Long-stay Nursing Home Residents Research Articles

Nursing Home and Market Factors and Risk-Adjusted Hospitalization Rates Among Urban, Micropolitan, and Rural Nursing Homes

ObjectivesHospitalizations are common among long-stay nursing home (NH) residents, but the role of rurality in hospitalization is understudied. This study examines the relationships between rurality, NH, and market characteristics and NH quarterly risk-adjusted hospitalization rates of long-stay residents over 10 quarters (2011 Q2-2013 Q3). DesignThe longitudinal associations of NH and market factors and hospitalization rates were modeled separately on urban, micropolitan, and rural NHs using generalized estimating equation models and a fully interacted model of all NH and market characteristics with micropolitan and rural indicators to test significance of differences compared with urban NHs. Setting and ParticipantsIn total, 14,600 unique NHs. MeasuresRisk-adjusted hospitalization rates were calculated from 2011 to 2013 national Medicare claims and NH Minimum Data Set 3.0. Rurality was defined based on the 2010 Rural Urban Commuting Area codes. NH and market characteristics were extracted from Certification and Survey Provider Enhanced Reporting and Area Health Resources File. ResultsOver the study period, risk-adjusted hospitalization rates averaged 9.8% (standard deviation = 8.2%). No difference was found in the overall hospitalization rates of long-stay NH residents among urban, micropolitan, and rural NHs. Generalized estimating equation models show that urban NHs with higher percentages of Medicare and Medicaid residents and any nurse practitioner/physician assistant were associated with lower rates, but these associations were insignificant in rural settings. Higher registered nurse to total nurses ratio was only associated with lower hospitalization rates in urban settings. Higher median household income was associated with lower hospitalization rates in micropolitan and rural NHs. Conclusions/ImplicationsRurality is not associated with hospitalization rates of long-stay residents, but NH and market factors (eg, payer distribution, staffing, and population income) may affect hospitalization differently in micropolitan/rural NHs than urban NHs. Future intervention on hospitalization should target factors unique to micropolitan/rural NHs which adopt strategies appropriate to their setting.

Risk Factors, Presentation, and Course of Coronavirus Disease 2019 in a Large, Academic Long-Term Care Facility

ObjectiveTo describe clinical characteristics and risk factors associated with coronavirus disease 2019 (COVID-19) in long-stay nursing home residents. Design and ParticipantsRetrospective cohort study (March 16, 2020 to May 8, 2020). SettingAcademic long-term chronic care facility (Boston, MA). ParticipantsLong-term care residents. MethodsPatient characteristics and clinical symptoms were obtained via electronic medical records and Minimum Data Set. Staff residence was inferred by zip codes. COVID-19 infection was confirmed by polymerase chain reaction testing using nasopharyngeal swabs. Residents were followed until discharge from facility, death, or up to 21 days. Risks of COVID-19 infection were modeled by generalized estimating equation to estimate the relative risk (RR) and 95% confidence intervals (CI) of patient characteristics and staff community of residence. ResultsOverall 146 of 389 (37.5%) long-stay residents tested positive for COVID-19. At the time of positive test, 66 of 146 (45.5%) residents were asymptomatic. In the subsequent illness course, the most common symptom was anorexia (70.8%), followed by delirium (57.6%). During follow-up, 44 (30.1%) of residents with COVID-19 died. Mortality increased with frailty (16.7% in pre-frail, 22.2% in moderately frail, and 50.0% in frail; P < .001). The proportion of residents infected with COVID-19 varied across the long-term care units (range: 0%‒90.5%). In adjusted models, male sex (RR 1.80, 95% CI 1.07, 3.05), bowel incontinence (RR 1.97, 95% CI 1.10, 3.52), and staff residence remained significant predictors of COVID-19. For every 10% increase in the proportion of staff living in a high prevalence community, the risk of testing positive increased by 6% (95% CI 1.04, 1.08). Conclusions and ImplicationsAmong long-term care residents diagnosed with COVID-19, nearly one-half were asymptomatic at the time of diagnosis. Predictors of COVID-19 infection included male sex, bowel incontinence, and staff residence in a community with a high burden of COVID-19. Universal testing of patients and staff in communities with high COVID-19 rates is essential to mitigate outbreaks.

