Postdischarge Noninvasive Telemonitoring and Nurse Telephone Coaching Improve Outcomes in Heart Failure Patients With High Burden of Comorbidity.

BACKGROUND: Noninvasive telemonitoring and nurse telephone coaching (NTM-NTC) is a promising postdischarge strategy in heart failure (HF). Comorbid conditions and disease burden influence health outcomes in HF, but how comorbidity burden modulates the effectiveness of NTM-NTC is unknown. This study aims to identify patients with HF who may benefit from postdischarge NTM-NTC based on their burden of comorbidity. METHODS AND RESULTS: In the Better Effectiveness After Transition - Heart Failure trial, patients hospitalized for acute decompensated HF were randomized to postdischarge NTM-NTC or usual care. In this secondary analysis of 1313 patients with complete data, comorbidity burden was assessed by scoring complication and coexisting diagnoses from index admissions. Clinical outcomes included 30-day and 180-day readmissions, mortality, days alive, and combined days alive and out of the hospital. Patients had a mean of 5.7 comorbidities and were stratified into low (0-2), moderate (3-8), and high comorbidity (≥9) subgroups. Increased comorbidity burden was associated with worse outcomes. NTM-NTC was not associated with readmission rates in any comorbidity subgroup. Among high comorbidity patients, NTM-NTC was associated with significantly lower mortality at 30 days (hazard ratio 0.25, 95% confidence interval 0.07-0.90) and 180 days (hazard ratio 0.51, 95% confidence interval 0.27-0.98), as well as more days alive (160.1 vs 140.3, P = .029) and days alive out of the hospital (152.0 vs 133.2, P = .044) compared with usual care. CONCLUSIONS: Postdischarge NTM-NTC improved survival among patients with HF with a high comorbidity burden. Comorbidity burden may be useful for identifying patients likely to benefit from this management strategy.

Intervention to improve acute care nurses confidence and knowledge in hospital dementia care.

PROBLEM: Acute care nurses are the front line of hospital care for persons with dementia (PwD), yet many have inadequate dementia education and lack the confidence to appropriately manage PwD in the hospital setting. IMPLEMENTATION: Two acute care units with high rates of PwD in a large tertiary-care hospital were provided an education intervention involving interactive case-based discussion of the challenges of inpatient dementia care. RESULTS: Out of 190 nurses, 171 completed a one-hour virtual educational session, 142 completed pre/post-session confidence surveys, and 123 completed pre/post-session knowledge tests. There was a statistically significant improvement in knowledge scores from 75.8% pre-session to 88.4% post-session (p < 0.001), and pre/post-session dementia care confidence increased from 3.49 to 4.44 ( + 27.22%; p < 0.001) CONCLUSION: An interactive virtual education intervention improves acute care nurses' confidence and knowledge in managing PwD in the acute care setting and may improve hospital outcomes for this population.

Symptomology following mRNA vaccination against SARS-CoV-2.

Despite demonstrated efficacy of vaccines against severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), the causative agent of coronavirus disease-2019 (COVID-19), widespread hesitancy to vaccination persists. Improved knowledge regarding frequency, severity, and duration of vaccine-associated symptoms may help reduce hesitancy. In this prospective observational study, we studied 1032 healthcare workers who received both doses of the Pfizer-BioNTech SARS-CoV-2 mRNA vaccine and completed post-vaccine symptom surveys both after dose 1 and after dose 2. We defined appreciable post-vaccine symptoms as those of at least moderate severity and lasting at least 2 days. We found that symptoms were more frequent following the second vaccine dose than the first (74% vs. 60%, P < 0.001), with >80% of all symptoms resolving within 2 days. The most common symptom was injection site pain, followed by fatigue and malaise. Overall, 20% of participants experienced appreciable symptoms after dose 1 and 30% after dose 2. In multivariable analyses, female sex was associated with greater odds of appreciable symptoms after both dose 1 (OR, 95% CI 1.73, 1.19-2.51) and dose 2 (1.76, 1.28-2.42). Prior COVID-19 was also associated with appreciable symptoms following dose 1, while younger age and history of hypertension were associated with appreciable symptoms after dose 2. We conclude that most post-vaccine symptoms are reportedly mild and last <2 days. Appreciable post-vaccine symptoms are associated with female sex, prior COVID-19, younger age, and hypertension. This information can aid clinicians in advising patients on the safety and expected symptomatology associated with vaccination.

