Nursing Home Status Research Articles

Racial and ethnic differences in lifetime Medicare expenditures for dementia patients

AbstractBackgroundResearch on racial and ethnic disparities in lifetime dementia costs is sparse. We analyzed lifetime Medicare expenditures for dementia patients to identify when during the course of care costs are the highest, and whether these costs differ by race and ethnicity.MethodWe analyzed data from the 2000‐2016 Health and Retirement Survey (HRS) linked with corresponding Medicare claims to estimate total Medicare expenditures for four “phases”: 1) the year before dementia diagnosis; 2) the first year following a dementia diagnosis; 3) ongoing care for dementia after the first year; and 4) the last year of life. We then estimated each patient’s phase‐specific and lifetime Medicare expenditures by using a race‐specific survival model and monthly expenditures adjusted for demographics, socio‐economic status, year of dementia diagnosis, nursing home status, functional limitations, cognitive impairment, comorbidities, and Medicaid eligibility status.ResultAdjusted mean lifetime Medicare expenditures for non‐Hispanic Blacks ($166,548) and Hispanics with dementia ($163,425) exceeded corresponding expenditures for non‐Hispanic whites ($135,648) (Figure). In the year preceding and immediately following an initial dementia diagnosis, mean Medicare expenditures for non‐Hispanic Blacks ($26,384 and $20,824) exceeded expenditures for Hispanics and non‐Hispanic whites (ranging $21,340‐23,379 and 17,382‐18,085). Ongoing care costs for non‐Hispanic Blacks with dementia (mean $1,734/month) exceeded costs for Hispanics ($1,538/month) and non‐Hispanic whites ($1,424/month). Of the four phases, the last year of life was responsible for the greatest cost contribution: $52,003 for non‐Hispanic Blacks, $48,377 for Hispanics, and $39,648 for non‐Hispanic whites.ConclusionsTotal mean Medicare expenditures for non‐Hispanic Black and Hispanic beneficiaries with dementia exceeded corresponding expenditures for non‐Hispanic whites. Expenditures were highest for non‐Hispanic Blacks with dementia in every phase of care. Compared to non‐Hispanic whites, Hispanics had lower expenditures in the first year following dementia diagnosis and similar monthly ongoing care expenditures but much higher expenditures during their last year of life. Research should identify factors contributing to the disparities identified here so that policy makers can address problems adversely affecting disadvantaged populations. Figure: Estimated mean lifetime Medicare expenditures for beneficiaries newly diagnosed with dementia, by phase of care and by race and ethnicity (adjusted)

Assessing out-of-pocket expenses and indirect costs for the Alzheimer disease continuum in the United States.

BACKGROUND: The societal costs of Alzheimer disease (AD) are considerable. Cost data stratified by cost category (direct and indirect) and AD severity in the United States are limited. OBJECTIVE: To describe out-of-pocket (OOP) expenses and indirect costs from unpaid caregiving and work impairment among patients with AD by severity and among patients with mild cognitive impairment (MCI) in a representative sample of the US population. METHODS: Data from the Health and Retirement Study (HRS) were used. HRS respondents were included if they reported an AD diagnosis or were considered as having MCI based on their cognitive performance. MCI and AD severity staging was performed using a crosswalk from results of the modified Telephone Interview of Cognitive Status to the Mini-Mental State Examination. OOP expenses were assessed along with indirect costs (costs to caregivers from providing unpaid help and costs to employers). Sensitivity analyses were performed by varying assumptions of caregiver employment, missed workdays, and early retirement. Patients with AD were stratified by nursing home status, type of insurance, and income level. All cost calculations applied sampling weights. RESULTS: A total of 18,786 patients were analyzed. Patients with MCI (n = 17,885) and AD (n = 901) were aged 67.8 ± 10.7 and 80.9 ± 9.3 years, were 55.7% and 63.3% female, and were 28.3% and 0.9% employed, respectively. OOP expenses per patient per month increased with AD severity, ranging from $420 in mild to $903 in severe AD but were higher in MCI ($554) than in mild AD. Indirect costs to employers were similar across the AD continuum ($197-$242). Costs from unpaid caregiving generally increased by disease severity, from $72 (MCI) to $1,298 (severe AD). Total OOP and indirect costs increased by disease severity, from $869 (MCI) to $2,398 (severe AD). Sensitivity analysis assuming nonworking caregivers and zero costs to employers decreased the total OOP and indirect costs by 32%-53%. OOP expenses were higher for patients with AD who had private insurance (P < 0.01), had higher incomes (P < 0.01), or were in nursing homes (P < 0.01). Indirect costs to caregivers were lower for patients with AD in nursing homes ($600 vs $1,372, P < 0.01). Total indirect costs were higher for patients with AD with lower incomes ($1,498 vs $1,136, P < 0.01) and for those not in nursing homes ($1,571 vs $799, P < 0.01). CONCLUSIONS: This study shows that OOP expenses and indirect costs increase with AD severity, OOP expenses increase with higher income, subscription of private insurance, and nursing home residency, and total indirect costs decrease with higher income and nursing home residency in the United States. DISCLOSURES This study was financially sponsored by Eisai. Drs Zhang and Tahami are employees of Eisai. Drs Chandak, Khachatryan, and Hummel are employees of Certara; Certara is a paid consultant to Eisai. The views expressed here are those of the authors and are not to be attributed to their respective affiliations. Laura De Benedetti, BSc, provided medical writing support to the manuscript; she is an employee of Certara.