Advance Care Planning Video Intervention Among Long-Stay Nursing Home Residents

Standardized, evidenced-based approaches to conducting advance care planning (ACP) in nursing homes are lacking. To test the effect of an ACP video program on hospital transfers, burdensome treatments, and hospice enrollment among long-stay nursing home residents with and without advanced illness. The Pragmatic Trial of Video Education in Nursing Homes was a pragmatic cluster randomized clinical trial conducted between February 1, 2016, and May 31, 2019, at 360 nursing homes (119 intervention and 241 control) in 32 states owned by 2 for-profit corporations. Participants included 4171 long-stay residents with advanced dementia or cardiopulmonary disease (hereafter referred to as advanced illness) in the intervention group and 8308 long-stay residents with advanced illness in the control group, 5764 long-stay residents without advanced illness in the intervention group, and 11 773 long-stay residents without advanced illness in the control group. Analyses followed the intention-to-treat principle. Five 6- to 10-minute ACP videos were made available on tablet computers or online. Designated champions (mostly social workers) in intervention facilities were instructed to offer residents (or their proxies) the opportunity to view a video(s) on admission and every 6 months. Control facilities used usual ACP practices. Twelve-month outcomes were measured for each resident. The primary outcome was hospital transfers per 1000 person-days alive in the advanced illness cohort. Secondary outcomes included the proportion of residents with or without advanced illness experiencing 1 or more hospital transfer, 1 or more burdensome treatment, and hospice enrollment. To monitor fidelity, champions completed reports in the electronic record whenever they offered to show residents a video. The study included 4171 long-stay residents with advanced illness in the intervention group (2970 women [71.2%]; mean [SD] age, 83.6 [9.1] years), and 8308 long-stay residents with advanced illness in the control group (5857 women [70.5%]; mean [SD] age, 83.6 [8.9] years), 5764 long-stay residents without advanced illness in the intervention group (3692 women [64.1%]; mean [SD] age, 81.5 [9.2] years), and 11 773 long-stay residents without advanced illness in the control group (7467 women [63.4%]; mean [SD] age, 81.3 [9.2] years). There was no significant reduction in hospital transfers per 1000 person-days alive in the intervention vs control groups (rate [SE], 3.7 [0.2]; 95% CI, 3.4-4.0 vs 3.9 [0.3]; 95% CI, 3.6-4.1; rate difference [SE], -0.2 [0.3]; 95% CI, -0.5 to 0.2). Secondary outcomes did not significantly differ between trial groups among residents with and without advanced illness. Based on champions' reports, 912 of 4171 residents with advanced illness (21.9%) viewed ACP videos. Facility-level rates of showing ACP videos ranged from 0% (14 of 119 facilities [11.8%]) to more than 40% (22 facilities [18.5%]). This study found that an ACP video program was not effective in reducing hospital transfers, decreasing burdensome treatment use, or increasing hospice enrollment among long-stay residents with or without advanced illness. Intervention fidelity was low, highlighting the challenges of implementing new programs in nursing homes. ClinicalTrials.gov Identifier: NCT02612688.

Leadership Perceptions and Practices of Hospitality in Senior Care.

Senior care providers are increasingly focused on hospitality to distinguish themselves from competitors. A mixed-methods approach was used to examine perceptions of hospitality from leadership (i.e., administrators of nursing homes and assisted living facilities) and use of hospitality practices across settings and lines of service. Results indicated that hospitality practices readily exist in senior care settings (i.e., nursing homes, assisted living facilities), but may be referred to by names other than hospitality. There also appear to be more similarities than differences in practices across long-term care service lines (i.e., short- and long-stay nursing home residents, assisted living), suggesting that, regardless of provider type, hospitality in senior care is becoming part of the expected culture and cadre of services for residents. Overall, findings suggest hospitality practices are related to providers' census, payer mix, and organizational performance.

Texture-Modified Diet for Improving the Management of Oropharyngeal Dysphagia in Nursing Home Residents: An Expert Review

ObjectivesThis paper provides evidence-based and, when appropriate, expert reviewed recommendations for long-stay residents who are prescribed texture-modified diets (TMDs), with the consideration that these residents are at high risk of worsening oropharyngeal dysphagia (OD), malnutrition, dehydration, aspiration pneumonia, and OD-associated mortality, poorer quality of life and high costs.DesignNestlé Health Science funded an initial virtual meeting attended by all authors, in which the unmet needs and subsequent recommendations for OD management were discussed. The opinions, results, and recommendations detailed in this paper are those of the authors, and are independent of funding sources.SettingOD is common in nursing home (NH) residents, and is defined as the inability to initiate and perform safe swallowing. The long-stay NH resident population has specific characteristics marked by a shorter life expectancy relative to community-dwelling older adults, high prevalence of multimorbidity with a high rate of complications, dementia, frailty, disability, and often polypharmacy. As a result, OD is associated with malnutrition, dehydration, aspiration pneumonia, functional decline, and death. Complications of OD can potentially be prevented with the use of TMDs.ResultsThis report presents expert opinion and evidence-informed recommendations for best practice on the nutritional management of OD. It aims to highlight the practice gaps between the evidence-based management of OD and real-world patterns, including inadequate dietary provision and insufficient staff training. In addition, the unmet need for OD screening and improvements in therapeutic diets are explored and discussed.ConclusionThere is currently limited empirical evidence to guide practice in OD management. Given the complex and heterogeneous population of long-stay NH residents, some ‘best practice’ approaches and interventions require extensive efficacy testing before further changes in policy can be implemented.

