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BACKGROUND: Epidemiological and mechanistic data support a potential causal link between cardiovascular disease (CVD) and cancer. Abdominal aortic aneurysms (AAAs) represent a common form of CVD with at least partially distinct genetic and biologic pathogenesis from other forms of CVD. The risk of cancer and how this risk differs compared with other forms of CVD, is unknown among AAA patients. We conducted a retrospective cohort study using the IBM MarketScan Research Database to test whether individuals with AAA have a higher cancer risk independent of traditional shared risk factors. METHODS: All individuals ≥18 years of age with ≥36 months of continuous coverage between 2008 and 2020 were enrolled. Those with potential Mendelian etiologies of AAA, aortic aneurysm with nonspecific anatomic location, or a cancer diagnosis before the start of follow-up were excluded. A subgroup analysis was performed of individuals having the Health Risk Assessment records including tobacco use and body mass index. The following groups of individuals were compared: (1) with AAA, (2) with non-AAA CVD, and (3) without any CVD. RESULTS: The propensity score-matched cohort included 58â 993 individuals with AAA, 117â 986 with non-AAA CVD, and 58â 993 without CVD. The 5-year cumulative incidence of cancer was 13.1% (12.8%-13.5%) in participants with AAA, 10.1% (9.9%-10.3%) in participants with non-AAA CVD, and 9.6% (9.3%-9.9%) in participants without CVD. Multivariable-adjusted Cox proportional hazards regression models found that patients with AAA exhibited a higher cancer risk than either those with non-AAA CVD (hazard ratio, 1.28 [95% CI, 1.23-1.32]; P<0.001) or those without CVD (hazard ratio, 1.32 [95% CI, 1.26-1.38]; P<0.001). Results remained consistent after excluding common smoking-related cancers and when adjusting for tobacco use and body mass index. CONCLUSIONS: Patients with AAA may have a unique risk of cancer requiring further mechanistic study and investigation of the role of enhanced cancer screening.
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Aneurisma da Aorta Abdominal , Neoplasias , Humanos , Aneurisma da Aorta Abdominal/epidemiologia , Aneurisma da Aorta Abdominal/diagnóstico , Masculino , Incidência , Feminino , Estudos Retrospectivos , Pessoa de Meia-Idade , Idoso , Fatores de Risco , Neoplasias/epidemiologia , Neoplasias/diagnóstico , Medição de Risco , Estados Unidos/epidemiologia , Fatores de Tempo , Bases de Dados Factuais , Adulto , Idoso de 80 Anos ou maisRESUMO
BACKGROUND: Ovarian cancer is associated with delayed diagnosis and poor survival; thus, interest is high in identifying predictive and prognostic biomarkers and novel therapeutic agents. Although the costs of ovarian cancer care are likely to increase as newer, more effective, but more expensive treatment regimens become available, information on the current costs of care for ovarian cancer-across the care continuum from diagnosis to the end of life-are lacking. OBJECTIVE: This study aimed to estimate real-world mean and median costs of ovarian cancer care within the first 5 years after diagnosis by patients' phase of care, age, race/ethnicity, and geographic region. STUDY DESIGN: We performed a retrospective cohort study of ovarian cancer patients diagnosed between January 1, 2015 and December 31, 2020. We used claims data from Optum's de-identified Clinformatics® Data Mart database, which includes inpatient, outpatient, and prescription claims for commercial insurance and Medicare beneficiaries nationwide. Cost of ovarian cancer care were calculated for the start of care (ie, the first 6 months), continuing care (ie, period between the initial and end-of-life care), and end-of-life care (ie, the last 6 months) phases and reported in 2021 U.S. dollar amounts. Ovarian cancer care costs were stratified by age, race/ethnicity, and geographic region. Due to the skewed nature of cost data, the mean cost data were log-transformed for modelling. Ordinary least-squares regression was conducted on the log costs, adjusting for patient categorical age, race/ethnicity, and geographic region. RESULTS: A total of 7913 patients were included in the analysis. The mean cost per year for ovarian cancer care was >$200,000 during the start of care, between $26,000 and $88,000 during the continuing care phase, and >$129,000 during the end-of-life care phase. There were statistically significant associations between age and costs during each phase of care. Compared to younger patients, older patients incurred higher costs during the continuing care phase and lower costs during the end-of-life care phase. Geographic differences in the costs of ovarian cancer care were also noted regardless of the phase of care. There were no associations between cost and race/ethnicity in our cohort. CONCLUSIONS: Ovarian cancer care costs are substantial and vary by the phase of care, age category, and geographic region. As more effective but expensive treatment options for ovarian cancer become available with potential survival benefit, sustainable interventions to reduce the cost of care for ovarian cancer will be needed throughout the cancer care continuum.