Patterns of Diagnostic Evaluation and Determinants of Treatment in Older Patients With Non-transfusion Dependent Myelodysplastic Syndromes.

Older patients with myelodysplastic syndromes (MDS), particularly those with no or one cytopenia and no transfusion dependence, typically have an indolent course. Approximately, half of these receive the recommended diagnostic evaluation (DE) for MDS. We explored factors determining DE in these patients and its impact on subsequent treatment and outcomes. We used 2011-2014 Medicare data to identify patients ≥66 years of age diagnosed with MDS. We used Classification and Regression Tree (CART) analysis to identify combinations of factors associated with DE and its impact on subsequent treatment. Variables examined included demographics, comorbidities, nursing home status, and investigative procedures performed. We conducted a logistic regression analysis to identify correlates associated with receipt of DE and treatment. Of 16 851 patients with MDS, 51% underwent DE. patients with MDS with no cytopenia (n = 3908) had the lowest uptake of DE (34.7%). Compared to patients with no cytopenia, those with any cytopenia had nearly 3 times higher odds of receiving DE [adjusted odds ratio (AOR), 2.81: 95% CI, 2.60-3.04] and the odds were higher for men than for women [AOR, 1.39: 95%CI, 1.30-1.48] and for Non-Hispanic Whites [vs. everyone else (AOR, 1.17: 95% CI, 1.06-1.29)]. The CART showed DE as the principal discriminating node, followed by the presence of any cytopenia for receiving MDS treatment. The lowest percentage of treatment was observed in patients without DE, at 14.6%. In this select older patients with MDS, we identified disparities in accurate diagnosis by demographic and clinical factors. Receipt of DE influenced subsequent treatment but not survival.

Incidence of Aggressive End-of-Life Care Among Older Adults With Metastatic Cancer Living in Nursing Homes and Community Settings

Nearly 10% of the 1.5 million persons residing in nursing homes (NHs) have received or will receive a diagnosis of cancer. Although aggressive end-of-life (EOL) care is common among community-dwelling patients with cancer, little is known about such patterns of care among NH residents with cancer. To compare markers of aggressive EOL care between older adults with metastatic cancer who are NH residents and their community-dwelling counterparts. This cohort study used the Surveillance, Epidemiology, and End Results database linked with the Medicare database and the Minimum Data Set (including NH clinical assessment data) for deaths occurring from January 1, 2013, to December 31, 2017, among 146 329 older patients with metastatic breast, colorectal, lung, pancreas, or prostate cancer, with a lookback period in claims data through July 1, 2012. Statistical analysis was conducted between March 2021 and September 2022. Nursing home status. Markers of aggressive EOL care were cancer-directed treatment, intensive care unit admission, more than 1 emergency department visit or more than 1 hospitalization in the last 30 days of life, hospice enrollment in the last 3 days of life, and in-hospital death. The study population included 146 329 patients 66 years of age or older (mean [SD] age, 78.2 [7.3] years; 51.9% men). Aggressive EOL care was more common among NH residents than community-dwelling residents (63.6% vs 58.3%). Nursing home status was associated with 4% higher odds of receiving aggressive EOL care (adjusted odds ratio [aOR], 1.04 [95% CI, 1.02-1.07]), 6% higher odds of more than 1 hospital admission in the last 30 days of life (aOR, 1.06 [95% CI, 1.02-1.10]), and 61% higher odds of dying in the hospital (aOR, 1.61 [95% CI, 1.57-1.65]). Conversely, NH status was associated with lower odds of receiving cancer-directed treatment (aOR, 0.57 [95% CI, 0.55-0.58]), intensive care unit admission (aOR, 0.82 [95% CI, 0.79-0.84]), or enrollment in hospice in the last 3 days of life (aOR, 0.89 [95% CI, 0.86-0.92]). Despite increased emphasis to reduce aggressive EOL care in the past several decades, such care remains common among older persons with metastatic cancer and is slightly more prevalent among NH residents than their community-dwelling counterparts. Multilevel interventions to decrease aggressive EOL care should target the main factors associated with its prevalence, including hospital admissions in the last 30 days of life and in-hospital death.

