Post-acute Care Unit Research Articles

Defining the Cost of Arthroscopic Rotator Cuff Repair

Background: Rotator cuff repair (RCR) is a frequently performed outpatient orthopaedic surgery, with substantial financial implications for health-care systems. Time-driven activity-based costing (TDABC) is a method for nuanced cost analysis and is a valuable tool for strategic health-care decision-making. The aim of this study was to apply the TDABC methodology to RCR procedures to identify specific avenues to optimize cost-efficiency within the health-care system in 2 critical areas: (1) the reduction of variability in the episode duration, and (2) the standardization of suture anchor acquisition costs. Methods: Using a multicenter, retrospective design, this study incorporates data from all patients who underwent an RCR surgical procedure at 1 of 4 academic tertiary health systems across the United States. Data were extracted from Avant-Garde Health’s Care Measurement platform and were analyzed utilizing TDABC methodology. Cost analysis was performed using 2 primary metrics: the opportunity costs arising from a possible reduction in episode duration variability, and the potential monetary savings achievable through the standardization of suture anchor costs. Results: In this study, 921 RCR cases performed at 4 institutions had a mean episode duration cost of $4,094 ± $1,850. There was a significant threefold cost variability between the 10th percentile ($2,282) and the 90th percentile ($6,833) (p < 0.01). The mean episode duration was registered at 7.1 hours. The largest variability in the episode duration was time spent in the post-acute care unit and the ward after the surgical procedure. By reducing the episode duration variability, it was estimated that up to 640 care-hours could be saved annually at a single hospital. Likewise, standardizing suture anchor acquisition costs could generate direct savings totaling $217,440 across the hospitals. Conclusions: This multicenter study offers valuable insights into RCR cost as a function of care pathways and suture anchor cost. It outlines avenues for achieving cost-savings and operational efficiency. These findings can serve as a foundational basis for developing health-economics models. Level of Evidence: Economic and Decision Analysis Level III. See Instructions for Authors for a complete description of levels of evidence.

P149: Chronic fatigue syndrome and its response to the use of a multimodal antidepressant

Objective:We present a case that shows a very favourable response of the antidepressant vortioxetine in the functional and cognitive recovery in a patient with Chronic Fatigue Syndrome and its role as a pain modulator.Methods:This is an observational study using a clinical case. An 80-year-old female patient admitted to the Postacute care unit for recovering her functional baseline following surgical intervention for a hip fracture. On admission, the main symptom was residual pain at the level of the operated lower limb, as well as allodynia and a tingling sensation, which did not subside with conventional analgesia. During admission she also presented, insomnia, daytime hypersomnolence, bradypsychia, and emotional instability in the form of easy crying. It is worth mentioning that prior to admission the patient presented with multiple nonspecific somatic complaints, such as fatigue, headache, myalgia, and arthralgia, adding over time, great difficulty in planning and performing household tasks. The functional progress of the patient during admission was very slow, mainly due to the combination of lack of engagement, together with episodes of irritability, restlessness and suffering from fear of falling syndrome. Given the suspicion of previously undiagnosed Chronic Fatigue Syndrome, exacerbated by the decline in her functional baseline after surgery, treatment was started with vortioxetine in addition to non-pharmacological measures and psychotherapy, obtaining excellent results in approximately 4 weeks.Results:Great effectiveness of vortioxetine in the treatment of Chronic Fatigue Syndrome and in the control of concomitant pain (despite that indication is not included in the molecule's data sheet). The patient followed a very favourable evolution achieving, on discharge, an ad integrum recovery of her functional state.Conclusion:As presented in this case, treatment with multimodal antidepressant treatment (vortioxetine) could have positive impact for patients with Chronic Fatigue Syndrome, achieving improvements in the affective-cognitive aspect and controlling the pain related to this syndrome, avoiding polypharmacy.

