Intermediate Care Facilities Research Articles

Cardiovascular Outcomes and Rehospitalization Rates in Homeless Patients Admitted With Acute Myocardial Infarction

ObjectiveTo study the in-hospital outcomes and 30-day readmission data in homeless patients admitted with acute myocardial infarction (AMI). MethodsAdult patients (>18 years of age) who were admitted with AMI between January 1, 2015, and December 31, 2016, were identified in the National Readmission Database. Patients were classified into homeless or non-homeless. Baseline characteristics, rates of invasive assessment and revascularization, mortality, 30-day readmission rates, and reasons for readmission were compared between the 2 cohorts. ResultsA total of 3938 of 1,100,241 (0.4%) index hospitalizations for AMI involved homeless patients. Compared with non-homeless patients, homeless patients were younger (mean age, 57±10 years vs 68±14 years; P<.001) and had a lower prevalence of atherosclerotic risk factors (hypertension, hyperlipidemia, and diabetes) but a higher prevalence of anxiety, depression, and substance abuse. Homeless patients were less likely to undergo coronary angiography (38.1% vs 54%; P<.001), percutaneous coronary intervention (24.1% vs 38.7%; P<.001), or coronary artery bypass grafting (4.9% vs 6.7%; P<.001). Among patients who underwent percutaneous coronary intervention, bare-metal stent use was higher in homeless patients (34.6% vs 12.1%; P<.001). After propensity score matching, homeless patients had similar mortality but higher rates of acute kidney injury, discharge to an intermediate care facility or against medical advice, and longer hospitalizations. Thirty-day readmission rates were significantly higher in homeless patients (22.5% vs 10%; P<.001). Homeless patients had more readmissions for psychiatric causes (18.0% vs 2.0%; P<.001). ConclusionConsiderable differences in cardiovascular risk profile, in-hospital care, and rehospitalization rates were observed in the homeless compared with non-homeless cohort with AMI. Measures to remove the health care barriers and disparities are needed.

Development and validation of a novel scoring tool for predicting facility discharge after elective posterior lumbar fusion

BACKGROUND CONTEXTDischarge to acute/intermediate care facilities is a common occurrence after posterior lumbar fusion and can be associated with increased costs and complications after these procedures. This is particularly relevant with the growing popularity of bundled payment plans, creating a need to identify patients at greatest risk. PURPOSETo develop and validate a risk-stratification tool to identify patients at greatest risk for facility discharge after open posterior lumbar fusion. STUDY DESIGNRetrospective cohort study. PATIENT SAMPLEPatients were queried using separate databases from the institution of study and the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) for all patients undergoing open lumbar fusion between 2011 and 2018. OUTCOME MEASURESDischarge to intermediate care and/or rehabilitation facilities. METHODSUsing an 80:20 training and testing NSQIP data split, collected preoperative demographic and operative variables were used in a multivariate logistic regression to identify potential risk factors for postoperative facility discharge, retaining those with a p value <.05. A nomogram was generated to develop a scoring system from this model, with probability cutoffs determined for facility discharge. This model was subsequently validated within the NSQIP database, in addition to external validation at the institution of study. Overall model performance and calibration was assessed using the Brier score and calibration plots, respectively. RESULTSA total of 11,486 patients (10,453 NSQIP, 1,033 local cohort) were deemed eligible for study, of which 16.1% were discharged to facilities (16.7% NSQIP, 9.6% local cohort). Utilizing training data, age (p<.001), body mass index (p<.001), female sex (p<.001), diabetes (p=.043), peripheral vascular disease (p=.001), cancer (p=.010), revision surgery (p<.001), number of levels fused (p<.001), and spondylolisthesis (p=.049) were identified as significant risk factors for facility discharge. The area under the receiver operating characteristic curve (AUC) indicated a strong predictive model (AUC=0.750), with similar predictive ability in the testing (AUC=0.757) and local data sets (AUC=0.773). Using this tool, patients identified as low- and high-risk had a 7.94% and 33.28% incidence of facility discharge in the testing data set, while rates of 4.44% and 16.33% were observed at the institution of study. CONCLUSIONSUsing preoperative variables as predictors, this scoring system demonstrated high efficiency in risk-stratifying patients with an approximate four to fivefold difference in rates of facility discharge after posterior lumbar fusion. This tool may help inform medical decision-making and guide reimbursement under bundled-care repayment plans.

The Impact of Atrial Fibrillation on In-Hospital Outcomes in Patients With Acute Myocardial Infarction Complicated by Cardiogenic Shock Undergoing Coronary Revascularization with Percutaneous Ventricular Assist Device Support.