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BACKGROUND: Geographic areas have been developed for many healthcare sectors including acute and primary care. These areas aid in understanding health care supply, use, and outcomes. However, little attention has been given to developing similar geographic tools for understanding rehabilitation in post-acute care. The purpose of this study was to develop and characterize post-acute care Rehabilitation Service Areas (RSAs) in the United States (US) that reflect rehabilitation use by Medicare beneficiaries. METHODS: A patient origin study was conducted to cluster beneficiary ZIP (Zone Improvement Plan) code tabulation areas (ZCTAs) with providers who service those areas using Ward's clustering method. We used US national Medicare claims data for 2013 to 2015 for beneficiaries discharged from an acute care hospital to an inpatient rehabilitation facility (IRF), skilled nursing facility (SNF), long-term care hospital (LTCH), or home health agency (HHA). Medicare is a US health insurance program primarily for older adults. The study population included patient records across all diagnostic groups. We used IRF, SNF, LTCH and HHA services to create the RSAs. We used 2013 and 2014 data (n = 2,730,366) to develop the RSAs and 2015 data (n = 1,118,936) to evaluate stability. We described the RSAs by provider type availability, population, and traveling patterns among beneficiaries. RESULTS: The method resulted in 1,711 discrete RSAs. 38.7% of these RSAs had IRFs, 16.1% had LTCHs, and 99.7% had SNFs. The number of RSAs varied across states; some had fewer than 10 while others had greater than 70. Overall, 21.9% of beneficiaries traveled from the RSA where they resided to another RSA for care. CONCLUSIONS: Rehabilitation Service Areas are a new tool for the measurement and understanding of post-acute care utilization, resources, quality, and outcomes. These areas provide policy makers, researchers, and administrators with small-area boundaries to assess access, supply, demand, and understanding of financing to improve practice and policy for post-acute care in the US.
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Instalações de Saúde , Medicare , Humanos , Idoso , Estados Unidos , Seguro Saúde , Instituições de Cuidados Especializados de Enfermagem , Pessoal AdministrativoRESUMO
BACKGROUND AND AIM: Acute on chronic liver failure (ACLF) in patients with cirrhosis has high short-term mortality. Data comparing ACLF admissions to academic centers (AC) and non-academic centers (NAC) are scanty. METHODS: National Inpatient Sample (2006-2014) was queried for admissions with cirrhosis and ACLF using the ICD-09 codes, and was stratified to AC or NAC. RESULTS: Of 1,928,764 admissions with cirrhosis (2006-2014), 112,174 (5. 9%) had ACLF. 6.7% of 1,018,568 cirrhosis admissions to AC had ACLF versus 5% of 910,196 admissions to NAC, P < 0.0001. Proportion of ACLF admissions to AC increased from 49% during 2006-2008 to 59% during 2012-2014. In a cohort of 73,630 ACLF admissions (36,615 each to AC and NAC) matched for patient demographics, cirrhosis etiology, number of comorbidities, elective versus emergent admission, ACLF grade, and type of organ failure. In-hospital mortality declined by 7% over the study period, but remained higher in AC (46% vs. 42%, P < 0.001), with 11% increased odds for in-hospital mortality compared to admission to NAC. Further admissions to AC versus NAC had higher median (IQR) length of stay at 13 (6-25) versus 11 (5-20) days, with higher median (IQR) hospital charges: 138,239 (66,772-275,603) versus 116,209 (55,767-232,699) USD, P < 0.001 for both. CONCLUSION: Patients with ACLF have high in-hospital mortality. Further, this is higher among admissions to AC. Although the in-hospital mortality is improving, strategies are needed on early identification of patients with futility of care for early discussion on goals of care, and optimal utilization of hospital resources among admissions with ACLF.