Reducing Transfers among Long-Stay Nursing Facility Residents to Acute Care Settings: Effect of the 2013‒2016 Centers for Medicare and Medicaid Services Initiative

ObjectivesFrom 2013 to 2016, the Centers for Medicare and Medicaid Services Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents (“the Initiative”) tested a series of clinical interventions and care models, through organizations called Enhanced Care and Coordination Providers (ECCPs), with the goal of reducing avoidable inpatient hospital admissions among long-stay nursing home residents. We identify the effect of the Initiative on the probability and count of acute care transfers [capturing any transfer to the hospital, including hospitalizations (inpatient stays), emergency department visits, and observation stays]. DesignWe evaluate the effect of the Initiative on the probability and count of all-cause acute care transfers and potentially avoidable acute care transfers and estimate the average effect of the Initiative per resident per year. Setting and ParticipantsWe use 2011–2016 data from the Centers for Medicare and Medicaid Services Minimum Data Set, version 3.0, nursing home resident assessments linked with Medicare eligibility and enrollment data and Medicare inpatient and outpatient hospital claims. Our sample is limited to Medicare fee-for-service beneficiaries in participating ECCP facilities and a comparison group of long-stay nursing facility residents. MethodsWe evaluate the effect of the Initiative on both the probability and count of all-cause acute care transfers and potentially avoidable acute care transfers using difference-in-differences regression models controlling for both resident-level clinical and demographic characteristics as well as facility-level characteristics. ResultsWe found statistically significant evidence of a reduction in both the probability and count of all-cause and potentially avoidable acute care transfers among long-stay nursing facility residents who participated in the Initiative, relative to comparison group residents. Conclusions and ImplicationsThe clinical interventions and care models implemented by the ECCPs show that by using staff education, facility leadership and physician engagement, and/or clinical assessment and treatment of residents who experienced a change in condition, it is possible to reduce acute care transfers of nursing facility residents. This could lead to better outcomes and reduced cost of care for this vulnerable patient population.

Impact of Physician Orders for Life-Sustaining Treatment (POLST) Program Maturity Status on the U.S. Nursing Home Resident's Place of Death (TH311D)

•Identify impact of POLST program usage, specifically different maturity status of the program and associated outcomes in nursing home residents, for short and long-stay residents.•Discuss predictors of nursing home deaths, classified by resident level and facility level predictors. The Physician Orders for Life-Sustaining Treatments (POLST) program was developed to enhance quality of care delivered at end-of-life (EoL). Although positive effects of POLST program use on dying individual's EoL care have been identified, the association between a state's POLST program maturity status and nursing home (NH) resident's place of death is unknown. Examine the impact of state-level POLST program maturity status on elderly NH residents' place of death. The POLST program data were linked to the following national-level datasets: Minimum Data Set 3.0, Vital Statistics Data, Medicare Chronic Conditions File, Certification and Survey Provider Enhanced Reports, and Area Health Resource File. Stratifying residents on long-stay and short-stay, we used descriptive statistics and multivariate logistic regression models to examine the impact of POLST maturity status on nursing home residents' place of death. Controlling for individual and contextual variables, long-stay residents living in states where the POLST program was mature had 20% increased odds of dying in NHs (OR: 1.20; CI 1.02-1.43) compared to those in states with non-conforming status. Residents in states with endorsed or developing POLST status also had greater odds of dying in NHs (OR: 1.09; CI 0.98-1.21 endorsed; OR: 1.12; CI 1.02-1.24 developing) compared to the residents in states with non-conforming status. No significant difference was noted for short-stay residents. Higher POLST maturity status was associated with greater likelihood of dying in NHs among long-stay nursing home residents. Our findings demonstrate that a well-structured advance care planning program such as POLST enhances care outcomes among elderly patients living in NHs.

Economic Barriers to Antiretroviral Therapy in Nursing Homes.

