Nursing Facility Research Articles

Is Frailty Discouraging Surgeons from Performing Thoracolumbar Fusion? A Retrospective Study.

Retrospective cohort study. To evaluate whether frailty scoring is associated with adverse outcomes and management of thoracolumbar fractures (TLF) patients. Trauma patients with TLF often face longer recovery. The Canadian Study of Health and Aging clinical frailty scale (CSHA-CFS) predicts outcomes in older trauma patients. Adult trauma patients admitted from 2017 to 2021 who presented with TLF were included. Frailty was scored using CSHA-CFS. Endpoints were in-hospital mortality, hospital length of stay, surgery, complications, and discharge disposition. Multivariate analyses adjusting for baseline characteristics were performed. P<0.05 was considered significant. Overall, 1456 patients were included; 1013 fit, 240 pre-frail, and 203 frail. Frail patients underwent fewer surgeries (OR=0.5 [0.32-0.77], P=0.002). TL fusion was associated with lower mortality (OR=0.31 [0.11-0.85], P=0.024). Pre-frailty and frailty were associated with increased risk of pneumonia (OR=2.522 [1.428-4.456], P=0.001; OR=2.93 [1.32-6.54], P=0.008, respectively) and death (OR=3.581 [1.853-6.921], P<0.001; OR=2.46 [1.07-5.67], P=0.035). Pre-frail and frail patients were more likely to discharge to skilled nursing facilities (OR=1.687 [1.024-2.780], P=0.04; OR=4.89 [2.66-9.0]), P<0.001). Pre-frailty and frailty were associated with poor outcomes and higher level of care at discharge. Frail patients were less likely to undergo TL fusion, despite its association with improved survival. This suggests frailty should not discourage surgeons from performing thoracolumbar fusion. Frailty scoring upon admission may help guide management and set realistic expectations for patients and their families.

Analgesic regimens administered to older adults receiving skilled nursing facility care following hip fracture: a proof-of-concept federated analysis

BackgroundAlthough a majority of patients in the U.S. receive post-acute care in skilled nursing facilities (SNFs) following hip fracture, large-sample observational studies of analgesic prescribing and use in SNFs have not been possible due to limitations in available data sources. We conducted a proof-of-concept federated analysis of electronic health records (EHRs) from 11 SNF chains to describe analgesic use during hip fracture post-acute care.MethodsWe included residents with a diagnosis of hip fracture between January 1, 2018 and June 30, 2021 who had at least one administration of an analgesic. Use of analgesics was ascertained from EHR medication orders and medication administration records. We quantified the proportion of residents receiving analgesic regimens based on the medications that were administered up to 100 days after hip fracture diagnosis. Plots visualizing trends in analgesic use were stratified by multiple resident characteristics including age and Alzheimer’s Disease and Related Dementias (ADRD) diagnosis.ResultsThe study included 23,706 residents (mean age 80.5 years, 68.6% female, 87.7% White). Most (~ 60%) residents received opioids + APAP. Monotherapy with APAP or opioids was also common. The most prevalent regimens were oxycodone + APAP (20.1%), hydrocodone + APAP (15.8%), APAP only (15.1%), tramadol + APAP (10.4%), and oxycodone only (4.3%). During the study period, use of APAP-only increased, opioids-only decreased, and opioids + APAP remained stable. Use of APAP-only appeared to be more prevalent among individuals aged > 75 years (versus ≤ 75 years) and those with ADRD (versus without).ConclusionsWe successfully leveraged federated SNF EHR data to describe analgesic use among residents receiving hip fracture post-acute care.

Impact of skilled nursing facility quality on Medicare beneficiaries with dementia: Evidence from vacancies.