Background rates of adverse events of special interest for COVID-19 vaccine safety monitoring in the United States, 2019-2020.

The U.S. Food and Drug Administration (FDA) Biologics Effectiveness and Safety (BEST) Initiative conducts active surveillance of adverse events of special interest (AESI) after COVID-19 vaccination. Historical incidence rates (IRs) of AESI are comparators to evaluate safety. We estimated IRs of 17 AESI in six administrative claims databases from January 1, 2019, to December 11, 2020: Medicare claims for adults ≥ 65 years and commercial claims (Blue Health Intelligence®, CVS Health, HealthCore Integrated Research Database, IBM® MarketScan® Commercial Database, Optum pre-adjudicated claims) for adults < 65 years. IRs were estimated by sex, age, race/ethnicity (Medicare), and nursing home residency (Medicare) in 2019 and for specific periods in 2020. The study included >100 million enrollees annually. In 2019, rates of most AESI increased with age. However, compared with commercially insured adults, Medicare enrollees had lower IRs of anaphylaxis (11 vs 12-19 per 100,000 person-years), appendicitis (80 vs 117-155), and narcolepsy (38 vs 41-53). Rates were higher in males than females for most AESI across databases and varied by race/ethnicity and nursing home status (Medicare). Acute myocardial infarction (Medicare) and anaphylaxis (all databases) IRs varied by season. IRs of most AESI were lower during March-May 2020 compared with March-May 2019 but returned to pre-pandemic levels after May 2020. However, rates of Bell's palsy, Guillain-Barré syndrome, narcolepsy, and hemorrhagic/non-hemorrhagic stroke remained lower in multiple databases after May 2020, whereas some AESI (e.g., disseminated intravascular coagulation) exhibited higher rates after May 2020 compared with 2019. AESI background rates varied by database and demographics and fluctuated in March-December 2020, but most returned to pre-pandemic levels after May 2020. It is critical to standardize demographics and consider seasonal and other trends when comparing historical rates with post-vaccination AESI rates in the same database to evaluate COVID-19 vaccine safety.

Nursing Home Status Adjustment for Standardized Mortality and Hospitalization in Dialysis Facility Reports

Compared to the original nursing home status (any nursing home stay in the previous calendar year), new nursing home status variables were developed to improve the risk adjustment of Standardized Mortality/Hospitalization Ratio (SMR/SHR) models used in public reporting of dialysis quality of care, such as the Annual Dialysis Facility Report. Retrospective observational study. 625,040 US maintenance dialysis patients with>90 kidney failure days in2019. Nursing home status variables; patient characteristics; comorbid conditions. Mortality/hospitalization. We assigned patients and patient times (SMR/SHR model) to one of 3 mutually exclusive categories: long-term care (≥90 days), short-term care (1-89 days), or non-nursing home, based on nursing home stay during the previous 365 days from the first day of the time period at risk. Nursing home status was derived from the Nursing Home Minimum Data Set. Comparisons of hazard ratios from adjusted models, facility SMR/SHR performance, and model C-statistics between the original/new models were performed. SMR's hazard ratio of original nursing home status (2.09) was lower than both ratios of short-term care (2.38) and long-term care (2.43), whereas SHR's hazard ratio of original nursing home status (1.10) was between the ratios of long-term care (1.01) and short-term care (1.20). There was a difference in hazard ratios between short-term care and long-term care for both measures. Small percentages of facilities changed performance categories: 0.7% for SMR and 0.4% for SHR. The SMR C-statistic improved whereas the SHR C-statistic was relatively unchanged. Limited capture of subacute rehabilitation stays in the nursing home by using a 90-day cutoff for short-term care and long-term care; unable to draw causal inference about nursing home care. Use of a nursing home metric that effectively separates short-term from long-term nursing home utilization results in more meaningful risk adjustment that generally comports with Medicare payment policy, potentially resulting in more interpretable results for dialysis stakeholders.

Prior Antibiotic Use Increases Risk of Urinary Tract Infections Caused by Resistant Escherichia coli among Elderly in Primary Care: A Case-Control Study.