Systems Addressing Frail Elder Care: Description of a Successful Model.

OBJECTIVE: The aim of this article is to describe the Systems Addressing Frail Elder (SAFE) Care model, features of the interprofessional team and reengineered workflow, and details of the intervention. BACKGROUND: Older inpatients are vulnerable to adverse events related to frailty. SAFE Care, an interprofessional team-based program, was developed and evaluated in a cluster randomized controlled trial (C-RCT). Results found reduced length of stay and complications. The purpose of this article is to support and encourage the replication of this innovation or to help facilitate implementation of a similar process of organizational change. METHODS: This was a review of model features and intervention data abstracted from electronic health records. RESULTS: Salient features of team composition, training, and workflow are presented. The C-RCT intention-to-treat sample included 792 patients, of whom 307 received the SAFE Care huddle intervention. The most frequent problem was mobility (85.7%), and most frequent recommendation was fall precautions protocol (83.1%). CONCLUSIONS: The SAFE Care model may provide a standardized framework to approach, assess, and address the risks of hospitalized older adults.

Systems Addressing Frail Elders (SAFE) Care: Description of Successful Partnerships Across Hospitals.

Systems Addressing Frail Elders (SAFE) Care is an interprofessional team-based program, which was developed and evaluated in a cluster randomized controlled trial. Results of this trial included reduced length of stay and complications for patients. This article describes a successful partnership across 4 Magnet hospitals in the dissemination of the model. A 2-year sequential implementation process was completed, with an approach of adoption, adaptation, and abandonment. The model was successfully implemented at each participating Magnet hospital. Implementation included capacity building, organizational change, and process implementation.

Depression and Coleman Care Transitions Intervention.

The Coleman Care Transitions Intervention (CTI) is a "Patient Activation Model." Depression can be a barrier to activation and may challenge CTI. This study addressed whether CTI coaches modified the intervention for older adults who screened positive for depression. Over 4,500 clients in a Centers for Medicare and Medicaid Services demonstration completed screening for depression with the PHQ-9; one in five screened positive (score = 9+). Our findings suggest that coaches modified CTI and played a more directive role for clients who screened positive for depression, resulting in similar 30-day readmission rates among patients who screened positive for depression risk and those who did not. That finding stands in contrast to the widely reported higher readmission rates among people screening positive for depression.

Identification and team-based interprofessional management of hospitalized vulnerable older adults.

BACKGROUND: Extended hospital stays and complications are common among older adults and may lead to morbidity and loss of independence. Specialized geriatric units have been shown to improve outcomes but, with the growing numbers of older adults, may be difficult to scale to meet needs. PURPOSE: The purpose was to evaluate a quality improvement initiative that redesigned unit-based workflow and trained interprofessional teams on general medical/surgical units to create care plans for vulnerable older adults using principles of comprehensive geriatric assessment and team management. METHOD: The evaluation included a cluster randomized controlled trial of 10 medical/surgical units and intention-to-treat analysis of all patients meeting risk screening criteria. RESULTS: N = 1,384, median age = 80.9 years, and 53.5% female. Mean difference in observed vs. expected length of stay was 1.03 days shorter (p = .006); incidence of complications (odds ratio [OR] = 0.45; 95% confidence interval [CI] = 0.21-0.98) and transfer to intensive care (OR = 0.45; 95% CI = 0.25-0.79) lower among patients admitted to intervention units; incidence of discharge to institutional care was higher (OR = 1.43; 95% CI = 1.06-1.93). Mortality during hospitalization (OR = 0.64; 95% CI = 0.37-1.11) did not differ between groups. CONCLUSION: Reorganizing general medical/surgical units to provide team-based interprofessional care can improve outcomes among hospitalized older adults.

Ambulatory Care Nurse-Sensitive Indicators Series: Reaching for the Tipping Point in Measuring Nurse-Sensitive Quality in the Ambulatory Surgical and Procedure Environments.

The value of the ambulatory care nurse remains undocumented from a quality and patient safety measurement perspective and the practice is at risk of being highly variable and of unknown quality. The American Academy of Ambulatory Care Nursing and the Collaborative Alliance for Nursing Outcomes propose nurse leaders create a tipping point to measure the value of nursing across the continuum of nursing care, moving from inpatient to ambulatory care. As care continues to shift into the ambulatory care environment, the quality imperative must also shift to assure highly reliable, safe, and effective health care.