People living with dementia are less likely to be admitted to high-rated nursing homes than people without dementia, despite their increased care needs. We investigated the effect of admission to nursing homes with higher staffing ratings on adverse outcomes for individuals with and without dementia post-hospitalization. Among Traditional Medicare beneficiaries discharged to nursing homes between 2011 and 2017, we examined the relationship between facility staffing star-ratings and short-term readmission and mortality using an instrumental variables approach to account for selection bias. The instrumental variables were the number of nearby vacant beds in high-rated facilities. Admission to a higher-rated nursing home lowered post-discharge mortality risk at 90 days and reduced 30- and 90-day readmission. Point estimates were larger for people with dementia. Findings underscore the need for enhancing direct care staffing in nursing homes and addressing access disparities, particularly for individuals with dementia who benefit significantly from high-quality care. We assessed how admission to nursing homes with higher staffing ratings impacted outcomes for individuals with and without dementia by exploiting variation in local bed vacancies as a source of quasi-random assignment. For both persons with and without dementia, adjusted short-term mortality and readmission rates were lower among those discharged to nursing homes with higher staffing ratings. Effects were larger for persons with dementia, indicating welfare loss from inequitable access to higher-rated nursing homes. Increasing staffing in nursing homes and reducing disparities for persons with dementia is essential for enhancing both equity and value.

Cross-country price comparison of institutional long-term care: In search of suitable data

Abstract Background In European ageing societies, the national expenditure on institutional long-term care (LTC) has been growing for decades, currently exceeding 1% of the GDP in many countries. At the same time, however, comparative analyses of (day) prices in the nursing and residential care facilities (NRCFs) are still lacking. The data reported by international databases vary substantially in the services they cover which makes cross-country comparisons very difficult. Methods We combine publicly available data from Eurostat (System of Health Accounts), OECD and national sources on the number of recipients of LTC in NRCFs, the number of beds in NRCFs and the expenditure on LTC in NRCFs in over 20 European countries. Our aim is to compute internationally comparable daily prices of LTC in NRCFs using gross-costing approach. We first validate the data by cross-checking and documenting which health care functions and providers are reported by each country. Second, based on that we identify countries with comparable data and, third, perform a cross-country comparison of the daily spending on LTC in NRCFs. Results The reported data vary substantially with respect to their coverage. For instance, while some countries include NRCFs for all disabled people at all ages, others focus only on the NRCFs for the elderly. The ways the beds and the recipients are counted also show substantial variation. Moreover, we found inconsistencies in the reported numbers not only between but also within countries. Conclusions The considerable cross-country diversity in the LTC provision within the NRCFs poses inevitable challenges to international standardised reporting. Our analysis shows, however, that at least some of the challenges can be overcome by, e.g. improving the consistency of the reported numbers at the country level. Key messages • A consistent definition application markedly improves the comparability of data on LTC in NRCFs. • Given the rising demand for and economic importance of the LTC sector standardised data on NRCF services are greatly needed.

Value-based versus usual care for heart failure patients leads to reduction in cost, hospital admissions and improved survival

Abstract Background OptumCare (OC) in our city, Nevada established a heart failure (HF) program comprised of a team of outpatient cardiologists including two who are board certified in advanced heart failure. Referred patients are enrolled in the HF program once HF is diagnosed by a cardiologist. Patients are managed by an interdisciplinary team of cardiologists, advanced practice clinicians (APC), registered nurse case managers (RNCM), and a social worker. Patients at higher risk for HF admissions are enrolled in remote patient telemonitoring. In contrast, OC in Arizona utilizes a "usual" care approach of fee-for-service contracted cardiology groups to manage HF patients in outpatient and in-patient settings. Purpose A head-to-head comparison was performed between the cohort of patients enrolled in HF program in OC Nevada (treatment group) and patients with HF diagnosis in OC Arizona (control group). The groups were compared on the following measures: medical cost, hospital admissions, and survival rates. Methods In this retrospective study, a 1:1 iterative propensity score (PS) matching was performed to closely approximate patient demographics and comorbidities, which resulted in 818 matched pairs (total n=1,636) of the patients with program enrollment or 1st HF diagnosis between March 1, 2019 and June 30, 2022. For Difference-in-Difference Analysis (Diff-in-Diff), generalized linear models were used on PS matched data to test the difference in difference in medical cost and utilizations changes between control and treatment group over a six month period. Log-Binomial regression was used to estimate the relative risk of post period 30-day readmission and hospice enrollment. Kaplan Meier Estimator was used to test the difference in survival rates over time. Results Average age of patients was 77.6 years old, and 49% were female. The treatment group resulted in significantly lower overall medical costs per member per month (PMPM), significantly less emergency room (ER) visits, less acute hospital and skilled nursing facility (SNF) admissions, and shorter overall hospital length of stays. The control group was twice as likely to be readmitted to the hospital. Lastly, the treatment group had a significantly better survival rate than the control group. 19% of the patients in the control group expired within 12 months of enrollment vs. 10% of the patients in the treatment group expired during the same time period. Average survival was 142 days in the control group vs. 200 days in the treatment group. Conclusions A value-based care approach involving a multidisciplinary team in an outpatient-based cardiology HF program resulted in statistically significant improvement in medical costs, acute care visits/admissions, and survival rates compared to "usual" care approach for HF patients.