Atrial fibrillation (AF) is common in acute myocardial infarction complicated by cardiogenic shock (AMI-CS) requiring percutaneous ventricular assist device (pVAD-Impella®) support during percutaneous coronary interventions (PCI). We evaluated the effects of a coexistent diagnosis of AF on clinical outcomes in patients with AMI-CS undergoing PCI with pVAD support. The National Inpatient Sample (2008-2014) was queried to identify patients with AMICS requiring PCI with pVAD support and had a concomitant diagnosis of AF. Propensity-matched cohorts (AF+ vs AF-) were compared for in-hospital outcomes. A total of 840 patients with AMICS requiring PCI with pVAD support (420 AF+ vs 420 AF-) were identified in the matched cohort. Patients with AF were older (mean 69.7±12.0 vs 67.9±11.3 yrs, p=0.030). All-cause in-hospital mortality rates between the two groups were similar (40.5% vs 36.7%, p=0.245); however, higher postprocedural respiratory complications (9.5% vs 4.8%, p=0.007) were seen in AF+ group. In-hospital cardiac arrests were more frequent in the AF- group (32.0% vs 19.2%, p<0.001). We examined the length of stay (LOS), transfer to other facilities, and hospital charges as metrics of health care resource consumption and found that the AF+ cohort experienced fewer routine discharges (13.1% vs 30.2%), more frequent transfers to other facilities including skilled nursing facilities or intermediate care facilities (27.3% vs 17.8%; p<0.001), more frequently required the use of home health care (14.3% vs 7.1%; p<0.001). The mean LOS (11.9±10.1 vs 9.11±6.8, p<0.001) and hospital charges ($308,478 vs $277,982, p=0.008) were higher in the AF+ group. In patients suffering AMICS requiring PCI and pVAD support, a coexistent diagnosis of AF was not associated with an increase in all-cause in-hospital mortality as compared to patients without AF. However, healthcare resource consumption as assessed by various metrics was consistently greater in the AF+ group.

Utilization of drugs for the management of cardiovascular diseases at intermediate care facilities for older adults in Japan

ObjectivesNo established approaches exist for the pharmacological management of cardiovascular diseases (CVDs) in residents of long-term care facilities (LTCFs). This study aimed to evaluate the use of drugs for CVD prevention and treatment (CVD-related drugs) in a major type of LTCF in Japan. MethodsThis study included 1318 randomly selected residents at 349 intermediate care facilities for older adults (called Roken). Prescriptions were investigated at admission and two months after admission according to therapeutic categories. Logistic regression was used to identify residents’ characteristics that were associated with prescriptions of CVD-related drugs. ResultsPrescriptions of all types of drugs and CVD-related drugs decreased in 36 % and 16 % of residents, respectively. Half of the residents received antihypertensives, a quarter received antiplatelets and diuretics, whereas one-tenth received antidiabetics, oral anticoagulants, and lipid-modifying drugs. The prevalence of most of individual drug categories were similar among residents with different physical or cognitive function, except for fewer antihypertensive and lipid-modifying drugs in those with severe cognitive disability. Adjusted analyses for prescriptions at two months after admission revealed that bedridden residents were more likely to be prescribed diuretics but less likely to be prescribed antihypertensives, antiplatelets, or lipid-modifying drugs. Residents with severe cognitive disability were less likely to be prescribed antihypertensives or lipid-modifying drugs. A known history of cardiovascular events was associated with greater use of CVD-related drugs. ConclusionCVD-related drugs were commonly prescribed for Roken residents, including those with low physical and cognitive functions. Deprescribing may contribute to the optimization of pharmacotherapy in LTCF residents.

Availability of home palliative care services and dying at home in conditions needing palliative care: A population-based death certificate study

Background: Avoiding inappropriate care transition and enabling people with chronic diseases to die at home have become important health policy issues. Availability of palliative home care services may be related to dying at home. Aim: After controlling for the presence of hospital beds and primary care physicians, we examined the association between availability of home palliative care services and dying at home in conditions requiring such services. Design: Death certificate data in Japan in 2016 were linked with regional healthcare statistics. Setting/participants: All adults (18 years or older) who died from conditions needing palliative care in 2016 in Japan were included. Results: There were 922,756 persons included for analysis. Malignant neoplasm (37.4%) accounted for most decedents, followed by heart disease including cerebrovascular disease (31.4%), respiratory disease (14.7%) and dementia/Alzheimer’s disease/senility (11.5%). Of decedents, 20.8% died at home or in a nursing home and 79.2% died outside home (hospital/geriatric intermediate care facility). Death at home was more likely in health regions with fewer hospital beds and more primary care physicians, in total and per condition needing palliative care. Number of home palliative care services was negatively associated with death at home. The adjustment for home palliative care services disappeared in heart disease including cerebrovascular disease and reversed in respiratory disease. Conclusion: Specialised home palliative care services may be suboptimal, and primary care services may serve as a key access point in providing baseline palliative care to people with conditions needing palliative care. Therefore, primary care services should aim to enhance their palliative care workforce.