Improving hospital patient falls: leveraging staffing characteristics and processes of care.

OBJECTIVE: Predictive models for falls, injury falls, and restraint prevalence were explored within nursing unit structures and processes of care. BACKGROUND: The patient care team is responsible for patient safety, and improving practice models may prevent injuries and improve patient safety. METHODS: Using unit-level self-reported data from 215 hospitals, falls, injury falls, and restraint prevalence were modeled with significant covariates as predictors. RESULTS: Fewer falls/injury falls were predicted by populations with fewer frail and at-risk patients, more unlicensed care hours, and prevention protocol implementation, but not staffing per se, restraint use, or RN expertise. Lower restraint use was predicted by fewer frail patients, shorter length of stay, more RN hours, more certified RNs, and implementation of fall prevention protocols. CONCLUSION: In the presence of risk, patient injuries and safety were improved by optimizing staffing skill mix and use of prevention protocols.

Comparative Effectiveness of Psychotherapy vs Antidepressants for Depression in Heart Failure: A Randomized Clinical Trial.

Importance: Heart failure (HF) affects more than 6 million adults in the US and more than 64 million adults worldwide, with 50% prevalence of depression. Patients and clinicians lack information on which interventions are more effective for depression in HF. Objective: To compare the effectiveness of behavioral activation psychotherapy (BA) vs antidepressant medication management (MEDS) on patient-centered outcomes inpatients with HF and depression. Design, Setting, and Participants: This pragmatic randomized comparative effectiveness trial was conducted from 2018 to 2022, including 1-year follow-up, at a not-for-profit academic health system serving more than 2 million people from diverse demographic, socioeconomic, cultural, and geographic backgrounds. Participant included inpatients and outpatients diagnosed with HF and depression, and data were analyzed as intention-to-treat. Data were analyzed from 2022 to 2023. Interventions: BA is an evidence-based manualized treatment for depression, promoting engagement in personalized pleasurable activities selected by patients. MEDS involves the use of an evidence-based collaborative care model with care managers providing coordination with patients, psychiatrists, and primary care physicians to only administer medications. Main Outcomes and Measures: The primary outcome was depressive symptom severity at 6 months, measured using the Patient Health Questionnaire 9-Item (PHQ-9). Secondary outcomes included physical and mental health-related quality of life (HRQOL), measured using the Short-Form 12-Item version 2 (SF-12); heart failure-specific HRQOL, measured using the Kansas City Cardiomyopathy Questionnaire; caregiver burden, measured with the Caregiver Burden Questionnaire for Heart Failure; emergency department visits; readmissions; days hospitalized; and mortality at 3, 6, and 12 months. Results: A total of 416 patients (mean [SD] age, 60.71 [15.61] years; 243 [58.41%] male) were enrolled, with 208 patients randomized to BA and 208 patients randomized to MEDS. At baseline, mean (SD) PHQ-9 scores were 14.54 (3.45) in the BA group and 14.31 (3.60) in the MEDS group; both BA and MEDS recipients experienced nearly 50% reduction in depressive symptoms at 3, 6, and 12 months (eg, mean [SD] score at 12 months: BA, 7.62 (5.73); P < .001; MEDS, 7.98 (6.06); P < .001; between-group P = .55). There was no statistically significant difference between BA and MEDS in the primary outcome of PHQ-9 at 6 months (mean [SD] score, 7.53 [5.74] vs 8.09 [6.06]; P = .88). BA recipients, compared with MEDS recipients, experienced small improvement in physical HRQOL at 6 months (mean [SD] SF-12 physical score: 38.82 [11.09] vs 37.12 [10.99]; P = .04), had fewer ED visits (3 months: 38% [95% CI, 14%-55%] reduction; P = .005; 6 months: 30% [95% CI, 14%-40%] reduction; P = .008; 12 months: 27% [95% CI, 15%-38%] reduction; P = .001), and spent fewer days hospitalized (3 months: 17% [95% CI, 8%-25%] reduction; P = .002; 6 months: 19% [95% CI, 13%-25%] reduction; P = .005; 12 months: 36% [95% CI, 32%-40%] reduction; P = .001). Conclusions and Relevance: In this comparative effectiveness trial of BA and MEDS in patients with HF experiencing depression, both treatments significantly reduced depressive symptoms by nearly 50% with no statistically significant differences between treatments. BA recipients experienced better physical HRQOL, fewer ED visits, and fewer days hospitalized. The study findings suggested that patients with HF could be given the choice between BA or MEDS to ameliorate depression. Trial Registration: ClinicalTrials.gov Identifier: NCT03688100.