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Centros Médicos Acadêmicos/tendências , Insuficiência Hepática Crônica Agudizada/mortalidade , Insuficiência Hepática Crônica Agudizada/terapia , Mortalidade Hospitalar/tendências , Hospitalização/tendências , Hospitais/tendências , Insuficiência Hepática Crônica Agudizada/diagnóstico , Idoso , Bases de Dados Factuais/tendências , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Mortalidade/tendências , Pontuação de PropensãoRESUMO
OBJECTIVE: The purpose of this study was to determine the association between mobility, self-care, cognition, and caregiver support and 30-day potentially preventable readmissions (PPR) for individuals with dementia. DESIGN: This retrospective study derived data from 100% national Centers for Medicare and Medicaid Services data files from July 1, 2013, through June 1, 2015. PARTICIPANTS: Criteria from the Home Health Claims-Based Rehospitalization Measure and the Potentially Preventable 30-Day Post Discharge Readmission Measure for the Home Health Quality Reporting Program were used to identify a cohort of 118,171 Medicare beneficiaries. MAIN OUTCOME MEASURE: The 30-day PPR rates with associated 95% CIs were calculated for each patient characteristic. Multilevel logistic regression was used to study the relationship between mobility, self-care, caregiver support, and cognition domains and 30-day PPR during home health, adjusting for patient demographics and clinical characteristics. RESULTS: The overall rate of 30-day PPR was 7.6%. In the fully adjusted models, patients who were most dependent in mobility (odds ratio [OR], 1.59; 95% CI, 1.47-1.71) and self-care (OR, 1.73; 95% CI, 1.61-1.87) had higher odds for 30-day PPR. Patients with unmet caregiving needs had 1.11 (95% CI, 1.05-1.17) higher odds for 30-day PPR than patients whose caregiving needs were met. Patients with cognitive impairment had 1.23 (95% CI, 1.16-1.30) higher odds of readmission than those with minimal to no cognitive impairment. CONCLUSIONS: Decreased independence in mobility and self-care tasks, unmet caregiver needs, and impaired cognitive processing at admission to home health are associated with risk of 30-day PPR during home health for individuals with dementia. Our findings indicate that deficits in mobility and self-care tasks have the greatest effect on the risk for PPR.
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Cuidadores/psicologia , Demência/enfermagem , Serviços de Assistência Domiciliar , Readmissão do Paciente/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Medicare , Estudos Retrospectivos , Estados UnidosRESUMO
BACKGROUND: Ocular conditions are common following stroke and frequently occur in combination with pre-existing ophthalmologic disease. The Medicare International Statistical Classification of Diseases and Related Health Problems (ICD-10) coding system for identifying vision related health conditions provides a much higher level of detail for coding these complex scenarios than the previous ICD-9 system. While this new coding system has advantages for clinical care and billing, the degree to which providers and researchers are utilizing the expanded code structure is unknown. The purpose of this study was to describe the use of ICD-10 vision codes in a large cohort of stroke survivors. METHODS: Retrospective cohort design to study national 100% Medicare claims files from 2015 through 2017. Descriptive data analyses were conducted using all available ICD-10 vision codes for beneficiaries who had an acute care stay because of a new stroke. The outcome of interest was ≥1 ICD-10 visual code recorded in the claims chart. RESULTS: The cohort (n = 269,314) was mostly female (57.1%) with ischemic stroke (87.8%). Approximately 15% were coded as having one or more ocular condition. Unspecified glaucoma was the most frequently used code among men (2.83%), those over 85+ (4.80%) and black beneficiaries (4.12%). Multiple vision codes were used in few patients (0.6%). Less than 3% of those in the oldest group (85+ years) had two or more vision codes in their claims. CONCLUSIONS: Ocular comorbidity was present in a portion of this cohort of stroke survivors, however the vision codes used to describe impairments in this population were few and lacked specificity. Future studies should compare ophthalmic examination results with billing codes to characterize the type and frequency of ocular comorbidity. It important to understand how the use of ICD-10 vision codes impacts clinical decision making, recovery, and outcomes.
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Oftalmopatias/diagnóstico , Classificação Internacional de Doenças , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Oftalmopatias/epidemiologia , Feminino , Humanos , Revisão da Utilização de Seguros , Masculino , Medicare , Estudos Retrospectivos , Acidente Vascular Cerebral/epidemiologia , Estados UnidosRESUMO
Acute-on-chronic liver failure (ACLF) is characterized by multiple organ failure (OF) with high short-term mortality. There is lack of population-based data on trends on etiology specific ACLF related burden. National Inpatient Sample (2006-2014) was queried using ICD-09 codes for admissions with cirrhosis and ACLF (≥2 extrahepatic OF). Of 1,928,764 admissions for cirrhosis between 2006 and 2014, 112,174 (5.9%) had ACLF (4.5%, 1.2%, and 0.2% with ACLF 1, 2, and 3, respectively). The brain was the most common OF in 11.9%, followed by respiratory failure in 7.7%, cardiac failure in 6.3%, and renal failure in 5.6%. ACLF increased by 24% between 2006 and 2014 with a 63% increase in 179,104 patients with nonalcoholic steatohepatitis (NASH) cirrhosis (3.5% to 5.7%); a 28% increase in patients with 429,306 alcoholic cirrhosis (5.6% to 7.2%); a 25% increase in patients with 1,091,053 with other etiologies (5.2% to 6.5%); and no significant change in 229,301 patients with viral hepatitis (VH) (4.0% to 4.1%). In-hospital mortality was higher among ACLF patients compared with patients without ACLF (44% versus 4.7%; P < 0.0001). Each NASH-related ACLF patient compared with other etiologies had a longer mean length of stay (14 versus 12 days), was associated with higher median total charges (US $151,196 versus US $134,597), and had more frequent use of dialysis (45% versus 36%) and longterm care (32% versus 26%; P < 0.0001 for all). Results remained similar in a subgroup analysis after including half of admissions with cryptogenic cirrhosis as NASH. In conclusion, NASH cirrhosis is the most rapidly growing indication for ACLF-related hospitalization and use of hospital resources. In the setting of improved treatment options for chronic hepatitis, the health care burden of chronic viral-related liver disease remains stable. Population-based strategies are needed to reduce the health care burden of cirrhosis, particularly related to NASH.