We investigated whether prior use of antibiotics affects the risk of mecillinam/trimethoprim/nitrofurantoin/multi-resistant Escherichia coli urinary tract infection (UTI) among elderly patients in general practice. Data on urine culture came from urine samples performed in general practice and sent to hospitals in the Capital Region of Denmark, and prescription data came from a nationwide prescription database. The study population consisted of patients with UTI episodes (n = 41,027) caused by E. coli that received a concurrent antibiotic prescription against UTI from 2012 to 2017. We used a case-control design. Cases were UTI episodes caused by mecillinam, trimethoprim, nitrofurantoin or multi-resistant E. coli and controls were UTI episodes caused by E. coli not displaying the respective resistance pattern. We analyzed whether exposure to antibiotics in a period of 8–90 days prior to the UTI episode affected the risk of antibiotic resistant uropathogenic E coli. The analyses were adjusted for age, sex, hospital admission and nursing home status. The odds of resistance to all of the four antibiotics increased significantly after exposure to antibiotics within 90 days prior to the UTI episode. In general, mecillinam showed the lowest increase in the odds for selection of resistance. The results indicate that mecillinam is a favorable antibiotic choice in terms of selection of resistance.

Choosing unwisely: Low-value care in older adults with a diagnosis of myelodysplastic syndrome.

1532 Background: In tandem with the Choosing Wisely initiative, ASCO’s Cost of Care Task Force has proposed a list of low-value (LV) procedures and therapies that may be of limited benefit to patients. Myelodysplastic syndrome (MDS) is the most common myeloid malignancy in the US. A complete diagnostic evaluation (CDE) of MDS requires a bone marrow biopsy, fluorescence in situ hybridization and chromosomal analysis. As a potential LV procedure, we evaluated receipt of CDE in MDS patients with isolated or no cytopenias and no transfusion dependence. Methods: Using national 2011-2014 Medicare data, we identified fee-for-service Medicare patients 66 years of age or older with an MDS diagnosis, one or no cytopenias, and no blood transfusions in the 16 weeks before or after an MDS diagnosis (n = 16,779). We examined the following variables that may have provided a clinical context to (or not to) pursue CDE – demographics (age, race, sex); number of Elixhauser comorbid conditions ( &lt; 5 vs &gt;5); nursing home status, prior history of lymphoma, myeloma, MGUS and other cancers; chronic kidney disease (CKD); colonoscopy; and therapies received including erythropoiesis stimulating agents (ESAs), hypomethylating agents (HMAs) or lenalidomide. We conducted Classification and Regression Tree (CART) analysis, a machine learning approach to identify combinations of factors in patients with little clinical justification for CDE, and Cox proportional hazards regression analysis to compare survival outcomes between those with or without CDE. Results: Over half of our study population (51%) received CDE. Of those, 46.6% were 80 years of age or older, 4.8% were nursing home residents; and 33.6% had 5 or more chronic conditions. Results from CART analysis showed that among patients with an isolated cytopenia (e.g., isolated anemia), 46.0% of patients &gt;80 years (n = 860), and 57.7% (n = 1,156) of those in the 66-79 age group underwent CDE in the absence of CKD, colonoscopy, HMA, or ESA. Among those with no cytopenia (n = 3890), 866 patients received CDE in the absence of HMA, ESA, or history of lymphoma or progression to leukemia. In adjusted analyses, no survival benefit was associated with receipt of CDE (p = 0.24). Conclusions: A substantial number of patients with an MDS diagnosis, isolated or no cytopenias, and no transfusion dependence received a CDE in the absence of other diagnoses, procedures, or therapies that may have explained the clinical decision to perform CDE. These procedures entail costs, pain and anxiety, but do not appear to yield useful information to guide clinical management, as evidenced by the comparable survival outcomes between patients who did and did not undergo CDE. To promote patient-centered care, careful patient selection that reduces unnecessary CDE in MDS patients should be a priority in clinical decision-making.

Risk of COVID-19 in shielded and nursing care home patients: a cohort study in general practice.

