be particularly vulnerable to increased mortality risk following hurricane exposure. The results highlight the need to pay special attention to mortality risk in NH residents, particularly those with COPD, following hurricane exposure.