Our aim was to clarify if persons living with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) have adequate economic access to antiretroviral therapy (ART) when admitted to nursing homes (NHs). Medicare Part A pays NHs a bundled skilled nursing rate that includes prescription drugs for up to 100 days, after which individuals are responsible for the costs. A cross-sectional study. NHs. A total of 694 newly admitted long-stay (>100 d) NH residents with HIV. We used Minimum Dataset v.3.0, pharmacy dispensing data, NH provider surveys, and Medicare claims from 2011 to 2013. We assessed receipt of any HIV antiretrovirals or recommended combinations (ART), as defined by national care guidelines, and the source of payment. We identified predictors of antiretroviral use with risk-adjusted generalized estimating equation logistic models. All study persons living with HIV/AIDS in NHs had prescription drug coverage through Medicare's Part D program, and ART was 100% covered. However, only 63.9% received recommended ART, and 15.2% never received any antiretrovirals during their NH stay. The strongest predictor of not receiving antiretrovirals was the first 100 days of a long NH stay (odds ratio [OR] = .44; 95% confidence interval [CI] = .24-.80). The strongest predictor of receiving recommended ART was health acuity (OR = 1.51; 95% CI = 1.20-1.88). People living with HIV in NHs do not always receive lifesaving ART, but the reasons are unclear and appear unrelated to economic barriers. J Am Geriatr Soc 68:777-782, 2020.

Construction and Validation of Risk-adjusted Rates of Emergency Department Visits for Long-stay Nursing Home Residents.

Long-stay nursing home (NH) residents are at high risk of having emergency department (ED) visits, but current knowledge regarding risk-adjusted ED rates is limited. To construct and validate 3 quarterly risk-adjusted rates of long-stay residents' ED use: any ED visit, ED visits without hospitalization or observation stay (outpatient ED), and potentially avoidable ED visits (PAED). The authors calculated quarterly NH risk-adjusted ED rates from 2011 Q2 to 2013 Q3 national Medicare claims and Minimum Data Set data. Using random-effect linear regressions, the authors validated these rates against Nursing Home Compare overall 5-star quality ratings and examined their associations with hospitalization rates to provide a quality context. Resident-quarter observations (7.3 million) from 15,235 unique NHs. Risk-adjusted rates of any ED, outpatient ED, and PAED averaged 9.7%, 3.4%, and 3.2%, respectively. Compared with NHs with 1 or 2 stars overall rating, NHs with ≥3 stars were significantly associated with lower rates of any ED visit, outpatient ED, and PAED (β, -0.23%, -0.16%, and -0.11%, respectively; all P<0.01). Pearson Correlation coefficients between hospitalization rates and rates of any ED visit, outpatient ED, and PAED were 0.74, 0.31, and 0.46, respectively. The moderately negative associations of 5-star ratings with ED rates provide supportive evidence to their validity. Outpatient ED and PAED were moderately correlated to hospitalizations suggesting they provided more information about quality than any ED.

PUBLIC REPORTING OF NH ANTIPSYCHOTIC USE: CHANGES IN THE REPORTING OF EXCLUSIONARY DIAGNOSES?

Antipsychotics (APMs) are commonly used off-label to control behavioral symptoms of dementia in nursing home (NH) residents despite FDA warnings. As part of the Centers for Medicare and Medicaid Services’ (CMS) partnership to reduce the use of APMs in long-stay NH residents with dementia, CMS began publicly reporting an APM quality measure on the NH Compare website in July of 2012. This measure proxies for potentially “inappropriate” use by excluding residents with diagnoses in which APMs may be appropriate. While APM use as declined, some question if the quality measure creates an incentive to change documentation of exclusionary diagnoses to show improvements in the publicly reported APM quality measure. These exclusionary diagnoses include: Huntington’s disease, Tourette syndrome, and schizophrenia. Using Minimum Data Set (MDS) assessments from long-stay NH residents in freestanding NHs (2011-2015), we utilized a difference-in-differences framework to compared the proportion of assessments with exclusionary diagnoses in NHs that were required to report the APM quality measure (treatment) to NHs that were exempt from reporting the measure (control). We also stratified the results by grouping residents under and over 65 year of age. We find no change in exclusionary diagnoses immediately following the implementation of public reporting. However, starting in 2014, the use of exclusionary diagnoses increased in the treatment group, especially among residents aged 65+. While APM use declined for all groups over the study period, our results indicate that the reduction in APM use may not be as large as expected, especially after 2014.