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Insuficiência Hepática Crônica Agudizada/etiologia , Efeitos Psicossociais da Doença , Hospitalização/estatística & dados numéricos , Cirrose Hepática/epidemiologia , Hepatopatia Gordurosa não Alcoólica/epidemiologia , Insuficiência Hepática Crônica Agudizada/mortalidade , Idoso , Progressão da Doença , Feminino , Mortalidade Hospitalar , Humanos , Fígado/patologia , Cirrose Hepática/complicações , Cirrose Hepática/patologia , Cirrose Hepática/terapia , Masculino , Pessoa de Meia-Idade , Hepatopatia Gordurosa não Alcoólica/complicações , Hepatopatia Gordurosa não Alcoólica/patologia , Hepatopatia Gordurosa não Alcoólica/terapia , Estudos Retrospectivos , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Beginning in 2019, home health agencies' rates of potentially preventable hospital readmissions over the 30 days following discharge will be publicly reported. OBJECTIVES: Our primary objective was to determine the association between patients' functional status at discharge from home health care and 30-day potentially preventable readmissions. A secondary objective was to identify the most common conditions resulting in potentially preventable readmissions. DESIGN: This was a retrospective cohort study. PARTICIPANTS: A total of 1,510,297 Medicare fee-for-service beneficiaries discharged from home health care in 2013-2015. Average age was 75.9 (SD, 10.9) years, 60.0% were female, and 84.2% non-Hispanic white. MEASUREMENTS: Thirty-day potentially preventable readmissions following home health discharge. Functional status measures included mobility, self-care, and impaired cognition. RESULTS: The overall rate of 30-day potentially preventable readmissions was 2.6% (N=39,452), which accounted for 40% of all 30-day readmissions. After adjusting for sociodemographic and clinical characteristics, the odds ratios for the most dependent score quartile versus the most independent was 1.58 [95% confidence interval (CI), 1.53-1.63] for mobility and 1.65 (95% CI, 1.59-1.69) for self-care. The odds ratios for impaired versus intact cognition was 1.21 (95% CI, 1.18-1.24). The 5 most common conditions resulting in a potentially preventable readmission were congestive heart failure (23.6%), septicemia (16.7%), bacterial pneumonia (9.8%), chronic obstructive pulmonary disease (9.4%), and renal failure (7.5%). CONCLUSIONS: Functional limitations at discharge from home health are associated with increased risk for potentially preventable readmissions. Future research is needed to determine whether improving functional independence decreases the risk for potentially preventable readmissions following home health care.
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Atividades Cotidianas , Serviços de Assistência Domiciliar/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Idoso , Planos de Pagamento por Serviço Prestado , Feminino , Humanos , Masculino , Medicare , Estudos Retrospectivos , Fatores de Risco , Autocuidado/estatística & dados numéricos , Estados UnidosRESUMO
Elder abuse and mistreatment (EM) continues to be a growing problem as the US population ages. Despite the growth, detection of EM continues to lag. However, Medicare claims data and the electronic health record might provide an opportunity to encourage better detection. We evaluated Medicare claims data from 2012-2014 for beneficiaries who had a diagnostic code for EM discharged from any types of facility. We extracted records for 10,181 individuals examining demographic characteristics, residential characteristics, residential location, type of facility providing care, disease co-morbidities, and disability-related conditions. Of our sample, most were female (65.1%), white (78.8%), over 75 years of age (52.6%), and from an urban setting (85.2%). While the greatest number were discharged from acute care settings, almost one-third were hospitalized in psychiatric hospitals (34.6%). Mood disorders (27.5%) and dementia (14.2%) were the most common primary diagnoses. Hypertension (67.7%), depression (44.6%), fluid and electrolyte disorder (43.6%), and cardiac arrhythmia (28.2%) were the most common co-morbidities. In Medicare claims data, we found unique features and co-morbidities associated with EM. These findings could be used to develop a clinical algorithm predictive of older adults requiring screening for EM.