Factors associated with successful home discharge after inpatient rehabilitation in frail older stroke patients

BackgroundStroke is a highly prevalent disease among older people and can have a major impact on daily functioning and quality of life. When community-dwelling older people are hospitalized due to stroke, discharge to an intermediate care facility for geriatric rehabilitation is indicated when return to the previous living situation is expected but not yet possible. However, a substantial proportion is still unable to return home after discharge and has to be admitted to a residential care setting. This study aims to identify which factors are associated with home discharge after inpatient rehabilitation among frail and multimorbid older stroke patients.MethodsThis study is a longitudinal cohort study among 92 community-dwelling stroke patients aged 65 years or over. All patients were admitted to one of eight participating intermediate care facilities for geriatric rehabilitation, under the expectation to return home after rehabilitation. We examined whether 16 potentially relevant factors (age; sex; household situation before admission; stroke history; cardiovascular disorders; diabetes mellitus; multimorbidity; cognitive disability; neglect; apraxia; dysphagia; urinary and bowel incontinence; emotional problems; sitting balance; daily activity level; and independence in activities of daily living) measured at admission were associated with discharge to the former living situation. Logistic regression analysis was used for statistical analysis.ResultsMean age of the patients was 79.0 years (SD 6.4) and 51.1% was female. A total of 71 patients (77.1%) were discharged to the former living situation within 6 months after the start of geriatric rehabilitation. Of the 16 factors analysed, only a higher level of independence in activities of daily living at admission was significantly associated with home discharge.ConclusionsOur study shows that the vast majority of previously identified factors predicting home discharge among stroke patients, could not predict home discharge among a group of frail and multimorbid older persons admitted to geriatric rehabilitation. Only a higher level of independence in activities of daily living at admission was significantly related to home discharge. Additional insight in other factors that might predict home discharge after geriatric rehabilitation among this specific group of frail older stroke patients, is needed. Trial registration: ISRCTN ISRCTN62286281. Registered 19-3-2010.

The effect of discharge destination and primary insurance provider on hospital discharge delays among patients with traumatic brain injury: a multicenter study of 1,543 patients

BackgroundHospital length of stay (HLOS) is a commonly used measure of hospital quality and is influenced by clinical and non-clinical factors. To reduce HLOS, it is key to identify factors placing patients at increased risk of lengthy HLOS and discharge delays.MethodsThis was a retrospective cohort study of patients age ≥ 18 admitted to four level 1 trauma centers between 1/1/2015 and 3/31/2018 with traumatic brain injury (TBI). The primary outcome was discharge delay, defined as discharge ≥24 h after case management notes indicated the patient was ready for discharge. The independent variables of interest were primary insurance provider and discharge destination. Chi-square, Fisher exact, and unadjusted and adjusted logistic regression analyses were used to assess associations between discharge delay and the two primary independent variables, as well as other patient demographic and clinical characteristics. Complications developing during the delay period were also examined.ResultsA total of 1543 patients with TBI were included. The median age was 61 years, and the median HLOS was 5 days. Approximately half of patients were discharged home (54%). The most common insurance providers were Medicare (35%) and commercial/private (35%). Two-hundred ten (14%) patients experienced a discharge delay. The median delay period was 3 days, and the most common reasons for delay were insurance authorization (52%) and lack of accepting bed (41%). Compared to being discharged home, patients discharged to a skilled nursing facility (adjusted odds ratio (AOR) = 10.35) or intermediate care facility (AOR = 10.64) had the highest odds of discharge delay. Compared to Medicare patients, uninsured/self-pay patients (AOR = 2.98) and those with Medicaid (AOR = 2.83) or commercial/private insurance (AOR = 2.22) had higher odds of delay. Thirty-two patients (15% of those delayed) experienced at least one complication during the delay, some of which were clinically severe.ConclusionsA substantial portion of TBI patients in this study experienced discharge delays, and discharge destination and primary insurance provider were significant drivers of these delays. Evaluation of a facility’s quality of care should consider the specific causes of these delays.