LEARNING FROM LIFE STORIES: RECRUITING NURSING HOME RESIDENTS FOR A LIFE STORY WORK PROGRAM

Recruiting nursing home (NH) residents to participate in program evaluations is a consistent challenge. This was evident in a federally supported project to improve person-centered care of long-stay NH residents enrolled in Medicaid. Evaluators sought to examine the impact of a life story work intervention using a pre-post study design involving interviews of NH residents and surveys of their family members and staff. Other resident eligibility criteria included willingness to participate in both research and life story interviews, age 60+, a Brief Inventory Mental Status (BIMS) score of 8 or higher, English-speaking, and consent from a legal guardian, if applicable. A total of 16 NHs agreed to participate in the implementation and evaluation of the program, which developed complimentary, individualized life story booklets for residents and a companion summary for staff. Of the homes’ combined population of 1,817 residents, 569 met eligibility criteria for the research study. Non-response from legal guardians excluded 37 residents, and 174 residents approached for recruitment declined to have their names released to the researchers. During baseline interviews, 20 residents failed the BIMS, 21 were unavailable, and 79 refused when approached by a research interviewer. Ultimately, 238 resident interviews were completed at baseline. Common themes for refusals included disinterest in participating in life story work, statements that theirs was not a good life worth talking about, and doubts that quality of care would improve. Strategies for addressing such challenges included displaying sample life story materials during recruitment and providing residents additional time to consider participation.

Predictors of Hip Fracture Despite Treatment with Bisphosphonates among Frail Older Adults.

Bisphosphonates are effective at preventing hip fractures among older adults, yet many patients still fracture while on treatment and may benefit from additional preventive interventions. Little data are specifically available to target such efforts among bisphosphonate users. We aimed to identify predictors of hip fracture unique to frail older adults initiating pharmacologic treatment for osteoporosis. Retrospective cohort using 2008-2013 linked national Minimum Data Set assessments, Medicare claims, and nursing home (NH) facility data. NHs in the United States. Long-stay NH residents 65 years or older who initiated treatment with a bisphosphonate (N = 17 753). Estimates for bisphosphonate initiators were contrasted with those for calcitonin initiators (control group; N = 5348). Hospitalized hip fracture outcomes were measured using Part A claims. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated for 36 a priori selected potential predictors. The mean (SD) age of the study population was 84 (8) years, 85% were women, and 51% had moderate to severe cognitive impairment. Predictors associated with a higher risk of hip fracture despite bisphosphonate use included age 75 years or older to 85 years (vs ≥65 to <75 y; HR = 1.25; 95% CI = 1.02-1.55), female sex (HR = 1.33; 95% CI = 1.06-1.67), white race (vs black race (HR = 1.87; 95% CI = 1.36-2.58), and body mass index = 18.5-24.9 (vs ≥30; HR = 1.93; 95% CI = 1.53-2.42). Independent ability to transfer (vs total dependence; HR = 3.11; 95% CI = 1.83-5.30) and occasional urinary incontinence (vs frequent; HR = 1.45; 95% CI = 1.18-1.78) were also important predictors. Dementia, diabetes, psychoactive drug use, and other characteristics were not associated with post-prescribing hip fracture. Predictors did not differ between bisphosphonate and calcitonin users. Predictors of hip fracture among frail older adults did not differ between those who were new users of bisphosphonates vs calcitonin. Given the absence of risk factors unique to bisphosphonate users, targeting of fracture prevention efforts should extend beyond pharmacologic therapy to include existing nonpharmacologic therapies, particularly fall prevention strategies. J Am Geriatr Soc 68:256-260, 2020.

Validation of the FRAiL model to predict non-vertebral and hip fractures in nursing home residents.

Tools were unavailable to assess fracture risk in nursing homes (NH); therefore, we developed the Fracture Risk Assessment in Long term care (FRAiL) model. The objective of this validation study was to assess the performance of the FRAiL model to predict 2-year risk of non-vertebral and hip fractures in a separate large cohort of NH residents. This retrospective cohort study included most long-stay NH residents in the United States (N = 896,840). Hip and non-vertebral fractures were identified using Medicare claims. The Minimum Data Set (MDS) was used to identify characteristics from the original FRAiL model. Multivariable competing risk regression was used to model risk of fracture. Mean age was 83.8 years (±8.2 years) and 70.7% were women. Over a mean follow-up of 1.52 years (SD 0.65), 41,531 residents (4.6%) were hospitalized with non-vertebral fracture (n = 30,356 hip fractures). In the fully adjusted model, 14/15 model characteristics remained significant predictors of non-vertebral fracture. Female sex (HR = 1.55, 95% CI 1.52, 1.59), wandering (HR = 1.30, 95% CI 1.26, 1.34), and falls (HR = 1.28, 95% CI 1.26, 1.31) were strongly associated with non-vertebral fracture rate. Total dependence in ADLs (versus independence) was associated with a decrease in non-vertebral fracture rate (HR = 0.57, 95% CI 0.52, 0.64). Discrimination was moderate in men (C-index = 0.68 for hip, 0.66 for non-vertebral) and women (C-index = 0.68 for hip, 0.65 for non-vertebral), and calibration was excellent. Our model comprised entirely from routinely collected data was able to identify NH residents at greatest risk for non-vertebral fracture.