Association of Intellectual and Developmental Disabilities With Worse Outcomes After Surgical Treatment of Cancer.

Patients with intellectual and developmental disabilities (IDD) face unique challenges resulting in disparities in their health care. We sought to define the effect that IDD had on achievement of a "textbook outcome" (TO) following a cancer operation among a nationally representative cohort of patients. Data on patients who underwent surgery for a malignant indication, including lung, breast, liver, biliary tract, pancreas, and colorectal, between 2014 and 2020 were extracted from the 100% Medicare Standard Analytical Files database. The association of IDD with TO (defined as the absence of postoperative complications, extended length of stay, 90-day readmission, and 90-day mortality), expenditures, and discharge status was assessed using multivariable logistic regression. Among 500,472 Medicare beneficiaries, 4,326 (0.9%) with IDD had a cancer diagnosis (breast, n=481; lung, n=419; hepatobiliary, n=194; pancreas, n=145; colorectal, n=3,087). Although overall incidence of TO was 50.5%, patients with IDD were less likely to achieve a TO than those without (37.1% vs 50.6%, respectively; odds ratio [OR], 0.50; 95% CI, 0.46-0.53; P<.001). On multivariable regression, patients with IDD had higher odds of a postoperative complication (OR, 1.53; 95% CI, 1.43-1.64), extended length of stay (OR, 2.06; 95% CI, 1.93-2.21), 90-day readmission (OR, 1.15; 95% CI, 1.07-1.24), 90-day mortality (OR, 1.90; 95% CI, 1.70-2.13), and discharge to a skilled nursing facility (OR, 4.28; 95% CI, 3.97-4.62) (all P<.001). Patients with IDD had a much lower chance of a postoperative TO, as well as discharge to a nonhome setting. The data highlight the need to improve the care of patients with IDD to assure equitable oncologic surgical care.

Twenty Years of Sustained Improvement in Quality of Care and Outcomes for Patients Hospitalized With Stroke or Transient Ischemic Attack: Data From The Get With The Guidelines-Stroke Program.

The Get With The Guidelines-Stroke program is a quality improvement initiative designed to enhance adherence to evidence-based stroke care. Since its inception in 2003, over 2800 hospitals in the United States have participated in the program. We examined patient characteristics, adherence to performance measures, and in-hospital outcomes in patients hospitalized for acute ischemic stroke, subarachnoid hemorrhage, intracerebral hemorrhage, and transient ischemic attack in The Get With The Guidelines-Stroke hospitals from 2003 through 2022. We quantified temporal changes in performance measure adherence and clinical outcomes over time. Performance measure denominators consisted of patients who were eligible, excluding those with contraindications. Over the 20 years of the program, a total of 7837 849 stroke cases (median age 71 years, 51.0% female; 69.2% ischemic strokes, 3.9% SAHs, 11.5% ICHs, and 15.3% TIAs) were entered into the registry. Except for antithrombotics at discharge, in which the baseline performance was >92%, there was sustained improvement in all performance metrics regardless of type of cerebrovascular event (P<0.01 for all). In patients with acute ischemic stroke, large improvements were observed for anticoagulation for atrial fibrillation (55.7% in 2003 to 97.2% in 2022), smoking cessation counseling (44.7%-97.8%), dysphagia screening (53.8%-83.5%), thrombolytic treatment for patients arriving by 3.5 hours, treat by 4.5 hours (15.2%-92.9%), door-to-needle time within 60 minutes (19.0%-75.3%), and endovascular door-to-puncture time within 90 minutes (54.7%-62.8%). Similar improvements were also observed for measures relevant to patients with subarachnoid hemorrhage, intracerebral hemorrhage, and transient ischemic attack. Multivariable analysis showed that there was a sustained increase in odds of receiving each performance measure over time, independent of patient and hospital characteristics for each type of cerebrovascular event. After risk adjustment, there were temporal trends that patients were less likely to be discharged to a skilled nursing facility, and, for ischemic stroke only, more likely to be discharged directly home. During the first 20 years, Get With The Guidelines-Stroke participation was associated with sustained improvement in evidence-based care and outcomes for patients with stroke and transient ischemic attack in the United States.