Early recognition of risk factors for adverse outcomes during hospitalization among Medicare patients: a prospective cohort study.

BACKGROUND: There is a persistently high incidence of adverse events during hospitalization among Medicare beneficiaries. Attributes of vulnerability are prevalent, readily apparent, and therefore potentially useful for recognizing those at greatest risk for hospital adverse events who may benefit most from preventive measures. We sought to identify patient characteristics associated with adverse events that are present early in a hospital stay. METHODS: An interprofessional panel selected characteristics thought to confer risk of hospital adverse events and measurable within the setting of acute illness. A convenience sample of 214 Medicare beneficiaries admitted to a large, academic medical center were included in a quality improvement project to develop risk assessment protocols. The data were subsequently analyzed as a prospective cohort study to test the association of risk factors, assessed within 24 hours of hospital admission, with falls, hospital-acquired pressure ulcers (HAPU) and infections (HAI), adverse drug reactions (ADE) and 30-day readmissions. RESULTS: Mean age = 75(±13.4) years. Risk factors with highest prevalence included >4 active comorbidities (73.8%), polypharmacy (51.7%), and anemia (48.1%). One or more adverse hospital outcomes occurred in 46 patients (21.5%); 56 patients (26.2%) were readmitted within 30 days. Cluster analysis described three adverse outcomes: 30-day readmission, and two groups of in-hospital outcomes. Distinct regression models were identified: Weight loss (OR = 3.83; 95% CI = 1.46, 10.08) and potentially inappropriate medications (OR = 3.05; 95% CI = 1.19, 7.83) were associated with falls, HAPU, procedural complications, or transfer to intensive care; cognitive impairment (OR = 2.32; 95% CI = 1.24, 4.37), anemia (OR = 1.87; 95% CI = 1.00, 3.51) and weight loss (OR = 2.89; 95% CI = 1.38, 6.07) were associated with HAI, ADE, or length of stay >7 days; hyponatremia (OR = 3.49; 95% CI = 1.30, 9.35), prior hospitalization within 30 days (OR = 2.66; 95% CI = 1.31, 5.43) and functional impairment (OR = 2.05; 95% CI = 1.02, 4.13) were associated with 30-day readmission. CONCLUSIONS: Patient characteristics recognizable within 24 hours of admission can be used to identify increased risk for adverse events and 30-day readmission.

The Association Between Korean American Nurse and Primary Care Provider Burnout, Areas of Worklife, and Perceptions of Pandemic Experience: Cross-sectional Study.

BACKGROUND: Korean immigrants are among the fastest-growing ethnic minority groups and make up the fifth-largest Asian group in the United States. A better understanding of the work environment factors and its impact on Korean American nurse and primary care provider (PCP) burnout may guide the development of targeted strategies to help mitigate burnout and workplace stressors, which is critical for the retention of Korean American nurses and PCPs to promote better alignment of national demographic trends and meet patients' preference for cultural congruence with their health care providers (HCPs). Although there is a growing number of studies on HCP burnout, a limited number of studies specifically focus on the experience of ethnic minority HCPs, particularly during the COVID-19 pandemic. OBJECTIVE: In light of these gaps in literature, the aim of this study was to assess burnout among Korean American HCPs and to identify work conditions during a pandemic that may be associated with Korean American nurse and PCP burnout. METHODS: A total of 184 Korean American HCPs (registered nurses [RNs]: n=97; PCPs: n=87) practicing in Southern California responded to a web-based survey between February and April 2021. The Maslach Burnout Inventory, Areas of Worklife Survey, and Pandemic Experience & Perceptions Survey were used to measure burnout and work environment factors during the pandemic. A multivariate linear regression analysis was used to assess work environment factors associated with the 3 subcategories of burnout. RESULTS: No significant differences were found in the level of burnout experienced by Korean American nurses and PCPs. For RNs, greater workload (P<.001), lower resource availability (P=.04), and higher risk perception (P=.02) were associated with higher emotional exhaustion. Greater workload was also associated with higher depersonalization (P=.003), whereas a greater (professional) community (P=.03) and higher risk perception (P=.006) were associated with higher personal accomplishment. For PCPs, greater workload and poor work-life balance were associated with higher emotional exhaustion (workload: P<.001; worklife: P=.005) and depersonalization (workload: P=.01; worklife: P<.001), whereas only reward was associated with personal accomplishment (P=.006). CONCLUSIONS: Findings from this study underscore the importance of strategies to promote a healthy work environment across multiple levels that recognize demographic variation among Korean American RNs and PCPs, potentially influencing their burnout mitigation needs. A growing recognition of identity-informed burnout experiences across frontline Korean American RNs and PCPs argues for future explorations that capture nuance both across and within this and other ethnic minority nurse and PCP groups. By recognizing and capturing these variations, we may better support the creation of targeted, burnout-mitigating strategies for all.