Nursing Home Star Ratings and New Onset of Depression in Long-Stay Nursing Home Residents

ObjectivesTo examine the association between nursing home (NH) quality and new onset of depression and severity of depressive symptoms in a national cohort of long-stay NH residents in the United States. DesignCohort study. Setting and participants129,837 long-stay residents without indicators of depression admitted to 13,921 NHs. MethodsNH quality was measured by Nursing Home Compare star ratings (overall, health inspection, staffing, quality measures) closest to admission. Study outcomes at 90 days from the Minimum Data Set 3.0 included depression diagnosis and severity of depressive symptoms (minimal; mild; moderate; moderately severe/severe). Symptoms were measured by resident self-report Patient Health Questionnaire (PHQ-9) or a staff-report observational version (PHQ-9-OV). Logistic and multinomial logistic models with generalized estimating equations were used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs). ResultsAt 90 days postadmission, 14.1% of residents had a new diagnosis of depression, and odds did not differ across star ratings. Nearly 90% of these residents had minimal depressive symptoms, with only 8.5% reporting mild symptoms and 2.6% with moderate to severe symptoms. Using minimal depressive symptoms as the reference, residents in NHs with 5-star overall ratings were 12% less likely than those in 3-star NHs to experience mild (95% CI: 0.81-0.96) and 31% less likely to experience moderate symptoms (95% CI: 0.58-0.82). In NHs with 1-star staffing compared to 3-star, residents had 37% higher odds of moderate symptoms (95% CI: 1.14-1.64) and 57% higher odds of moderately severe to severe depressive symptoms (95% CI: 1.17-2.12). The odds of any above-minimal depressive symptoms decreased as quality measure ratings increased. Conclusions/ImplicationsLower NH quality ratings were associated with more severe depressive symptoms. Further investigation is warranted to identify potential mechanisms for a targeted intervention to improve quality and provide more equitable care.

Nursing Home Characteristics Associated With Implementation of an Advance Care Planning Video Intervention

ObjectivesAdvance care planning (ACP) is important to ensure that nursing home (NH) residents receive care concordant with their goals. Video interventions have been developed to improve the process of ACP. Yet, little is known about which NH characteristics are associated with implementation of ACP video interventions in clinical practice. Our objective was to examine NH-level characteristics associated with the implementation of an ACP video intervention as part of the Pragmatic trial of Video Education in Nursing Homes (PROVEN) trial. DesignCross-sectional study of NHs in PROVEN. Setting and participants119 NHs randomized to receive the ACP video intervention. MeasurementsThe outcomes were the proportion of short- (<100 days) and long-stay (≥100 days) NH residents who were (1) offered to watch a video and (2) shown a video, aggregated to the NH-level, and measured using electronic forms of video offers. The association between outcomes and NH facility characteristics (eg, staffing, resident acuity) and participation in other aspects of the PROVEN trial (eg, monthly check-in calls) were estimated using multivariate linear regression models. NH characteristics were measured using data from Online Survey Certification and Reporting data, Long-term Care: Facts on Care in the US and NH Compare. ResultsOffer rates were 69% [standard deviation (SD): 28] for short-stay and 56% (SD: 20) for long-stay residents. Show rates were 19% (SD: 21) for short-stay and 17% (SD: 17) for long-stay residents. After adjusting for NH characteristics, compared to 1-star NHs, higher star-rated NHs had higher offer rates. Champions' participation in check-in calls was positively associated with both outcomes for long-stay residents. Conclusions/implicationsLower-quality NHs seem unable to integrate a novel ACP video education program into routine care processes. Ongoing support for and engagement with NH staff to champion the intervention throughout implementation is important for the success of a pragmatic trial within NHs.

Cost Benefit of High-Dose vs Standard-Dose Influenza Vaccine in a Long-Term Care Population During an A/H1N1-Predominant Influenza Season