Falling Again? Falls in Geriatric Adults—Risk Factors and Outcomes Associated With Recidivism

BackgroundThe elderly population is at increased risk of fall-related readmissions (FRRs). This study is aimed to identify the factors predictive of repeat falls and to analyze the associated outcomes. MethodsWe studied the Nationwide Readmission Database for the year 2010 and identified the patients (≥65 years) who were admitted after falls, and from that subset, further analyzed patients with ≥1 FRRs. Descriptive statistics were used to analyze continuous and categorical variables. Multivariable logistic regression was used to identify predictors of readmission in geriatric patients after controlling for covariates. ResultsA total of 358,581 initial fall-related admissions in geriatric adults were identified, and of these, 21,713 experienced ≥1 FRRs (6.06% risk of repeat fall-related admission). Females outnumbered males, and female gender was identified as an independent predictor of FRR (OR 1.10 95% CI 1.07-1.14 P = 0.000). The other independent predictors significantly associated with FRR were age (OR 1.007, 95% CI 1.005-1.009), depression (OR 1.25, 95% CI 1.21-1.30), drug abuse (OR 1.37, 95% CI 1.15-1.63), liver disease (OR 1.25, 95% CI 1.15-1.43, P < 0.001), psychosis (OR 1.16, 95% CI 1.09-1.23), valvular heart disease (OR 1.07, 95% CI 1.02-1.12), chronic pulmonary disease (OR 1.10, 95% CI 1.06-1.13), and number of chronic conditions (OR 1.022, 95% CI 1.016-1.29). Patients admitted emergently or urgently had higher odds of FRR (OR 1.44, 95% CI 1.36-1.52). Hospital demographic was a significant predictor of FRR, as hospitals with bed number >500 was associated with lower odds (OR 0.95, 95% CI 0.92-0.98, P < 0.001). Geriatric patients admitted at nonteaching hospitals and hospitals in large metro areas (population > 1 million) had higher odds of FRR (OR 1.10, 95% CI 1.03 – 1.16) and (OR 1.10, 95% C1 1.07-1.14), respectively. With respect to discharge disposition, patients in the FRR group were less likely to go home (5.9% versus 21.0%) or with home health care (12.6% versus 18.5%), but more likely to be discharged to skilled nursing or intermediate-care facilities (64.1% versus 54.9%) and short-term hospitals (2.8% versus 1.4%). The mortality rate was higher in the FRR group but was not statistically significant (OR 1.06, 95% CI 0.99-1.14). ConclusionsGiven the high burden of fall-related injuries and FRRs to patients and the health care system, it is essential to identify those who are at risk. This study provides a comprehensive list of high-risk predictors as well as the impact on patient outcomes, and hence a chance to intervene for patients with FRRs.

Negotiating Tensions on the Front Line: Circuits of Accountability and Self-governance in Institutional Care of Adults with Intellectual Disability

This article explores how circuits of accountability impact front-line service work in an intermediate care facility for individuals with intellectual disability (ICF/IID). Institutional ethnography as a theory and methodology guided the data collection and analysis processes. Participant observation and interviews were completed, and text work was employed to make visible the ways staff enacted what they believed to be their roles and responsibilities. Results indicated the service criteria established by regulatory agencies were interpreted and executed in ways that negatively influenced staff’s moral care to residents and restricted their ability to self-govern and utilize their experiential knowledge. Additionally, the institution’s circuits of accountability reflected ideals of front-line work that were inconsistent with staff’s perception of their responsibilities. These findings have implications for management and implementation of direct care in ICFs/IID and underscore the importance of aligning moral care and self-governance to front-line service work.