​​Making Homes in a Nursing Facility in Athens​

This Photo Essay seeks to visualise the room-homes of the residents in one of the largest semi-public nursing homes in Athens, Greece. Unlike in other facilities, residents are given the opportunity to intervene in their individual rooms, to change and fill the space with objects from their past lives and the houses they lived in, such as furniture, curtains, carpets, computers, crockery, or flowerpots. They also bring and live through photographs of their previous lives. I focus on the room-homes people create in this nursing home, the worlds they build. I conceive this visual ethnography as an account of the process of ‘house-ing’ (Biehl and Neiburg 2021, 540), ‘charting how forms and figures of dwelling constitute the house as a sensorial archiving machine of sorts, shaping affective pasts and the stories and trajectories of tomorrow’ (2021, 544).

Benzodiazepine Utilization in Ischemic Stroke Survivors: Analyzing Initial Excess Supply and Longitudinal Trends.

Benzodiazepines are commonly prescribed for post-acute ischemic stroke for anxiety, insomnia, and agitation. While guidelines discourage use in those aged ≥65 years, little is known about prescription patterns at the national level. We analyzed a 20% sample of US Medicare claims from April 1, 2013, to September 30, 2021. We selected beneficiaries aged ≥65 years discharged alive following an acute ischemic stroke who had traditional Medicare coverage and 6 months' prior enrollment in Parts A (hospital insurance), B (Medical insurance), and D (drug coverage). We excluded those with prior benzodiazepine prescriptions, self-discharges, or discharge to skilled nursing facilities. We examined demographics, comorbidities, first prescription days' supply, cumulative incidences of benzodiazepine first prescription fills within 90 days after discharge, and geographic and yearly trends. We included 126 050 beneficiaries with a mean age of 78 years (SD, 8); 54% were female and 82% were White. Within 90 days, 6127 (4.9%) initiated a benzodiazepine. Among new prescriptions, lorazepam (40%) and alprazolam (33%) were the most prescribed. Most (76%) of first fills had a day's supply over 7 days and 55% between 15 and 30 days. Female initiation rates were higher (5.5% [95% CI, 5.3-5.7]) than male initiation rates (3.8% [95% CI, 3.6%-3.9%]). Rates were highest in the southeast (5.1% [95% CI, 4.8%-5.3%]) and lowest in the midwest (4.0% [95% CI, 3.8%-4.3%]), with a modest nationwide initiation decline from 2013 to 2021 (cumulative incidence difference, 1.6%). Despite a gradual decline in benzodiazepine initiation from 2013 to 2021, we noted excessive supplies in prescriptions post-acute ischemic stroke discharge, underscoring the need for improved policies.

The Importance of an Interdisciplinary Approach in the Transition of At-Risk Patients From Hospital to Skilled Nursing Facilities: A Case Report

The Importance of an Interdisciplinary Approach in the Transition of At-Risk Patients From Hospital to Skilled Nursing Facilities: A Case Report

Surviving septic patients endotyped with a functional assay demonstrate active immune responses.