ObjectivesInfluenza is a leading cause of avoidable admissions for nursing home (NH) residents. We previously evaluated the effectiveness of a high-dose trivalent influenza vaccine (HD) compared to a standard-dose influenza vaccine (SD) through a cluster-randomized trial of NH residents. Fewer residents from facilities randomized to HD were hospitalized. In this article, we extend our analyses to consider direct medical care costs relative to vaccine costs for HD ($31.82/dose) as compared to SD ($12.04/dose). DesignPost hoc, cost-benefit analysis. Setting and participantsFrom the participating NH facilities (n = 817), we identified Medicare fee-for-service enrollees who were long-stay residents (>100 days) at the start of the 2013-2014 influenza season (November 1–May 31). The intervention was residence in a facility randomized to HD or SD influenza vaccine. MethodsWe summed expenditures from long-stay NH residents' Medicare Part A, B, and D fee-for-service claims and compared person-level expenditures between residents of facilities offering HD vs SD. Expenditures were adjusted for clustering of residents within NHs, person-time, and prespecified covariates using 2-part, generalized linear models with bootstrapped standard errors. We examined the incremental cost-benefit of HD vs SD vaccines from a payer perspective. ResultsThere were 18,605 and 18,658 Medicare fee-for-service long-stay residents in facilities offering HD and SD, respectively. Person- and facility-adjusted total expenditures differed by $546 (P = .006). The $20 incremental cost of HD to SD offset adjusted expenditures for a net benefit of $526 per NH resident and a financial return on investment of 546/20 = 27:1. Conclusions/implicationsThe use of HD influenza vaccine in long-stay NH residents reduced total health care expenditures for a net benefit despite HD being more expensive per dose. These cost offsets applied to Medicare beneficiaries residing in NHs could result in important savings to the Medicare program.

Nursing homes underreport antipsychotic prescribing

Objective: Determine the accuracy of nursing home self-reported antipsychotic prescribing before and after implementation of a Medicare campaign to reduce use.Methods: Quasi-experimental study comparing trends in self-reported antipsychotic prescribing relative to claims-based prescribing. Setting is a nationwide sample of 11,912 facilities, 2011–2013. Participants are long-stay nursing home residents (n = 586,281) with prescribing data in Medicare Minimum Data Set 3.0 and Medicare Part D claims database. Verified with a pharmacy dispensing database. Main outcomes are the discrepancies in quarterly prevalence of antipsychotic prescribing between nursing home self-reports and claims data and the characteristics of facilities and residents where discrepancies were identified.Results: Nursing homes underreport their antipsychotic prescribing levels, on average, by 1 percentage point per quarter relative to Medicare Part D claims (0.013, 95% confidence interval (CI), 0.012–0.015; p<.001). After the Medicare campaign, the underreporting gap increased by another half a percentage point (0.004, 95% CI .003–.005; p = .012). Nursing home residents with dementia, Alzheimer’s disease or bipolar disorders were at the highest risk for underreported antipsychotic prescribing before the campaign (Adjusted Odds ratio (AOR) 1.385, 95% CI: 1.330–1.444; AOR 1.234, 95% CI: 1.172–1.300; AOR 1.574, 95% CI: 1.444–1.716, respectively) and afterwards. After the launch of the Medicare campaign, underreported antipsychotic prescribing occurred most in for-profit nursing homes (AOR 1.088, 95% CI: 1.005–1.178) and facilities in the US South (AOR 1.262, 95% CI: 1.145–1.391). Agreement was high between claims and dispensing data (99.7%).Conclusion: Nursing homes did not identify up to 6,000 residents per calendar quarter as having received antipsychotics despite these prescriptions being paid by Medicare and dispensed by a pharmacy. Nursing home rates of antipsychotic prescribing from self-reported data may be biased.

The Increasing Prevalence of Obesity in Residents of U.S. Nursing Homes: 2005-2015.

Obesity prevalence has been increasing over decades among the U.S. population. This study analyzed trends in obesity prevalence among long-stay nursing home residents from 2005 to 2015. Data came from the Minimum Data Sets (2005-2015). The study population was limited to long-stay residents (ie, those residing in a nursing home ≥100 days in a year). Residents were stratified into body mass index (BMI)-based groups: underweight (BMI < 18.5), normal weight (18.5 ≤ BMI < 25), overweight (25 ≤ BMI < 30), and obese (BMI ≥ 30); residents with obesity were further categorized as having Class I (30 ≤ BMI < 35), Class II (35 ≤ BMI < 40), or Class III (BMI ≥ 40) obesity. Minimum Data Sets assessments for 2015 were used to compare clinical and functional characteristics across these groups. Obesity prevalence increased from 22.4% in 2005 to 28.0% in 2015. The prevalence of Class III obesity increased from 4.0% to 6.2%. The prevalence of underweight, normal weight, and overweight decreased from 8.5% to 7.2%, from 40.3% to 37.1%, and from 28.9% to 27.8%, respectively. In 2015, compared with residents with normal weight, residents with obesity were younger, were less likely to be cognitively impaired, had high levels of mobility impairment, and were more likely to have important medical morbidities. There was a steady upward trend in obesity prevalence among nursing home residents for 2005-2015. Medical and functional characteristics of these residents may affect the type and level of care required, putting financial and staffing pressure on nursing homes.

Effect of Bisphosphonates on Fracture Outcomes Among Frail Older Adults.