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Comorbidade , Abuso de Idosos/estatística & dados numéricos , Hipertensão/epidemiologia , Medicare/estatística & dados numéricos , Transtornos Mentais/epidemiologia , População Urbana/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Demência/epidemiologia , Feminino , Humanos , Masculino , Transtornos do Humor/epidemiologia , Alta do Paciente/estatística & dados numéricos , Estados UnidosRESUMO
BACKGROUND AND PURPOSE: Several studies have established the efficacy of home health in meeting the health care needs of people with Alzheimer disease and related dementias (ADRD) and helping them to remain at home. However, transitioning to the community after discharge from home health presents challenges to patient safety and quality of life. The severity of an individual's functional impairments, cognitive limitations, and behavioral and psychological symptoms may compound these challenges. The purpose of this study was to examine the association between dementia severity and successful discharge to community (DTC) from home health. METHODS: This was a retrospective study of 142 376 Medicare beneficiaries with ADRD. Successful DTC was defined as having no unplanned hospitalization or death within 30 days of DTC from home health. Successful DTC rates were calculated, and multilevel logistic regression was used to estimate the relative risk (RR) of successful DTC, by dementia severity category, adjusted for patient and clinical characteristics. Six dementia severity categories were identified using a crosswalk between items on the Outcome and Assessment Information Set and the Functional Assessment Staging Tool. RESULTS AND DISCUSSION: Successful DTC occurred in 71.2% of beneficiaries. Beneficiaries in the 2 most severe dementia categories had significantly lower risk of successful DTC (category 6: RR = 0.90, 95% CI = 0.889-0.910; category 7: RR = 0.737, 95% CI = 0.704-0.770) than those in the least severe dementia category. The RR of successful DTC for people with ADRD decreased as the level of independence with oral medication management decreased and when there was an overall greater need for caregiver assistance. CONCLUSIONS: Patient status at the time of admission to home health is associated with outcomes after discharge from home health. Early identification of people in advanced stages of ADRD provides an opportunity to implement strategies to facilitate successful DTC while people are still receiving home care services. The severity of ADRD and availability of caregiver assistance should be key considerations in planning for successful DTC for people with ADRD.
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Doença de Alzheimer , Demência , Humanos , Idoso , Estados Unidos , Estudos Retrospectivos , Alta do Paciente , Qualidade de Vida , Medicare , Doença de Alzheimer/psicologia , Demência/epidemiologiaRESUMO
Using 100% Medicare data files, this study explored whether primary elder mistreatment (EM) diagnosis, EM type, and facility type were associated with 3-year mortality and 1-year unplanned hospital readmission among older patients diagnosed with EM with hospital discharge from 10/01/2015 through 12/31/2018 (n = 11,023). We also examined outcome differences between older patients diagnosed with EM and matched non-EM patient controls. Neglect by others was the most common EM diagnosis. Three-year mortality was 56.7% and one-year readmission rate was 53.8%. Compared to matched non-EM patient controls, older EM patients were at an increased risk of mortality and readmission. Among patients diagnosed with EM, patients with a secondary (vs. primary) diagnosis and those discharged from a skilled nursing facility (vs. acute hospital) were at an increased risk for both mortality and readmission. Compared to other EM types, patients diagnosed with neglect by others had a greater risk for mortality following discharge.
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Abuso de Idosos , Alta do Paciente , Humanos , Idoso , Estados Unidos/epidemiologia , Assistência ao Convalescente , Medicare , Hospitalização , Fatores de RiscoRESUMO
BACKGROUND: Repeat fractures contribute substantially to fracture incidents in older adults. We examined the association between cognitive impairment and re-fractures during the first 90 days after older adults with hip fractures were discharged home from a skilled nursing facility rehabilitation short stay. METHODS: Multilevel binary logistic regression was used to analyze 100% of U.S. national postacute-care fee-for-service Medicare beneficiaries who had a hospital admission for hip fracture from January 1, 2018, to July 31, 2018; were admitted for a skilled nursing facility stay within 30 days of hospital discharge; and were discharged to the community after a short stay. Our primary outcome was rehospitalization for any re-fractures within 90 days of skilled nursing facility discharge. Cognitive status assessed at skilled nursing facility admission or before discharge was classified as either intact or having mild or moderate/severe impairment. RESULTS: In 29 558 beneficiaries with hip fracture, odds of any re-fracture were higher in those with minor (odds ratio: 1.48; 95% confidence interval: 1.19-1.85; p < .01) and moderate/major cognitive impairment (odds ratio: 1.42; 95% confidence interval: 1.07-1.89; p = .0149) than in those classified as intact. CONCLUSIONS: Beneficiaries with cognitive impairment were more likely than their counterparts with no cognitive impairment to experience re-fractures. Community-dwelling older adults with minor cognitive impairment may experience a higher likelihood of experiencing a repeat fracture leading to rehospitalization.