BackgroundCOVID-19 cases were first detected in the UK in January 2020 and vulnerable patients were asked to shield from March to reduce their risk of COVID-19 infection.AimTo determine the risk and determinants of COVID-19 diagnosis in shielded versus non-shielded groups, adjusted for key comorbidities not explained by shielding.Design & settingRetrospective cohort study of adults with COVID-19 infection between 1 February 2020 and 15 May 2020 in west London.MethodIndividuals diagnosed with COVID-19 were identified in SystmOne records using clinical codes. Infection risks were adjusted for sociodemographic factors, nursing home status, and comorbidities.ResultsOf 57 713 adults, 573 (1%) individuals were identified as shielded and 1074 adults had documented COVID-19 infections (1.9%). COVID-19 infection rate in the shielded group individuals compared with non-shielded adult individuals was 6.5% (n = 37/573) versus 1.8% (n = 1037/57 140), P<0.001. A multivariable fully adjusted Cox proportional hazards (CPH) regression identified that COVID-19 infection was increased with shielding status (adjusted hazard ratio [aHR] 1.52; 95% confidence interval [CI] = 1.00 to 2.30; P = 0.048). Other determinants of COVID-19 infection included nursing home residency (aHR 7.05; 95% CI = 4.22 to 11.77; P<0.001); Black African (aHR 2.52; 95% CI = 1.99 to 3.18; P<0.001), Other (aHR 1.74; 95% CI = 1.42 to 2.13; P<0.001), Non-stated (aHR 1.70; 95% CI = 1.02 to 2.84; P = 0.04), or South Asian ethnic group (aHR 1.46; 95% CI = 1.10 to 1.93; P = 0.01); history of respiratory disease (aHR 1.51; 95% CI = 1.06 to 2.16; P = 0.02); deprivation (third versus least deprived Index of Multiple Deprivation [IMD] quintile) (aHR 1.25 ; 95% CI = 1.01 to 1.56; P = 0.05); obesity (body mass index [BMI] >30 kg/m2) (aHR 1.39; 95% CI = 1.18 to 1.63; P<0.001); and age (aHR 1.02; 95% CI = 1.01 to 1.02; P<0.001. Male sex was associated with lower risk of COVID-19 infection (aHR 0.71; 95% CI = 0.62 to 0.82; P<0.001).ConclusionShielded individuals had a higher COVID-19 infection rate compared with non-shielded individuals, after adjusting for sociodemographic factors, nursing home status, and comorbidities.

Respiratory Microbial Co-infection With SARS-CoV-2.

Co-infection with additional pathogens is a well-known feature of pandemics. We determined the prevalence and type of a wide variety of respiratory pathogens in 12,075 United States subjects tested for SARS-CoV-2 infection in March and April 2020. Infections with other respiratory pathogens, which on their own produce at least some SARS-CoV-2 symptoms including mortality, were present in both SARS-CoV-2 + and SARS-CoV-2- subjects. Non-SARS-CoV-2 infection rates were significantly higher in SARS-CoV-2 + (86%) patients than SARS-CoV-2– patients (76%) (p < 0.0001). Among the co-pathogens present in both subject groups were K. pneumoniae and M. catarrhalis which can produce serious respiratory illness on their own, Advanced age and nursing home status were associated with higher SARS-CoV-2 + and co-infection rates. Testing for the presence of co-pathogens going forward will assist in the diagnosis and optimal treatment of suspected SARS-CoV-2 respiratory infections in the current pandemic.

No impact of a prescription booklet on medication consumption in nursing home residents from 2011 to 2014: a controlled before\u2013after study

BackgroundOlder persons are particularly exposed to adverse events from medication. Among the various strategies to reduce polypharmacy, educational approaches have shown promising results. We aimed to evaluate the impact on medication consumption, of a booklet designed to aid physicians with prescriptions for elderly nursing home residents.MethodsAmong 519 nursing homes using an electronic pill dispenser, we recorded the daily number of times that a drug was administered for each resident, over a period of 4 years. The intervention group comprised 113 nursing homes belonging to a for-profit geriatric care provider that implemented a booklet delivered to prescribers and pharmacists and specifically designed to aid with prescriptions for elderly nursing home residents. The remaining 406 nursing homes where no such booklet was introduced comprised the control group. Data were derived from electronic pill dispensers. The effect of the intervention on medication consumption was assessed with multilevel regression models, adjusted for nursing home status. The main outcomes were the average daily number of times that a medication was administered and the number of drugs with different presentation identifier codes per resident per month.Results96,216 residents from 519 nursing homes were included between 1 January 2011 and 31 December 2014. The intervention group and the control group both decreased their average daily use of medication (− 0.05 and − 0.06). The booklet did not have a statistically significant effect (exponentiated difference-in-differences coefficient 1.00, 95% confidence interval 0.99–1.02, P = .45).ConclusionWe observed an overall decrease in medication consumption in both the control and intervention groups. Our analysis did not provide any evidence that this reduction was related to the use of the booklet. Other factors, such as national policy or increased physician awareness, may have contributed to our findings.