Bounce-Back: Predicting Acute Readmission From Inpatient Rehabilitation for Patients With Stroke.

OBJECTIVE: The aim of the study was to identify demographic, medical, and functional risk factors for discharge to an acute hospital before completion of an inpatient rehabilitation program and 7- and 30-day readmissions after completion of an inpatient rehabilitation program. DESIGN: This cohort study included 138,063 fee-for-service Medicare beneficiaries with a primary diagnosis of new onset stroke discharged from an inpatient rehabilitation facility from June 2009 to December 2011. Multivariate models examined readmission outcomes and included data from 6 mos before onset of the stroke to 30 days after discharge from the inpatient rehabilitation facility. RESULTS: In the acute discharge model (n = 9870), comorbidities and complications added risk, and the longer the stroke onset to admission to inpatient rehabilitation facility, the more likely discharge to the acute hospital. In the 7-day (n = 4755) and 30-day (n = 9861) readmission models, patients who were more complex with comorbidities, were black, or had managed care Medicare were more likely to have a readmission. Functional status played a role in all three models. CONCLUSIONS: Results suggest that certain demographic, medical, and functional characteristics are associated differentially with rehospitalization after completion inpatient rehabilitation. The strongest model was the discharge to the acute hospital model with concordance statistic (c-statistic) of 0.87.

Evaluation of Team-Based Learning to Increase Nurses' Knowledge of the Ventricular Assist Device.

Ventricular assist devices (VAD) are used to extend life expectancy for patients with advanced heart failure. Approximately 102 hospitals nationwide have a VAD program, but the majority implant only a small number of devices each year. This low-volume and high-acuity patient population can create concerns for maintaining nursing knowledge skill levels. Nursing staff from a step-down telemetry floor in a large urban hospital completed an Individual Readiness Assessment Test to assess their knowledge and accuracy in the care of mechanical circulatory support patients using the Immediate Feedback Assessment Technique. The nurses were then assigned to small groups and worked as a team to complete the same test known as the Group Readiness Assessment Test. Study results suggest that team-based learning was effective in increasing knowledge of mechanical circulatory support. [J Contin Educ Nurs. 2021;52(1):13-20.].

Personalized treatments for depressive symptoms in patients with advanced heart failure: A pragmatic randomized controlled trial.

OBJECTIVES: Heart Failure is a chronic syndrome affecting over 5.7 million in the US and 26 million adults worldwide with nearly 50% experiencing depressive symptoms. The objective of the study is to compare the effects of two evidence-based treatment options for adult patients with depression and advanced heart failure, on depressive symptom severity, physical and mental health related quality of life (HRQoL), heart-failure specific quality of life, caregiver burden, morbidity, and mortality at 3, 6 and 12-months. METHODS: Trial design. Pragmatic, randomized, comparative effectiveness trial. Interventions. The treatment interventions are: (1) Behavioral Activation (BA), a patient-centered psychotherapy which emphasizes engagement in enjoyable and valued personalized activities as selected by the patient; or (2) Antidepressant Medication Management administered using the collaborative care model (MEDS). Participants. Adults aged 18 and over with advanced heart failure (defined as New York Heart Association (NYHA) Class II, III, and IV) and depression (defined as a score of 10 or above on the PHQ-9 and confirmed by the MINI International Neuropsychiatric Interview for the DSM-5) selected from all patients at Cedars-Sinai Medical Center who are admitted with heart failure and all patients presenting to the outpatient programs of the Smidt Heart Institute at Cedars-Sinai Medical Center. We plan to randomize 416 patients to BA or MEDS, with an estimated 28% loss to follow-up/inability to collect follow-up data. Thus, we plan to include 150 in each group for a total of 300 participants from which data after randomization will be collected and analyzed. CONCLUSIONS: The current trial is the first to compare the impact of BA and MEDS on depressive symptoms, quality of life, caregiver burden, morbidity, and mortality in patients with depression and advanced heart failure. The trial will provide novel results that will be disseminated and implemented into a wide range of current practice settings. REGISTRATION: ClinicalTrials.Gov Identifier: NCT03688100.