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Fraturas do Quadril , Medicare , Humanos , Idoso , Estados Unidos/epidemiologia , Hospitalização , Fraturas do Quadril/epidemiologia , Fraturas do Quadril/reabilitação , Alta do Paciente , Readmissão do Paciente , Instituições de Cuidados Especializados de Enfermagem , Estudos RetrospectivosRESUMO
Background: Cardiovascular disease (CVD) and cancer share several risk factors. Although preclinical models show that various types of CVD can accelerate cancer progression, clinical studies have not determined the impact of atherosclerosis on cancer risk. Objectives: The objective of this study was to determine whether CVD, especially atherosclerotic CVD, is independently associated with incident cancer. Methods: Using IBM MarketScan claims data from over 130 million individuals, 27 million cancer-free subjects with a minimum of 36 months of follow-up data were identified. Individuals were stratified by presence or absence of CVD, time-varying analysis with multivariable adjustment for cardiovascular risk factors was performed, and cumulative risk of cancer was calculated. Additional analyses were performed according to CVD type (atherosclerotic vs nonatherosclerotic) and cancer subtype. Results: Among 27,195,088 individuals, those with CVD were 13% more likely to develop cancer than those without CVD (HR: 1.13; 95% CI: 1.12-1.13). Results were more pronounced for individuals with atherosclerotic CVD (aCVD), who had a higher risk of cancer than those without CVD (HR: 1.20; 95% CI: 1.19-1.21). aCVD also conferred a higher risk of cancer compared with those with nonatherosclerotic CVD (HR: 1.11; 95% CI: 1.11-1.12). Cancer subtype analyses showed specific associations of aCVD with several malignancies, including lung, bladder, liver, colon, and other hematologic cancers. Conclusions: Individuals with CVD have an increased risk of developing cancer compared with those without CVD. This association may be driven in part by the relationship of atherosclerosis with specific cancer subtypes, which persists after controlling for conventional risk factors.
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INTRODUCTION: The objective of this study was to examine the relationship between dementia severity and early discharge from home health. METHODS: This was a retrospective study of 100% national Medicare home health da ta files (2016-2017). Multilevel logistic regression was used to study the relationship of dementia severity, caregiver support, and medication assistance with early discharge from home health. RESULTS: The final cohort consisted of 91 302 Medicare beneficiaries with an ADRD diagnosis. A pattern of early discharge rates across dementia severity levels was not demonstrated. The relative risk for early discharge was lower for individuals who needed assistance with medication and for those with unmet caregiver needs. DISCUSSION: The findings of this study do not support the hypothesis that dementia severity contributes to early discharge from home health. Further research is needed to fully understand key factors contributing to early discharge from home health.
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Doença de Alzheimer , Cuidadores , Demência , Idoso , Humanos , Doença de Alzheimer/diagnóstico , Demência/complicações , Medicare , Alta do Paciente , Estudos Retrospectivos , Estados UnidosRESUMO
Introduction: The objective of this study was to identify home health utilization factors associated with successful discharge to community after home health care for patients with and without Alzheimer's disease and related dementias (ADRD). Methods: This was a retrospective study of 100% national Medicare home health data files (2016 to 2017). Multilevel logistic regression was used to study the relationship of home health utilization with a modified definition of successful discharge to community (M-SDC) after home health (no readmission or discharge within 30 days). Significant interactions were identified using backward selection. The associations between domains were examined in a model stratified by ADRD, with and without controlling for mobility, self-care, and caregiver assistance. Results: The cohort consisted of 535,691 patients, 18.0% with ADRD. The overall M-SDC rate was 92.1%. The likelihood of M-SDC was increased when physical therapy services were provided, episodes of care were longer than 15 days, and the total number of therapy visits was greater than 10. The likelihood of M-SDC decreased when speech therapy, nursing, and home health aide services were provided and when patients were discharged early. When controlling for mobility, self-care, and caregiver support, length of home health episode was the only characteristic that showed a significant interaction with ADRD. Discussion: The results of this study indicate that the provision of physical therapy services and moderate lengths of care and volume of visits are associated with increased likelihood of M-SDC. A decreased likelihood of M-SDC when speech therapy, nursing, and home health aide services are delivered may be a proxy indicator of patient acuity and disease severity and needs to be further investigated. An important next step in understanding home health access and outcomes for people with ADRD is to examine the impact of the Patient-Driven Groupings Model on home health utilization characteristics, especially length of episodes. Highlights: Most people remain in the community after discharge from home health.Likelihood of modified successful discharge to community (M-SDC) increased with physical therapy, longer episodes, and more than 10 visits.Likelihood of M-SDC decreased with speech therapy, skilled nursing, home health aide visits, and early discharge.Longer home health episodes increased likelihood of M-SDC for people with Alzheimer's disease and related dementias.