Characteristics of Patients with Late-Stage Parkinsonism Who are Nursing Home Residents Compared with those Living at Home

ObjectivesTo determine clinical characteristics and treatment complications of patients with late-stage Parkinsonism living in nursing homes compared with those living at home. DesignCross-sectional analysis. Setting and ParticipantsThis study is an analysis of 692 patients with late stage Parkinsonism recruited to an in-depth international study, Care of Late-Stage Parkinsonism (CLaSP). MeasuresSociodemographic characteristics were compared between patients who were living in a nursing home (n = 194) and those living at home (n = 498). Clinical assessments included the Unified Parkinson's Disease Rating Scale (UPDRS), the nonmotor symptom scale, the neuropsychiatric inventory, and a structured interview of patients and carers. Predictors of nursing home status were determined in a multivariate analysis. ResultsNursing home placement was strongly associated with more severe cognitive impairment, worse UPDRS motor scores and disability, and with being unmarried and older. Although nursing home residents had significantly higher axial scores, falls were less common. Despite similar levodopa equivalence doses, they had less dyskinesia. Nonmotor symptom burden, particularly delusion, hallucination, and depression scores were higher in nursing home residents, and they were more frequently on psychotropic medication. They had lower rates of dopamine agonist use and lower rates of impulse control disorders. In multivariate analysis, being unmarried, presence of cognitive impairment, worse disease severity as assessed on the UPDRS parts II and III, severity of delusions, and lower rate of dyskinesia were associated with nursing home placement. Conclusions and ImplicationsThese clinical characteristics suggest that in patients with Parkinsonsim who are nursing home residents, presence of cognitive impairment and delusions particularly add to the higher overall symptom burden, and more often require specific treatments, including clozapine. Despite similar levodopa equivalent daily dose, motor severity is higher, and dyskinesias, indicative of a response to levodopa, are less common. Falls, however, also occur less commonly, and dopamine agonists are less frequently used, with lower rates of impulse control disorder

181 Geriatric Sepsis Remains a Rapidly Rising Source of Health Care Utilization and Admissions

Sepsis remains a major challenge in modern medicine. Despite significant attention and substantial research to improve patient care, outcomes are frequently poor, particularly in the geriatric population. Importantly, the incidence of sepsis continues to rise across the United States. Better characterization of increasingly susceptible groups is indicated to identify patients at risk of poor incomes, particularly in the emergency department (ED), where the majority of septic patients initially present. We sought to use California-wide population characteristics to describe changes in incidence and mortality specifically as they relate to age between 2008 and 2015 and better characterize high-risk populations. Multi-center retrospective longitudinal cohort study derived from data from the Office of Statewide Health Planning and Development (OSHPD) database in California. Institutional review board approval was obtained prior to investigation. The OSHPD database is a state-funded registry that receives data regarding ED visits, inpatient stays and discharge data. Inclusion criteria: adult patients (age ≥ 18 years), with a primary or secondary diagnosis of sepsis, severe sepsis or septic shock based on previously validated methodology. Incidence was calculated as the number of cases of sepsis per 1000 admissions whereas mortality was calculated as the proportion of admission. Age categories were defined as: 18 - 44, 45 - 64, 65 - 74, 75 - 84, and 85+. Microsoft Excel and SPSS, version 25, were used to analyze data. Descriptive statistics were used as indicated. A total of 1,566,283 patients with sepsis were identified between 2008 and 2015 from the OSHPD database. Patients older than 65 made up 60.3% of admissions for sepsis, despite representing approximately 12% of the population during this time period. Figure 1 shows a significant increase in the incidence of sepsis in all age groups with a decrease in mortality during this time period. The largest increase in incidence per 1000 admissions occurred in patients 75 - 84 years old and those 85+, from 83.3 to 111.8 and 100.2 to 133.3 over the 7-year time period, respectively. Other major associations with admission included multiple comorbidities, defined as a Charlson comorbidity score ≥ 3, particularly in the older age groups and nursing home status. Of patients 85+ years old, 18.5% were nursing home residents prior to admission whereas 37.3% were discharged to a nursing home. Geriatric sepsis remains a significant driver of health care utilization, resources and mortality despite increased sepsis awareness. Additional investigations into optimal care of the geriatric patient in the ED with sepsis are indicated.

Exploring the concurrent validity of the nationwide assessment of permanent nursing home residence in Denmark - A cross-sectional data analysis using two administrative registries