ANALYSIS OF READMISSION OUTCOMES AND MORBIDITY IN SURVIVORS OF ARDS

SESSION TITLE: Monday Electronic Posters 2 SESSION TYPE: Original Inv Poster Discussion PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM PURPOSE: Acute respiratory distress syndrome (ARDS) carries a significant mortality risk among patients affected. In those who survive, it also leads to increased risk for sustaining disabilities with impairments in cognition and physical function that impact the quality of life. The goal of this study is to assess the long-term morbidity among ARDS survivors based on hospital readmission rates, risk factors that increase it, as well as outcomes of subsequent hospitalizations. METHODS: This is a retrospective analysis based on the 2014 National Readmission Database (NRD). Adults over age 18 with a primary or secondary diagnosis of ARDS based on ICD-9 codes in their index admission were included in this study. Hospital readmission was defined as a successive admission with any non-trauma diagnosis within 30 days following discharge. Same day readmissions, as well as transfers, were excluded. The primary outcome was the rate of 30-day readmission. Secondary outcomes include readmission risk factors, mortality, discharge destination, resource utilization as defined by lengths of stay (LOS) and cost, and finally the most frequent primary readmission diagnoses. Multivariate regressions with Cox proportional hazard models were used to assess for independent readmission risk factors. RESULTS: A total of 521,415 patients with ARDS were identified in this cohort and 341,824 (34%) survived their index admission. Among the survivors, 35.7% had prolonged mechanical ventilation greater than 96 hours, 0.14% received ECMO, and 17.8% had concurrent septic shock. 34.8% of the survivors were discharged to home with routine care, 42.9% were discharged to either a skilled nursing (SNF) or intermediate care facility (ICF), and 15.8% were discharged home with nursing services. A total of 8,708 (2.5%) patients were readmitted within 30-days. The top 5 most common primary readmission diagnoses were unspecified septicemia (n=2,338), acute respiratory failure (n=1,997), pneumonia due to unspecified organism (n=174), aspiration pneumonia (n=170), and MRSA septicemia (n=111). Mortality in the readmitted population was 29.9%, and 51.3% were discharged to a SNF or ICF. The mean readmission LOS was 13.8 days and the mean cost was $41,593. Independent risk factors for readmission include lower income (HR 1.17), increasing age (HR 1.01), higher Charlson comorbidity index (HR 1.27), index SNF/ICF discharge (HR 1.49), and septic shock (HR 1.25). All p-values were <0.001. CONCLUSIONS: ARDS leads to significant complications in patients who survive, especially among those who are readmitted within 30 days. Sepsis-related diagnoses are the primary drivers of readmission. Further analysis will be conducted with longer follow-up periods at 60 to 90 days to assess ARDS' continued impact on survivors. CLINICAL IMPLICATIONS: Few prospective trials are available that address ARDS survivor outcomes, which can be areas of investigation in future studies. DISCLOSURES: No relevant relationships by Laura Chen, source=Web Response No relevant relationships by Di Pan, source=Web Response No relevant relationships by Bertin Salguero, source=Web Response No relevant relationships by Fernando Vazquez de Lara, source=Web Response

Socioeconomic Impacts of Opioid Dependence on Spinal Decompression and Fusion at Any Level: Analysis of a Nationwide Database

Abstract INTRODUCTION Increasing concern surrounds the impact of perioperative opioid dependence in spinal surgery candidates. Analysis of a national dataset following spinal decompression or fusion including all spinal levels in opioid-dependent patients has not been presented. METHODS Data were extracted from the Healthcare Cost and Utilization Project National Inpatient Sample (HCUP-NIS) for adults in 2008 to 2014 who underwent spinal fusion (ICD-9 81.00-81.08), decompression (ICD-9 03.09) or revision (ICD-9 81.30-81.39). Patients with vertebral fracture, cancer and drug dependence other than opioids were excluded. Patients were divided into opioid-dependent (OD; ICD-9 304.0x) and nondependent cohorts. RESULTS In total, 491 919 patients underwent spinal fusion and met inclusion criteria, with 2021 (0.4%) OD patients. Demographically, OD patients were more likely Medicaid recipients (prevalence 91 per 10 000, P &lt; .001) and had household incomes in the top quartile (50 per 10 000, P &lt; .001). The OD cohort had higher rates of revision (11.8% vs 4.7%; P &lt; .001), urgent admission (83.9% elective vs 90.8% elective; P &lt; .001) and any complication (39.3% vs 18.7%; P &lt; .001). Median total charges increased with OD [$117,400 (interquartile range $69,700-$197,100) vs $73,000 (interquartile range $46,000-$115,700); P &lt; .001]. OD was associated with a longer length of stay [OR 2.49 (95% CI 2.33-2.64), P = .012], discharge to short-term hospital [OR 3.434 (95% CI 2.352-5.013), P &lt; .001], and discharge to skilled nursing or intermediate care facility [OR 2.542 (95% CI 2.259-2.859); P &lt; .001]. CONCLUSION Our analysis supports two potential hypotheses: that preoperative OD increases the cost and complications of spinal procedures; or, that more complex and expensive spinal operations heighten the likelihood of postoperative OD. Although chronological relationships between OD, onset of pain, and spinal operations cannot be determined using the NIS, expanded consideration of multidisciplinary opioid adjuncts in the perioperative period (such as intrathecal pumps, physical therapy, and behavioral psychology) may prove cost-effective, reduce incidence of OD, and improve outcomes.