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OBJECTIVES: To examine the relationship between cognitive status and falls with and without injury among older adults during the first 18 days of a skilled nursing facility (SNF) and determine if this association is mediated by limitations in activities of daily living (ADL) and impaired balance. DESIGN: Cohort study of Medicare fee-for-service beneficiaries admitted to an SNF between October 1, 2016, and September 31, 2017. SETTINGS AND PARTICIPANTS: 815,927 short-stay nursing home residents admitted to an SNF within 3 days of hospital discharge. METHODS: Cognitive status at SNF admission was classified as intact, mild, moderate, or severe impairment. Residents were classified as having no falls, a fall without injury, and a fall with a minor or major injury. We used ordinal logistic regression to model the association between cognitive status and falls adjusting for resident and facility characteristics. A causal mediation analysis was used to test for the mediating effects of ADL limitations and impaired balance on the association between cognitive status and falls with an injury. RESULTS: Mild, moderate, and severe cognitive impairment were associated with 1.72 (95% CI: 1.68-1.75), 2.72 (95% CI: 2.66-2.78), and 2.61 (95% CI: 2.48-2.75) higher odds of being in a higher fall severity category, respectively, compared to being cognitively unimpaired. Greater ADL limitations and impaired balance were significantly associated with falls, but each mediated the association between cognitive status and falls by less than 2%. CONCLUSIONS AND IMPLICATIONS: Older adults with cognitive impairment are more likely to experience a fall during an SNF stay. ADL limitations and impaired balance are risk factors for falls but may not contribute to the increased fall risk for SNF residents with cognitive impairment. Continued research is needed to better understand the risk factors for falls among SNF residents with cognitive impairment.
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Atividades Cotidianas , Instituições de Cuidados Especializados de Enfermagem , Acidentes por Quedas , Idoso , Cognição , Estudos de Coortes , Humanos , Medicare , Alta do Paciente , Estudos Retrospectivos , Estados Unidos/epidemiologiaRESUMO
OBJECTIVES: A priority health outcome for patients, families, and the Centers for Medicare & Medicaid Services (CMS) is a patient's ability to return home and remain in the community without adverse events following discharge from post-acute care services. Successful discharge to community (DTC) is defined as being discharged to the community and not experiencing a readmission or death within 30 days of discharge. The objective of this study was to determine the association between patient factors and successful DTC after home health for individuals with Alzheimer's disease and related dementias (ADRD). DESIGN: This retrospective study derived data from 100% national CMS data files from October 1, 2016, through September 30, 2017. SETTINGS AND PARTICIPANTS: Criteria from the Home Health Quality Reporting program were used to identify a cohort of 790,439 Medicare home health beneficiaries, 143,164 (18.0%) with ADRD. MEASURES: Successful DTC rates with associated 95% confidence intervals (CIs) were calculated for each patient characteristic. Multilevel logistic regression was used to estimate the relative risk (RR) of successful DTC after home health, by ADRD diagnosis, mobility, self-care, caregiver support, and medication management, adjusted for patient demographics and clinical characteristics. RESULTS: Overall, 79.4% of beneficiaries had a successful DTC. Beneficiaries with ADRD had a significantly lower odds of successful DTC than those without ADRD (RR=0.947, 95% CI=0.944-0.950). This association remained significant after adjustment for caregiver support, assistance with medications, independence in mobility, and level of self-care. Greater need for caregiver support, greater need for assistance with medications, greater dependence in mobility, and greater self-care dependence were all associated with decreased risk of successful DTC. CONCLUSIONS AND IMPLICATIONS: Older adults with ADRD receiving home health had decreased RR of successful DTC. To have a successful DTC, older adults with ADRD need sufficient support from caregivers and independence in functioning.