Sepsis is a complex clinical syndrome characterized by a heterogenous host immune response. Historically, static protein and transcriptomic metrics have been employed to describe the underlying biology. Here, we tested the hypothesis that ex vivo functional TNF expression as well as an immunologic endotype based on both IFNγ and TNF expression could be used to model clinical outcomes in sepsis patients. This prospective, observational study of patient samples collected from the SPIES consortium included patients at five health systems enrolled over 17 months, with 46 healthy control patients, 68 ICU patients without sepsis, and 107 ICU patients with sepsis. Whole blood was collected on day 1, 4, and 7 of ICU admission. Outcomes included in-hospital and 180-day mortality and non-favorable discharge disposition defined by skilled nursing facility, long-term acute care facility, or hospice. Whole blood ELISpot assays were conducted to quantify TNF expression [stimulated by lipopolysaccharide (LPS)] and IFNγ expression (stimulated by anti-CD3/CD28 mAb), which were then used for assignment to one of four subgroups including an 'immunocompetent', 'immunosuppressed endotype', and two 'mixed' endotypes. Whole blood TNF spot-forming units were significantly increased in septic and CINS patients on days 4 and 7 compared to healthy subjects. In contrast, TNF expression per cell on days 1, 4, and 7 was significantly lower in both septic and critically ill non-septic (CINS) patients compared to healthy subjects. Early increases in total TNF expression were associated with favorable discharge disposition and lower in-hospital mortality. 'Immunocompetent' endotype patients on day 1 had a higher proportion of favorable to non-favorable discharges compared to the 'immunosuppressed' endotype. Similarly, 'immunocompetent' endotype patients on day 4 had a higher in-hospital survival compared to the 'immunosuppressed' endotype patients. Finally, among septic patients, decreased total TNF and IFNγ expression were associated with 180-day mortality. Increased ex vivo whole blood TNF expression is associated with improved clinical outcomes. Further, the early 'immunocompetent' endotype is associated with favorable discharge and improved in-hospital and 180-day survival. The ability to functionally stratify septic patients based on blood cell function ex vivo may allow for identification of future immune modulating therapies.

A Climate of Stigma, Uncertainty, and Distrust: Stakeholder Perception of Barriers to SNF Placement for Patients with Opioid Use Disorder Treated with Methadone.

Patients with opioid use disorder (OUD), especially those treated with methadone, face significant challenges to placement in a skilled nursing facility (SNF). Efforts to address this via legal actions have not resulted in improved access. To understand regulatory and non-regulatory factors that impact SNF placement of patients with OUD treated with methadone. Observational qualitative study. Stakeholders in the hospital-to-SNF referral process as well as those with specific expertise related to OUD. Open-ended, semi-structured interviews. Interviews with 15 participants identified three key themes that function together in addition to logistic and financial barriers: (1) stigma and perception of risk, (2) uncertain regulatory environment, and (3) distrust between responsible entities. Fundamentally, many SNFs do not feel they can provide necessary care related to OUD and methadone. They tend to be disinclined to care for patients with OUD and express concerns about perceived risks such as overdose, violence, or discomfort to other residents. SNFs are also very motivated to avoid regulatory citations and fines related to OUD or methadone. Since confusion and misinformation about relevant policies and procedures is common, many opt to decline these patients. Compounding these challenges, entities responsible for coordinating care demonstrate poor communication and lack of transparency with each other. Referral and declination information sent between hospitals and SNFs is often considered to be incomplete or incorrect, and many hospitals have stopped referring patients with OUDtreated with methadone to SNFs altogether. Regulatory bodies are often feared by healthcare providers and administrators and interaction is avoided. Finally, legal oversight representatives report that they do not receive sufficient information to properly investigate concerns. This study identifies the climate of stigma, uncertainty, and distrust between responsible entities that stymies improvement efforts. Creation of meaningful reform must address each of these areas.

Analysis of an expanded admission screening protocol for Candida auris at a New York City hospital.