Rising Trends in Medication Non-compliance and Associated Worsening Cardiovascular and Cerebrovascular Outcomes Among Hospitalized Adults Across the United States.

IntroductionSmall-scale studies have described concerning rates of non-compliance/nonadherence towards groups of medications for primary and secondary prevention. Trends in cardiovascular and cerebrovascular events (CCE) among hospitalized patients with a non-compliant behavior towards medication, on the whole, remains unexplored on a large scale.MethodsUsing the National Inpatient Sample databases (2007-2014), we sought to assess the prevalence and trends in all-cause mortality and CCE in adult patients hospitalized with medication non-compliance. We compared baseline characteristics and comorbidities in the non-compliant patients with and without concomitant in-hospital CCE.ResultsWe identified 7,453,831 adult hospitalizations with medication non-compliance from 2007 to 2014, of which 867,997 (11.6%) patients demonstrated in-hospital CCE. Non-compliant patients with CCE consisted of a higher number of older, white, male patients having greater comorbid risk factors. Non-compliant patients with CCE had higher all-cause in-hospital mortality (3% vs. 0.7%), frequent transfers [4.4% vs. 1.8% transfers to short-term hospitals, and 17.6% vs. 11.6% other transfers (skilled nursing or intermediate care facilities)], lower routine discharges (59.4% vs. 71.1%), and higher mean hospital charges ($52,740 vs. $30,748) compared to non-compliant patients without CCE. Remarkably, this study demonstrates the rising trend in medication non-compliance across all age, sex, and race groups, and related in-hospital mortality, CCE, transfers to other facilities, and the health care cost from 2007 to 2014.ConclusionsWe observed rising trends in the prevalence of medication non-compliance and subsequent in-hospital mortality in hospitalizations among adults from 2007 to 2014. Non-compliant patients with inpatient CCE demonstrated rising trends in all-cause mortality, complications, health care utilization, and cost from 2007 to 2014.

Acute Venous Thromboembolism Risk Highest Within 60 Days After Discharge From the Hospital in Patients With Inflammatory Bowel Diseases

Patients with inflammatory bowel diseases (IBDs) have a high risk of venous thromboembolism (VTE). We assessed the timing and risk factors associated with readmission to the hospital for VTE among patients with IBD. We collected data from the Nationwide Readmissions Database on IBD index admissions resulting in readmission to the hospital for VTE within 60 days, from 2010 through 2014. We used univariable and multivariable regression to assess risk factors associated with VTE readmission with unadjusted risk ratio (RR) and adjusted RR (aRR) as measures of effect. Time to VTE readmission was assessed in 10-day intervals, for up to 90 days. We identified 872,122 index admissions of patients with IBD; 1160 resulted in readmission with VTE. More than 90% of readmissions occurred within 60 days of discharge from the index admission. Factors associated with hospital readmission with VTE included prior VTE, longer length of hospital stay, comorbidities, having a flexible sigmoidoscopy or colonoscopy at index admission, and age older than 18 years. Additional risk factors included Clostridium difficile infection at index admission (aRR, 1.47; 95% CI, 1.17-1.85) and discharge to a skilled nursing facility or intermediate care facility (aRR, 1.39; 95% CI, 1.14-1.70) or discharge with home health services (aRR, 1.65; 95% CI, 1.41-1.94). Among patients admitted to the hospital with IBD, most readmissions with VTE occur within 60 days of discharge. Readmission with VTE is associated with C difficile infection and discharge to a skilled nursing facility, intermediate care facility, or with home health services. Studies are needed to evaluate the potential benefit of extending VTE prophylaxis for patients admitted to the hospital with IBD for up to 2 months after discharge, to minimize risk.