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Doença de Alzheimer , Demência , Idoso , Demência/terapia , Humanos , Medicare , Alta do Paciente , Estudos Retrospectivos , Autocuidado , Estados UnidosRESUMO
OBJECTIVE: To examine the association between cocalibrated functional scores across post-acute care settings and the subsequent risk of hospital readmission. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: We analyzed 781,021 fee-for-service Medicare beneficiaries discharged to either inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), or home health agencies (HHA) after an acute hospital stay for stroke (N = 143,277), lower extremity joint replacements (512,577), and hip/femur fracture (125,167) between January 1, 2013, and August 31, 2014. MEASURES: Functional items from IRF-PAI, MDS, and OASIS were categorized into self-care and mobility domains. We cocalibrated admission functional scores across post-acute settings and divided scores into 4 functional levels using quartiles (Q1-Q4, with Q4 representing the most independent function). The primary outcomes were 30-day and 90-day hospital readmissions (yes/no) after an initial post-acute stay. RESULTS: Patients who were more dependent in self-care and mobility at the initial post-acute setting were significantly more likely to experience hospital readmission [eg, hazard ratios of 30-day readmission in stroke: 1.54 (95% confidence interval [CI] 1.47-1.61), 1.18 (95% CI 1.14-1.23), and 1.12 (95% CI 1.08-1.16) for Q1, Q2 and Q3, compared to Q4]. We found similar results for risk of 90-day hospital readmission across impairment conditions. CONCLUSIONS AND IMPLICATIONS: Patients who were more functionally dependent at the initial post-acute setting had a higher risk to readmit to the hospitals after discharging from the post-acute setting for 30 and 90 days, compared with patients who were more functionally independent. This finding is consistent across impairment conditions and post-acute settings. Future research should determine effective strategies of maintaining and facilitating functional performance across post-acute settings to optimize long-term patient outcomes.
Assuntos
Estado Funcional , Readmissão do Paciente , Idoso , Humanos , Medicare , Alta do Paciente , Estudos Retrospectivos , Instituições de Cuidados Especializados de Enfermagem , Cuidados Semi-Intensivos , Estados UnidosRESUMO
OBJECTIVE: The aims of the study were to demonstrate a method for developing rehabilitation service areas and to compare service areas based on postacute care rehabilitation admissions to service areas based on acute care hospital admissions. DESIGN: We conducted a secondary analysis of 2013-2014 Medicare records for older patients in Texas (N = 469,172). Our analysis included admission records for inpatient rehabilitation facilities, skilled nursing facilities, long-term care hospitals, and home health agencies. We used Ward's algorithm to cluster patient ZIP Code Tabulation Areas based on which facilities patients were admitted to for rehabilitation. For comparison, we set the number of rehabilitation clusters to 22 to allow for comparison to the 22 hospital referral regions in Texas. Two methods were used to evaluate rehabilitation service areas: intraclass correlation coefficient and variance in the number of rehabilitation beds across areas. RESULTS: Rehabilitation service areas had a higher intraclass correlation coefficient (0.081 vs. 0.076) and variance in beds (27.8 vs. 21.4). Our findings suggest that service areas based on rehabilitation admissions capture has more variation than those based on acute hospital admissions. CONCLUSIONS: This study suggests that the use of rehabilitation service areas would lead to more accurate assessments of rehabilitation geographic variations and their use in understanding rehabilitation outcomes.
Assuntos
Mapeamento Geográfico , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Serviços de Assistência Domiciliar/estatística & dados numéricos , Assistência de Longa Duração/estatística & dados numéricos , Centros de Reabilitação/estatística & dados numéricos , Instituições de Cuidados Especializados de Enfermagem/estatística & dados numéricos , Cuidados Semi-Intensivos/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Humanos , Admissão do Paciente , TexasRESUMO
OBJECTIVES: Approximately 14% of Medicare beneficiaries are readmitted to a hospital within 30 days of home health care admission. Individuals with dementia account for 30% of all home health care admissions and are at high risk for readmission. Our primary objective was to determine the association between dementia severity at admission to home health care and 30-day potentially preventable readmissions (PPR) during home health care. A secondary objective was to develop a dementia severity scale from Outcome and Assessment Information Set (OASIS) items based on the Functional Assessment Staging Tool (FAST). DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: Home health care; 126,292 Medicare beneficiaries receiving home health care (July 1, 2013-June 1, 2015) diagnosed with dementia (ICD-9 codes). MEASURES: 30-day PPR during home health care. Dementia severity categorized into 6 levels (nonaffected to severe). RESULTS: The overall rate of 30-day PPR was 7.6% [95% confidence interval (CI) 7.4, 7.7] but varied by patient and health care utilization characteristics. After adjusting for sociodemographic and clinical characteristics, the odds ratio (OR) for dementia severity category 6 was 1.37 (95% CI 1.29, 1.46) and the OR for category 7 was 1.94 (95% CI 1.64, 2.31) as compared to dementia severity category 1/2. CONCLUSIONS AND IMPLICATIONS: Dementia severity in the later stages is associated with increased risk for potentially preventable readmissions. Our findings suggest that individuals admitted to home health during the later stages of Alzheimer's disease and related dementias may require greater supports and specialized care to minimize negative outcomes such as readmissions. Development of a dementia severity scale based on OASIS items and the FAST is feasible. Future research is needed to determine effective strategies for decreasing potentially preventable readmissions of individuals with severe dementia who receive home health care. Future research is also needed to validate the proposed dementia severity categories used in this study.