Measuring Frailty in Inpatient Rehabilitation.

BACKGROUND: In response to the global aging population, there has been increasing research on frailty. How frailty is conceptualized is shifting with the development of frailty models, especially in the acute care arena. OBJECTIVE: To explore frailty/vulnerability risk factors available at admission that were associated with salient patient outcomes within the context of inpatient rehabilitation. DESIGN: Methodologies in acute care are not easily adapted for a typical admission evaluation or a rehabilitation patient. In this study, the concept of frailty among patients admitted to rehabilitation was developed from risk factors available at admission that were associated with two patient outcomes, adverse hospital outcomes and 30-day hospital readmissions. SETTING: Inpatient rehabilitation. PATIENTS: Data were included on all patients (n = 768) discharged from an inpatient rehabilitation unit of an academic medical center from 1 January 2012 through 31 December 2012. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Adverse events within the inpatient rehabilitation stay and 30-day hospital readmissions. RESULTS: Significant independent factors associated with adverse events in the rehabilitation unit included African American (1.77 OR; 95% CI 1.06-2.96), Hispanic (3.17 OR; 95% CI 1.13-8.94), having >9 total comorbid conditions (1.44 OR; 95% CI 1.244-1.66), and sphincter control domain (including bladder and bowel management) ≤ 9 FIM (0.92 OR; 95% CI 0.86-0.98). For 30-day readmission three variables were found to be significant: onset ≥7 days (2.31 OR; 95% CI 1.28-4.22), requiring a tube for feeding (3.45 OR; 95% CI 1.433-11.12), and being obese (4.72 OR; 95% CI 1.433-15.58). CONCLUSIONS: The findings highlight the need for early admission screening and identification of risk factors which can provide the time in the rehabilitation setting for the clinical team to treat and prevent the potential for poor outcomes.

Inspiring Writing in Nursing: A Clinical Nurse Specialist-Led Program.

BACKGROUND: Hospitals are constantly involved in quality improvement and research projects investing considerable money, time, and effort in supporting these projects; however, there is not always a strong enough focus on publishing the results. The challenge lies in engaging clinicians to publish their work. One of the hallmarks of the clinical nurse specialist is mentoring, and this has led to the creation of our Inspiring Writing in Nursing (IWIN) program. PURPOSE: The goal of IWIN cohort was to engage and promote publication submissions from frontline clinicians. The 18-member Nursing Research and Evidence-Driven Practice Council (NR-EDPC) supports more than 3000 nurses in quality and research projects. Two senior librarians support our council and staff. In 2014, we launched our first IWIN cohort to mentor nurses in writing and submitting for publication. EVALUATION: The NR-EDPC motto "meet them where they are" applies to both location and level of research/EDPC knowledge and skill. An Annual Nursing Research Conference showcases the products of nursing science. The first cohort of IWIN enrolled 11 mentees, and after a yearlong journey, we submitted 5 of 11 manuscripts, 3 withdrew, and 3 are still under revisions. From the 5 submissions, 3 were published, 1 was rejected, and 1 is currently under revision. DISCUSSION: With support and the infrastructure of our NR-EDPC, we are launching our second IWIN cohort.

Frailty in a Post-Acute Care Population: A Scoping Review.

Frailty is a complex and growing phenomenon facing health care providers throughout the continuum of care. Frailty is not well understood in post-acute care (PAC) settings. The purpose of this scoping review was to summarize current evidence of frailty impact on outcomes and frailty mitigation initiatives in PAC. Three major publication databases were searched from January 2000 to June 2017 that identified 18 articles specifically addressing frailty in PAC. Three themes were identified: scales used to measure frailty, factors that led to an adverse outcome or diagnosis of frailty, and interventions to address frailty in PAC. Scales used to measure frailty were dominated by physical factors and scarce on nutrition and social support. Functional decline, grip strength, gait speed, polypharmacy, and nutrition were identified in the studies as factors that identify frailty and are associated with poor outcomes. All these frailty characteristics compromise patients' ability to benefit from rehabilitation, which further establishes the importance of PAC providers to identify, prevent, and treat frailty. Intervention studies had mixed outcomes, suggesting a need for further development in this area. The findings of this scoping review highlight the need for a comprehensive multidimensional assessment of frailty risks in PAC. LEVEL OF EVIDENCE: IV.