Predictors and outcomes of nonroutine discharge after hepatopancreatic surgery

BackgroundData on predictors of nonroutine discharge among patients undergoing hepatopancreatic surgery remain poorly defined. We sought to define factors associated with nonroutine discharge to home with home health care or to a skilled nursing facility or intermediate care facility and determine the impact of discharge destination on outcomes after hepatopancreatic surgery. MethodsThe Nationwide Readmissions Database was queried for individuals who underwent hepatopancreatic surgeries 2010–2014 and were discharged home with home health care or to a skilled nursing facility/intermediate care facility. ResultsA total of 42,189 patients underwent hepatopancreatic surgery. Of those, 2,825 (6.70%) were discharged to a skilled nursing facility or intermediate care facility, whereas 10,925 (25.9%) were discharged with home health care. A majority of patients underwent major hepatectomy (N = 14,516, 34.4%) or minor pancreatectomy (N = 13,824, 32.8%). Compared with patients discharged home, patients discharged to a skilled nursing facility or intermediate care facility were older (median age: 60 years, interquartile range: 50–68 vs 73, 67–79) and had more comorbidities (median score: 3, interquartile range: 1–8 vs 4, interquartile range: 2–8; P < .001). Type of operative procedure was not associated with discharge to a skilled nursing facility versus with home health care. Rather, patients with extreme loss of function, based on preoperative assessment, had 2.76 times higher odds of discharge to a skilled nursing facility or intermediate care facility versus with home health care (odds ratio 2.76, 95% confidence interval 1.98–3.85). Similarly, older (odds ratio 1.06, 95% confidence interval 1.06–1.07) and female patients (odds ratio 1.37, 95% confidence interval 1.25–1.51) were more likely to be discharged to a skilled nursing facility or intermediate care facility versus with home health care. ConclusionOne in four patients undergoing hepatopancreatic surgery were readmitted within 90 days of surgery. Age, severity of comorbidities, and perioperative course, including incidence of complications, were associated with nonroutine discharge.

Drug costs in long-term care facilities under a per diem bundled payment scheme in Japan.

The present study aimed to evaluate drug costs per resident at Japanese intermediate care facilities for older adults (called Roken) in relation to drug utilization after admission to these facilities. The payment, including coverage of drugs, is mainly determined by the resident's long-term care needs. A nationwide drug utilization survey was carried out. The participants were 1324 residents of 350 Roken (up to five individuals per facility) who were admitted in 2015 and agreed to participate in this study. Drug costs per resident per month at admission and 2 months later were calculated for drugs prescribed for regular use. Associations between characteristics of the residents and drug costs were examined. A wide variation in drug costs with a long right tail was observed. Median drug costs were $77 (interquartile range $34-147) at admission, and $46 (interquartile range $19-98) in month 2. There was no apparent association between the level of long-term care needs and drug costs, adjusting for sex, age and main place of residence before admission. Anti-dementia drugs accounted for the largest portion of total drug costs at admission (15.4%) and in month 2 (12.4%). The average drug cost per user was also the highest for anti-dementia drugs ($90.2 per user per month), followed by drugs for Parkinson's disease ($70.3). The proportion of generic drugs across all drug classes examined increased after admission. These findings might suggest that implementation of the bundled payment scheme would be effective for the reduction of medication costs in institutional long-term care. Geriatr Gerontol Int 2019; 19: 667-672.

A cost comparison analysis of paediatric intermediate care in a tertiary hospital and an intermediate care facility in Cape Town, South Africa.

BackgroundIn South Africa, 600–700 new cases of paediatric cancers have been reported every year for the past 25 years, and in the year 2000, HIV/AIDS was responsible for 42,479 deaths in children under five. These children need intermediate care but research in the field is lacking, with the few costing studies conducted in South Africa reporting a range of inpatient day costs.MethodsA retrospective cost analysis for the period April 2014-March 2015 was undertaken from the provider perspective in the public sector, using a step down costing approach. Costs of paediatric intermediate care were estimated for an intermediate care facility (ICF) and a tertiary hospital in Cape Town. Costs were inflated to 2016 prices and reported in US dollars.ResultsCost per inpatient day was $713.09 at the hospital and $695.17 at the ICF for any child requiring care at these institutions. The cost for a paediatric patient who is HIV/TB co-infected was $7 130.94 and $6 951.67 at the hospital and ICF respectively, assuming an average length of stay of 10 days. For a patient with terminal brain carcinoma the cost was $19 966.63 and $19 464.69 at the hospital and ICF respectively, assuming an average length of stay of 28 days. Personnel costs accounted for 60% and 17% of the total cost at the hospital and ICF respectively. Overhead costs accounted for 12.33% at the ICF and 4.48% at the hospital.ConclusionsThe drivers of cost are not uniform across settings. Providing intermediate care at an ICF could be less costly than providing this care at a hospital, however more in-depth analysis is needed. The costs presented in this study were considerably higher than those found in other studies, however, the paucity of cost data available in this area makes comparisons difficult.

Prevalence of cytochrome P450-mediated potential drug-drug interactions in residents of intermediate care facilities for older adults in Japan.