BackgroundMany register studies make use of information about permanent nursing home residents. Statistics Denmark (StatD) identifies nursing home residents by two different indirect methods, one based on reports from the municipalities regarding home care in taken place in a nursing home, and the other based on an algorithm created by StatD.The aim of the present study was to validate StatD’s nursing home register using dedicated administrative municipality records on individual nursing home residents as gold standard.MethodsIn total, ten Danish municipalities were selected. Within each Danish Region, we randomly selected one municipality reporting to Stat D (Method 1) and one not reporting where instead an algorithm created by StatD was used to discover nursing home residents (Method 2). Method 1 means that municipalities reported to Stat D whether home care has taken place in a nursing home or in a private home. Method 2 is based on an algorithm created by Stat D for the municipalities where Method 1 is not applicable. Our gold standard was the information from the local administrative system in all ten selected municipalities. Each municipality provided a list with all individuals > 65 years living in a nursing home on January 1st, 2013 as well as the central personal number. This was compared to the list of individuals >65 living in nursing home facilities in the same ten municipalities on January 1st, 2013 retrieved from StatD.ResultsAccording to the data received directly from the municipalities, which was used as our gold Standard 3821 individuals were identified as nursing home residents. The StatD register identified 6,141 individuals as residents. Additionally, 556 of the individuals identified by the municipalities were not identified in the StatD register.Overall sensitivity for the ten municipalities in the StatD nursing home register was 0.85 (95% CI 0.84-0.87) and the PPV was 0.53 (95% CI 0.52-0.54). The municipalities for which nursing home status was based on the StatD algorithm (method 2) had a sensitivity of 0.84 (95% CI 0.82-0.86) and PPV of 0.48 (95% CI 0.46-0.50). Both slightly lower than the reporting municipalities (method 1) where the sensitivity was 0.87(95% CI 0.85-0.88) and the PPV was 0.57 (95% CI 0.56-0.59).Additionally, the sensitivity and PPV of the Stat D register varied heavily among the ten municipalities from 0.51 (95% CI 0.43-0.59) to 0.96 (95% CI 0.95-0.98) and PPV correspondingly, from 0.14 (95% CI: 0.11-0.17) to 0.73 (95% CI 0.69-0.77).ConclusionsThe overall PPV of StatD nursing home register was low and differences between municipalities existed. Even in countries with extensive nation-wide registers, validating studies should be conducted for outcomes based on these registers.

QSOFA Has Poor Sensitivity for Prehospital Identification of Severe Sepsis and Septic Shock

Objectives: Sepsis is a common and deadly disease process for which early recognition and intervention can significantly improve clinical outcomes. Despite this, sepsis remains underrecognized and therefore undertreated in the prehospital setting. Recent recommendations by the Society of Critical Care and European Society of Intensive Care Medicine advocate use of the qSOFA (quick Sequential [Sepsis-related] Organ Failure Assessment) score in non-ICU settings to screen for septic patients at greater risk for poor outcomes. Methods: We retrospectively evaluated the sensitivity and specificity of a prehospital qSOFA score ≥ 2 for prehospital identification of patients with severe sepsis or septic shock. Emergency Department (ED) patients with confirmed or suspected infection were classified as having infection without sepsis (n = 71), sepsis (n = 38), or severe sepsis/septic shock (n = 43), where designation of severe sepsis/septic shock required evidence of end-organ dysfunction, hypoperfusion (lactate > 2), or vasopressor requirement. Results: We found that a prehospital qSOFA score ≥ 2 was 16.3% sensitive (95% CI 6.8–30.7%) and 97.3% specific (95% CI 92.1–99.4%) for patients ultimately confirmed to have severe sepsis/septic shock in the ED. Adding an additional point to the prehospital qSOFA score for a pulse > 100, nursing home residence, age > 50, or reported fever increased the sensitivity to 58.1% (95% CI 42.1–73.0%) and decreased the specificity to 78.0% (95% CI 69.0–85.4%). During their ED stay, approximately two-thirds of patients meeting severe sepsis/septic shock criteria eventually met qSOFA criteria with a sensitivity of 67.4% (95% CI 51.5–80.9) and specificity of 86.2% (95% CI 78.3–92). Failure to meet qSOFA criteria prehospital was predominantly due to a systolic blood pressure and respiratory rate that did not yet meet predetermined thresholds. Conclusions: These findings suggest that the dynamic nature of sepsis can make sensitive detection difficult in the prehospital setting, although combining qSOFA with other clinical information (age, nursing home status, fever, and tachycardia) can identify more patients with sepsis who may benefit from time critical interventions.

The Impact of Disability and Social Determinants of Health on Condition-Specific Readmissions beyond Medicare Risk Adjustments: A Cohort Study.