Variation in Rehabilitation Treatment Patterns for Hip Fracture Treated With Arthroplasty.

BACKGROUND: Recommendations for health care redesign often advocate for comparative effectiveness research that is patient-centered. For patients who require rehabilitation services, a first step in this research process is to understand current practices for specific patient groups. OBJECTIVE: To document in detail the physical and occupational therapy treatment activities for inpatient hip fracture rehabilitation among 3 patient subgroups distinguished by their early rate of functional recovery between time of surgery to rehabilitation admission. DESIGN: Multicenter prospective observational cohort, practice-based evidence, study. SETTING: Seven skilled nursing facilities and 11 inpatient rehabilitation facilities across the United States. PARTICIPANTS: A total of 226 patients with hip fractures treated with hip arthroplasty. METHODS: Comparisons of physical and occupational therapy treatment activities among 3 groups with different initial recovery trajectory (IRT) rates (slower, moderate, faster). MAIN OUTCOME MEASURE(S): Percent of patients in each IRT group exposed to each physical and occupational therapy activity (exposure), and mean minutes per week for each activity (intensity). RESULTS: The number of patients exposed to different physical or occupational therapy activities varied within the entire sample. More specifically, among the 3 IRT groups, significant differences in exposure occurred for 44% of physical therapy activities and 39% of occupational therapy activities. More patients in the slower recovery group, IRT 1, received basic activities of daily living treatments and more patients in the faster recovery group, IRT 3, received advanced activities. The moderate recovery group, IRT 2, had some treatments similar to IRT 1 group and others similar to IRT 3 group. CONCLUSIONS: Analyses of practice-based evidence on inpatient rehabilitation of hip fracture patients treated with arthroplasty identified differences in therapy activities among three patient groups classified by IRT rates. These results may enhance physiatrists', other physicians', and rehabilitation teams' understanding of inpatient rehabilitation for these patients and help design future comparative effectiveness research.

Effectiveness of Remote Patient Monitoring After Discharge of Hospitalized Patients With Heart Failure: The Better Effectiveness After Transition -- Heart Failure (BEAT-HF) Randomized Clinical Trial.

IMPORTANCE: It remains unclear whether telemonitoring approaches provide benefits for patients with heart failure (HF) after hospitalization. OBJECTIVE: To evaluate the effectiveness of a care transition intervention using remote patient monitoring in reducing 180-day all-cause readmissions among a broad population of older adults hospitalized with HF. DESIGN, SETTING, AND PARTICIPANTS: We randomized 1437 patients hospitalized for HF between October 12, 2011, and September 30, 2013, to the intervention arm (715 patients) or to the usual care arm (722 patients) of the Better Effectiveness After Transition-Heart Failure (BEAT-HF) study and observed them for 180 days. The dates of our study analysis were March 30, 2014, to October 1, 2015. The setting was 6 academic medical centers in California. Participants were hospitalized individuals 50 years or older who received active treatment for decompensated HF. INTERVENTIONS: The intervention combined health coaching telephone calls and telemonitoring. Telemonitoring used electronic equipment that collected daily information about blood pressure, heart rate, symptoms, and weight. Centralized registered nurses conducted telemonitoring reviews, protocolized actions, and telephone calls. MAIN OUTCOMES AND MEASURES: The primary outcome was readmission for any cause within 180 days after discharge. Secondary outcomes were all-cause readmission within 30 days, all-cause mortality at 30 and 180 days, and quality of life at 30 and 180 days. RESULTS: Among 1437 participants, the median age was 73 years. Overall, 46.2% (664 of 1437) were female, and 22.0% (316 of 1437) were African American. The intervention and usual care groups did not differ significantly in readmissions for any cause 180 days after discharge, which occurred in 50.8% (363 of 715) and 49.2% (355 of 722) of patients, respectively (adjusted hazard ratio, 1.03; 95% CI, 0.88-1.20; P = .74). In secondary analyses, there were no significant differences in 30-day readmission or 180-day mortality, but there was a significant difference in 180-day quality of life between the intervention and usual care groups. No adverse events were reported. CONCLUSIONS AND RELEVANCE: Among patients hospitalized for HF, combined health coaching telephone calls and telemonitoring did not reduce 180-day readmissions. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01360203.