Candida auris (Cauris) is an emerging global infectious disease threat, and screening practices for identification of Cauris are inconsistent across healthcare facilities. This study describes the utility of expanding a Cauris admission screening protocol at an acute care hospital to screen all patients presenting from any skilled nursing facility. A retrospective review identified all patients screened on admission for Cauris from January 2022 through September 2023. Patients were identified for risk potential, and those deemed high risk were placed on transmission-based precautions while awaiting culture results. Of the 591 patients screened, 14 cases were identified (2.4%). Nine cases presented with tracheostomies or were ventilator-dependent and classified as high risk. Five cases were considered low risk at the time of screening. Eight of these newly identified cases would not be screened under the prior criteria. This study's findings support prior studies that patients with tracheostomies or were ventilator-dependent have greater risk for Cauris colonization. Adopting an expanded admission screening program has allowed the hospital to detect more cases earlier to prevent nosocomial transmissions. Healthcare facilities should consider initiating or expanding admission screening programs for Cauris based on community prevalence rates of Cauris.

Access and care for people with opioid use disorder in U.S. skilled nursing facilities: A policy commentary

Referrals for people with opioid use disorder (OUD) to skilled nursing facilities (SNFs) are increasing in the United States (U.S.). Further, legal guidance from the U.S. Department of Justice states that people with OUD cannot be discriminated against by health care institutions because of OUD or treatment with medications for OUD (MOUD). As such, SNFs are an important touchpoint for initiating or continuing MOUD, particularly amid rising drug-related overdose deaths among older adults and because people with OUD experience frailty and other geriatric syndromes at younger chronological ages. Informed by research, clinical expertise, and lived experience, this commentary describes policy and practice opportunities to help address challenges faced by people with OUD in gaining access to care and MOUD in SNFs. We propose opportunities to intervene against barriers that impede SNF placement and access to MOUD for people with OUD, including further revisions to 42 CFR Part 8 regulations to extend waivers for certification as opioid treatment programs (OTPs) to SNFs, allowing them to administer and dispense methadone in the same way as hospitals. If passed, proposed federal changes under the Modernizing Opioid Treatment Act would eliminate the requirement for methadone to be dispensed through OTPs, offering another opportunity to improve access to methadone for SNF residents. Also, we propose national and state-level investment in mobile substance use disorder services and partnerships with OTPs and hospital-based addiction consult services. We also recognize the need for more compassionate attitudes toward people with OUD in healthcare settings and discuss opportunities to address stigma. Although people with OUD are referred to SNFs for skilled care needs and not specifically for OUD care, it is essential for SNFs to be prepared to continue MOUD. It is both legally mandated and imperative that people with OUD have access to high quality and equitable SNF care.

Acute mesenteric ischemia secondary to complete AV block and acute systolic heart failure: a case report

BackgroundAcute mesenteric ischemia (AMI) usually presents with abrupt and severe abdominal pain associated with nausea and vomiting. This case is notable due to the occurrence of AMI secondary to acute systolic heart failure caused by new onset complete heart block.Case PresentationA 65-year-old male presented with sudden onset epigastric pain. ECG showed complete AV block and acute ischemia, and a subsequent CTA revealed complete occlusion of the mid superior mesenteric artery. His emergent left heart catheterization showed non-occlusive coronary artery disease. The patient underwent emergent laparotomy and SMA thrombectomy. Postoperative complications included worsening congestive heart failure and persistent bradycardia, requiring a permanent pacemaker. The patient was discharged to a skilled nursing facility in stable condition.ConclusionsThis case highlights the diagnostic challenges of AMI in the setting of acute heart failure and new onset AV block mimicking acute cardiac events and emphasizes the importance of a multidisciplinary approach in managing such complex cases.