Readmission rates after pneumonia, heart failure, and acute myocardial infarction hospitalizations are risk-adjusted for age, gender, and medical comorbidities and used to penalize hospitals. To assess the impact of disability and social determinants of health on condition-specific readmissions beyond current risk adjustment. Retrospective cohort study of Medicare patients using 1) linked Health and Retirement Study-Medicare claims data (HRS-CMS) and 2) Healthcare Cost and Utilization Project State Inpatient Databases (Florida, Washington) linked with ZIP Code-level measures from the Census American Community Survey (ACS-HCUP). Multilevel logistic regression models assessed the impact of disability and selected social determinants of health on readmission beyond current risk adjustment. Outcomes measured were readmissions ≤30days after hospitalizations for pneumonia, heart failure, or acute myocardial infarction. HRS-CMS models included disability measures (activities of daily living [ADL] limitations, cognitive impairment, nursing home residence, home healthcare use) and social determinants of health (spouse, children, wealth, Medicaid, race). ACS-HCUP model measures were ZIP Code-percentage of residents ≥65years of age with ADL difficulty, spouse, income, Medicaid, and patient-level and hospital-level race. For pneumonia, ≥3 ADL difficulties (OR 1.61, CI 1.079-2.391) and prior home healthcare needs (OR 1.68, CI 1.204-2.355) increased readmission in HRS-CMS models (N = 1631); ADL difficulties (OR 1.20, CI 1.063-1.352) and 'other' race (OR 1.14, CI 1.001-1.301) increased readmission in ACS-HCUP models (N = 27,297). For heart failure, children (OR 0.66, CI 0.437-0.984) and wealth (OR 0.53, CI 0.349-0.787) lowered readmission in HRS-CMS models (N = 2068), while black (OR 1.17, CI 1.056-1.292) and 'other' race (OR 1.14, CI 1.036-1.260) increased readmission in ACS-HCUP models (N = 37,612). For acute myocardial infarction, nursing home status (OR 4.04, CI 1.212-13.440) increased readmission in HRS-CMS models (N = 833); 'other' patient-level race (OR 1.18, CI 1.012-1.385) and hospital-level race (OR 1.06, CI 1.001-1.125) increased readmission in ACS-HCUP models (N = 17,496). Disability and social determinants of health influence readmission risk when added to the current Medicare risk adjustment models, but the effect varies by condition.

Invited commentary on nursing home status is an independent risk factor for adverse 30-day postoperative outcomes after common, nonemergent inpatient procedures

Invited commentary on nursing home status is an independent risk factor for adverse 30-day postoperative outcomes after common, nonemergent inpatient procedures

Nursing home status is an independent risk factor for adverse 30-day postoperative outcomes after common, nonemergent inpatient procedures

BackgroundNursing home residents undergoing surgery have a higher rate of postoperative adverse outcomes than nonnursing home patients. This study seeks to determine what contribution nursing home status makes to theses occurrences, independent of comorbid conditions. MethodsUsing the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database, the 30-day postoperative outcomes of the 5 commonest nonemergent inpatient procedures performed on nursing home residents were compared with those in nonnursing home residents using logistic regression analysis. ResultsNursing home status was found to be an independent risk factor for septic complications in all procedures, for blood transfusion requirement after lower leg amputation, for pneumonia and stroke/cerebrovascular accident after thromboendarterectomy, and for mortality after partial colectomy with primary anastomosis. ConclusionsThese data suggest that, in addition to serving as a surrogate indicator of health status and current morbidity, residence in a nursing home makes an independent contribution to adverse postoperative outcomes.

Geriatric nursing home falls: A single institution cross-sectional study

BackgroundFalls are the leading cause of fatal injury in geriatric patients. Nursing home falls occur at twice the rate of community falls, yet few studies have compared these groups. We hypothesized that nursing home residents admitted for fall would be sicker than their community counterparts on presentation and have worse outcomes. MethodsRecords of 1708 patients, age 65 years and older with a documented nursing home status, admitted to our center between 2008 and 2012 were reviewed. Clinical data including injury severity score (ISS), admission Glasgow coma scale (GCS), in-hospital complications, length of stay (LOS), and in-hospital mortality were collected. Continuous data were analyzed using Mann–Whitney tests and categorical data using Fisher exact tests. Variables in the univariate tests were analyzed in a multivariate logistic regression. ResultsNursing home patients were older than community patients, presented with lower GCS, lower hemoglobin, higher international normalized ratio (INR) and a higher percentage of patients with body mass index (BMI)<18.5. LOS for nursing home patients was longer, and they suffered higher rates of in-hospital complications. ISS, rates of traumatic brain injury, operative intervention and mortality were not significantly different. In a multivariate logistic regression, ISS, GCS and age, but not nursing home status, were significant predictors of in-hospital mortality. ConclusionsIn comparison to their community counterparts, nursing home patients presenting after fall are more debilitated and have increased morbidity as evidenced by more in-house complications and increased LOS. However, nursing home residency was not a significant predictor of mortality.

Dual-Eligibility Status: A Marker of Vulnerability and Cancer-Related Disparities

Dual-Eligibility Status: A Marker of Vulnerability and Cancer-Related Disparities