Bisphosphonates are seldom used in frail, older adults, in part due to lack of direct evidence of efficacy in this population and increasing concerns about safety. We estimated the effects of bisphosphonates on hip fractures, nonvertebral fractures, and severe esophagitis among frail, older adults. Population-based retrospective cohort using 2008 to 2013 linked national Minimum Data Set assessments; Online Survey Certification and Reporting System records; and Medicare claims. US nursing homes (NHs). Long-stay NH residents 65 years and older without recent osteoporosis medication use (N = 24,571). Bisphosphonate initiators were 1:1 propensity score matched to calcitonin initiators (active comparator). Hospitalized hip fracture, nonvertebral fracture, and esophagitis outcomes were measured using part A claims. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated, controlling for over 100 baseline characteristics. The matched cohort included 5209 new bisphosphonate users and an equal number of calcitonin users (mean age [SD] = 85 [8] years; 87% female; 52% moderate-severe cognitive impairment). Over a mean follow-up of 2.5 (SD = 1.7) years, 568 residents (5.5%) had a hip fracture, 874 (8.4%) had a nonvertebral fracture, and 199 (1.9%) had a hospitalized esophagitis event. Users of bisphosphonates were less likely than calcitonin users to experience hip fracture (HR = 0.83; 95% CI = 0.71-0.98), with an average gain in time without fracture of 28.4 days (95% CI = 6.0-50.8 days). Bisphosphonate and calcitonin users had similar rates of nonvertebral fracture (HR = 0.91; 95% CI = 0.80-1.03) and esophagitis events (HR = 1.11; 95% CI = 0.84-1.47). The effects of bisphosphonates on fractures and esophagitis were generally homogeneous across subgroups, including those defined by age, sex, history of prior fracture, and baseline fracture risk. Use of bisphosphonates is associated with a meaningful reduction in hip fracture among frail, older adults, but little difference in nonvertebral fracture or severe esophagitis. J Am Geriatr Soc 67:768-776, 2019.

2170. The National Burden of Pneumonia and Influenza in U.S. Nursing Homes, 2013–2015

BackgroundNational data on pneumonia and influenza (P&I) morbidity is lacking for the U.S. nursing home (NH) population. Our primary objective was to determine the incidence of hospitalization due to P&I.MethodsThis retrospective cohort used nursing home Minimum Data Set clinical assessments and Medicare claims for U.S. nursing home residents. Any resident who stayed in a nursing home from January 1, 2013 through December 31, 2015 was included and classified as short-stay or long-stay (≥100 days in the home). Residents <65 years old or enrolled in an HMO plan were excluded. Hospitalizations due to P&I were identified in the first position on Part A claims (ICD9 diagnoses 480.xx–488.xx). Outcomes were reported for 2013–2014, to allow 1-year forward evaluation.ResultsThe study cohort comprised 4.2 million NH residents with 2.9 (69%) million short stays. Mean age (SD) was 80.5 (8.4) for short-stays vs. 83.0 (8.5) years for long-stays. Long-stay residents were more likely to be female (66.3% vs. 60.4%), African-American (10.9% vs. 6.6%) and Hispanic (4.1% vs. 2.8%). For long-stay residents, 23.7% had documented coronary artery disease, 23.2% congestive heart failure, 33.2% diabetes and 47.9% dementia. Incidence proportions are reported in Table 1. Short-stay and long-stay residents have a similar risk of hospitalization due to P&I at 1 year (4.1% vs. 4.5%).Table 1.Incidence of P&I Hospitalizations in Nursing Homes, 2013–2014Short-Stay Residents (n = 1,790,388)Long-Stay Residents (n = 873,254)30-day19,122 (1.1%)4,656 (0.5%)180-day50,433 (2.8%)22,156 (2.5%)365-day72,948 (4.1%)39,355 (4.5%)ConclusionThe national incidence of one-year P&I hospitalization was 4.1 and 4.5% among short-stay and long-stay NH residents. Vaccination, prompt diagnosis and treatment, hand-washing and environmental cleaning are all important interventions which can further reduce the morbidity of this disease.Disclosures K. Mcconeghy, Sanofi-Pasteur: Collaborator, Research support. A. Zullo, Sanofi-Pasteur: Collaborator, Research grant. R. Van Aalst, Sanofi-Pasteur: Employee, Salary. A. Chit, Sanofi-Pasteur: Employee, Salary. S. Gravenstein, Sanofi-Pasteur: Grant Investigator, Grant recipient, Research grant and Research support; Sequiris: Grant Investigator, Grant recipient, Research grant and Research support. V. Mor, Sanofi-Pasteur: Grant Investigator, Grant recipient, Research grant and Research support. Sequiris: Grant Investigator and Investigator, Grant recipient, Research grant and Research support.