The modified 5-factor frailty index predicts postoperative outcomes in patients with ovarian cancer undergoing hyperthermic intraperitoneal chemotherapy

ObjectiveThe objective of this research is to compare the ability of mFI5 to the mFI11 to predict frailty, postoperative complications, discharge location for patients with ovarian cancer undergoing hyperthermic intraperitoneal chemotherapy (HIPEC) at time of cytoreductive surgery. MethodsThis is a single-institution retrospective study in patients with advanced (Stage III, IV) or recurrent ovarian cancer treated with surgical cytoreduction with HIPEC. Logistic regression was used to evaluate frailty as well as factors associated with moderate to severe Accordion postoperative complications and discharge to home. Correlation was calculated between mFI5 and mFI11. ResultsOf 141 patients who received HIPEC between 2010 and 2020, 23 patients were classified as frail (mFI5 score ≥2), while 118 were not frail. Frail patients were significantly older with mean age 65.9 compared to non-frail patients who had mean age of 59.1 (p = 0.005), as well as a higher Charlston Comorbidity Index (p < 0.001), and more renal disease (p = 0.025), hypothyroidism (p = 0.005), and hyperlipidemia (p = 0.004). mFI5 and mFI11 scores for frailty were highly correlated (spearman rho 0.98, p < 0.001). Frail patients were more likely to be discharged to a skilled nursing facility (22.7 %) vs. 6.8 % of non-frail patients, or require home services (18.2 % vs 8.5 %, p = 0.025). On multivariable logistic regression, frail patients were more likely to experience moderate or higher Accordion postoperative complications (OR 3.08, p = 0.024). ConclusionsThe mFI5, a simpler tool than the mFI11, is also highly associated with postoperative complications and need for postoperative services in patients with ovarian cancer undergoing HIPEC at time of cytoreductive surgery.

An Automated Electronic Health Record Score to Estimate Length of Stay and Readmission in Patients Undergoing Radical Cystectomy for Bladder Cancer.

Patients treated with radical cystectomy experience a high rate of postoperative complications and frequent hospital readmissions. We sought to explore the utility of the Care Assessment Need (CAN) score, derived from electronic health data, to estimate the risk of these adverse clinical outcomes, thereby aiding patient counseling and informed treatment decision-making. We retrospectively examined data from 982 patients with bladder cancer who underwent radical cystectomy between 2013 and 2018 within the national Veterans Health Administration system. We tested for associations between the preoperative CAN score and length of stay, discharge location, and readmission rates. We observed a correlation between higher CAN scores and longer hospital stays (adjusted relative risk = 1.03 [95% CI: 1.02-1.05]). An increased CAN score was also linked to greater odds of discharge to a skilled nursing facility or death (adjusted odds ratio = 1.16 [95% CI: 1.06-1.26]). Furthermore, the score was associated with hospital readmission at both 30 and 90 days postdischarge (adjusted HR = 1.03 [95% CI: 1.00-1.07] and 1.04 [95% CI: 1.00-1.07], respectively). The CAN score is associated with length of hospital stay, discharge to a skilled nursing facility, and readmission within 30 and 90 days after radical cystectomy. These findings highlight the potential of health care systems leveraging electronic health records for automatically calculating multidimensional tools, such as the CAN score, to identify patients at risk of adverse clinical outcomes after radical cystectomy.

Factores predictivos del ingreso hospitalario y sociosanitario en la fijación de fracturas de tobillo por trauma de baja energía

Ankle fractures are increasingly common in frail patients, with hospitalization being the principal cost driver, particularly for the elderly who often need referral to nursing facilities. This study aims to identify factors affecting resource utilization per admission (hospital and nursing) in the fixation of low-energy ankle fractures. This retrospective cohort study examined patients undergoing fixation for low-energy ankle fractures. The primary outcome was the length of hospitalization. Secondary outcomes included delays in fixation and the need for referral to a nursing institution. Multiple linear and logistic regression models were used to determine predictors related to patient demographics, injury characteristics, and treatment. We analyzed 651 patients with a median age of 58 years. The median hospitalization duration was 9 days, primarily before surgery. Extended hospitalization was associated with antithrombotic treatment (b=4.08), fracture-dislocation (2.26), skin compromise (7.56), complications (9.90), and discharge to a nursing center (5.56). Referral to a nursing facility occurred in 17.2%, associated with older age (OR=1.10) and an ASA score ≥III (6.96). Prolonged hospitalization was mainly due to surgical delays and was related to fracture-dislocations, skin compromise, and complications. Older and comorbid patients were more likely to need nursing facilities, and delays in these facilities' availability contributed to extended hospital stays.