Limited information is available on the prevalence of drug-drug interactions (DDI) in residents of long-term care facilities who often receive multiple drugs. This study aimed to evaluate the prevalence of clinically relevant cytochrome P450-mediated potential DDI in residents of intermediate care facilities for older adults (called Roken) in Japan. A nationwide drug utilization study was carried out for Roken residents in 2015 (up to five residents per facility). Potential DDI were identified with an explicit list of drugs that can be involved in clinically relevant cytochrome P450-mediated DDI in Japan. Logistic regression was used to evaluate the association of the number of drugs prescribed with the presence of potential DDI, adjusted for age, sex and long-term care needs level. The study included 1222 residents of 348 Roken who were prescribed two or more active drug substances. The participants who received ≥6 and ≥10 drugs represented 49% and 10% of total participants, respectively. In total, 42 two-drug combinations involving potential DDI were identified in 33 participants (2.7%) - benzodiazepines, proton pump inhibitors, calcium channel blockers and anti-epileptic drugs were frequently involved. The adjusted odds ratios for potential DDI were 2.84 (95% confidence interval 1.15-7.02) or 7.82 (95% confidence interval 2.96-20.70) in residents receiving six to nine drugs or ≥10 drugs, compared with those receiving two to five drugs. Approximately 3% of Roken residents were at risk for clinically relevant DDI. Reducing the number of drugs prescribed through medication reviews would mitigate the potential risk. Geriatr Gerontol Int 2019; 19: 513-517.

In-hospital dementia-related deaths following implementation of the national dementia plan: observational study of national death certificates from 1996 to 2016

ObjectiveTo examine changes in places of dementia-related death following implementation of the national dementia plan and other policy initiatives.DesignObservational study.SettingJapan between October 1996 and September 2016. Four major changes in...

Whole genome sequencing of toxigenic Clostridium difficile in asymptomatic carriers: insights into possible role in transmission

Estimates of the prevalence of asymptomatically carried Clostridium difficile in elderly patients in long-term care range from 0% to 51%. Asymptomatic carriage is possibly a risk factor for the development of infection, and there is ongoing debate surrounding the role of asymptomatic carriage in transmission. To investigate the prevalence of asymptomatic carriage amongst patients residing in intermediate care (bedded) facilities (ICBFs), and to investigate whether asymptomatically carried C.difficile strains contribute to nosocomial C.difficile infection (CDI). Stools were collected from eligible asymptomatic patients in ICBFs, and a subset was also processed from symptomatic patients accessing primary or secondary care outside of ICBFs. All samples were cultured for C.difficile, and resulting colonies were processed through whole genome sequencing. In total, 151 asymptomatic patients were sampled, 22 of which were positive for C.difficile through stool culture, representing a carriage rate of 14.6%. Sequencing of these isolates, alongside 14 C.difficile polymerase chain reaction and culture-positive isolates from symptomatic individuals, revealed that all asymptomatic patients were carrying toxigenic C.difficile, and these strains were genetically similar to those from symptomatic patients. This small study of asymptomatic carriage revealed a rectal asymptomatic carriage rate of 14.6% in patients nursed in ICBFs, and a high level of genetic similarity of these strains to those recovered from symptomatic patients. As such, asymptomatic carriers may be important for the transmission of symptomatic CDI, although it is acknowledged that this study was small, and many other factors govern whether C.difficile is carried asymptomatically or causes symptoms.

Differences in trauma mortality between ACS-verified and state-designated trauma centers in the US

BackgroundTraumatic injury is a leading cause of deaths worldwide, and designated trauma centers are crucial to preventing these. In the US, trauma centers can be designated as level I-IV by states and/or the American College of Surgeons (ACS), reflecting the resources available for care. We examined whether state- and ACS-verified facilities of the same level (I-IV) had differences in mortality, complications, and disposition, and whether differences varied by center level. Materials and methodsUsing all admissions reported to the National Trauma Data Bank 2010–2015, we estimated risk ratios for the association between current ACS verification (vs. state designation) and patient mortality and complications, adjusting for trauma level and facility, injury, and demographic characteristics. We tested the interaction between trauma level and ACS verification, stratifying by trauma level in the presence of significant statistical interaction. ResultsOverall, patients admitted to ACS-verified vs state-designated facilities had similar adjusted mortality risk [RR 1.00; 95% CI 0.91–1.03] and lower risk of discharge to intermediate care facilities [RR 0.58; 95% CI 0.44 to 0.78]. However, Level III and IV facilities had lower adjusted mortality risk when ACS-verified, with much lower mortality risk in ACS-verified Level IV facilities [RR 0.25; 95% CI 0.12 to 0.54]. DiscussionFindings suggest that while outcomes are similar between ACS-verified and state-designated Level I and II centers, state-designated Level III and particularly Level IV centers show poorer outcomes relative to their ACS-verified counterparts. Further research could explore mechanisms for these differences, or inform potential changes to state designation processes for lower-level centers.