Psychological and physiological benefits of horticultural therapy for Chinese older adults

Background Gardening as a leisure activity has been shown to be potentially beneficial for older adults, this study aimed to assess the physiological and psychological impacts of a specific horticultural activity, watering indoor plants, compared with playing a computer game - the Klondike Solitaire Card Game. Methods This crossover study included 100 older adults recruited from a nursing care facility for older people in Shanghai, China. They were allocated to either engage in watering indoor plants (horticultural group) or playing a computer game (control group). For the inclusion criteria, screening for cognitive function was conducted to exclude those with severe cognitive impairments, thereby focusing on those capable of participating fully in the study activities. Brainwave activities, blood pressure, and psychological states were measured through pre- and post-test questionnaires to evaluate the physiological and psychological effects. Results The activity of watering indoor plants was associated with significant reductions in both systolic and diastolic blood pressure, in contrast to the computer game activity. Additionally, participants in the horticultural group showed increased brainwave mean values, indicating heightened relaxation and focus, while decreases were observed in the control group. The experimental group reported reduced anxiety scores, along with increased feelings of comfort and relaxation, and also exhibited significantly higher meditation levels, which indicates a profound mental relaxation effect. Conclusion Our findings suggest that engaging in indoor horticultural activities, such as watering houseplants for 10 minutes, can reduce mental and physical stress levels in older adults.

Counting the days: Exploring healthcare contact days during episodes of cancer care.

233 Background: Cancer diagnosis and treatment brings about not only emotional upheavals but also logistical hurdles of navigating a fragmented healthcare system. Little is known about the frequency of healthcare contact for cancer patients and its implications. Healthcare contact days, defined as the number of days a patient spends in direct contact with healthcare professionals outside of home, measures the patient’s interaction with the healthcare system. Methods: Using historical claims data (Part A institutional and Part B ambulatory claims) from the Enhancing Oncology Model (EOM) for 12 practices in The US Oncology Network covering the period between January 2019 to June 2022, we derived healthcare contact days per episode (6-month care periods initiating with the administration of chemotherapy), counting each unique date once. When patients encountered multiple care settings on a single date, the following hierarchy was used: inpatient (IP) &gt; emergency room (ER) &gt; skilled nursing facility (SNF)&gt; hospice &gt; ambulatory care. We further counted contact days for different services conducted during the ambulatory visits. Results: For the 75,246 episodes, an average of 31.9 days per episode (1 in every 6 days) were spent in healthcare contact. Cancer patients’ healthcare contact was predominantly within ambulatory care, and visits with oncology providers exceeded that with all other specialties. ER and IP visits, generally a representation of acute care events, accounted for &lt;10% of the contact days. Conclusions: During cancer treatment, patients spend approximately one-sixth of their time in healthcare contact. The optimal frequency of contact, pattern of primary care support, care of comorbidities, and the interrelationship between acute care and clinician visits are apt for further exploration. Healthcare contact days can reflect different care delivery approaches between providers and may be a metric to assess both healthcare efficiency and accessibility. Understanding caregiver burden and social disparities associated with high contact days offers an opportunity to improve care coordination and streamline healthcare encounters while balancing patients’ care needs. CMMI Disclaimer: The statements contained in this document are solely those of the authors and do not necessarily reflect the views or policies of CMS. The authors assume responsibility for the accuracy and completeness of the information contained in this document. Healthcare contact days. Mean Percentiles 5 th -95 th Per Episode Healthcare Contact Days 31.9 10-65 Ambulatory Visits* 8-55 Chemotherapy 6.6 0-18 Imaging 2.7 0-7 Procedure 1.8 0-7 Radiation 2.4 0-23 Testing 11.8 3-25 Clinician Oncology 6 1-14 Other Specialties 3.4 0-10 Primary Care 2.8 0-8 Facility Visits ER 0.4 0-2 Hospice (Facility) 0.1 0-0 IP 2.7 0-16 SNF 0.8 0-0 *Ambulatory visits days are not mutually exclusive.