22 Point prevalence study of therapeutic anticoagulation dosage based on renal function in an older population

Abstract Background Older patients (age > 65 years) are frequently prescribed Therapeutic Anticoagulation (TA), most commonly for Atrial Fibrillation (AF) and Venous Thrombo-Embolism (VTE). Importantly, advanced age (> 80 years) increases the risk of anticoagulation-associated major haemorrhage. Methods A point prevalence observational study of all patients admitted to a Post-Acute Care Unit (PACU) was undertaken. In addition to demographic information, prescribing data and indication for TA was collected. Laboratory data collected included serum creatinine (sCr) and estimated glomerular filtration rate (eGFR) using the MDRD formula. Dosing of anticoagulation based on renal function, age and weight was assessed and compared to the Health Products Regulatory Authority (HPRA) recommended guidelines. Results 70 patients were admitted to PACU on the day of study. 34.3% (n = 24) were prescribed TA, these patients were older (age 83.7 ± 7.9 years) and majority were male (M:F = 66%:34%), median weight was 60.45 kg (range = 41.3–91.6 kg). Indications for anticoagulation were AF 71% (n = 17), VTE 17% (n = 4), mixed AF/VTE 8% (n = 2) and mechanical valve replacement 4% (n = 1). Apixaban was the most commonly prescribed anticoagulant (66%, n = 16), followed by Rivaroxaban (12.5%, n = 3), Dabigatran (8%, n = 2), Enoxaparin (8%, n = 2) and Warfarin (4%, n = 1). In 66.7% (n = 16), the CrCl resulted in lower renal function than the eGFR, and in over 40% of cases the difference resulted in a dose adjustment of TA prescribed. Overall, CrCl was <50 mL/min in 58.3% (n = 14); CrCl 30–50 mL/min in 33% (n = 8), CrCl 15–29 mL/min in 21% (n = 5) and CrCl <15 mL/min in 4% (n = 1). In 25% of patients (n = 6), the dose of TA was incorrect with lower CrCl more likely to result in dose reduction of TA. Conclusion TA is an important treatment in older patients and this study showed that reduced renal function is likely to result in reduced dosing, which may produce a subtherapeutic response.

Implementation, Feasibility, and Acceptability of MATCH to Prevent Iatrogenic Disability in Hospitalized Older Adults: A Question of Geriatric Care Program?

Senior adults (>age 65) represent almost 20% of the population but account for 48% of hospital bed occupancy. In older adults, hospitalization often results in functional decline (i.e., iatrogenic disability) and, consequently, the loss of autonomy. Physical activity (PA) has been shown to counteract these declines effectively. Nevertheless, PA is not implemented in standard clinical practice. We previously showed that MATCH, a pragmatic, specific, adapted, and unsupervised PA program, was feasible and acceptable in a geriatric assessment unit (GAU) and a COVID-19 geriatric unit. This feasibility study aims to confirm that this tool could be implemented in other geriatric care programs, notably a geriatric rehabilitation unit (GRU) and a post-acute care unit (PACU), in order to reach the maximum number of older patients. Eligibility and consent were assessed by the physician for all the patients admitted to the three units (GAU, GRU, and PACU). The rehabilitation therapist taught each participant one of the five PA programs based on their mobility score on the decisional tree. Implementation (eligibility (%): patients eligible/number admitted and delay of implementation: number of days until prescription); feasibility (adherence (%): number sessions completed/number sessions prescribed and walking time (%): total walking time/time prescribed time); and acceptability (healthcare team (%): tool adequacy (yes/no) and patient: System Usability Scale questionnaire (SUS: x/100)) were evaluated and analyzed using a Kruskal-Wallis ANOVA or Fisher's exact test. Eligibility was different between the units (GRU = 32.5% vs. PACU = 26.6% vs. GAU = 56.0%; p < 0.001), but the time before implementation was similar (days: GRU = 5.91 vs. PACU = 5.88 vs. GAU = 4.78; p > 0.05). PA adherence (GRU = 83.5% vs. PACU = 71.9% vs. GAU = 74.3%) and walking time (100% in all units) were similar (p > 0.05). Patients (SUS: GRU = 74.6 vs. PACU = 77.2 vs. GAU = 77.2; p > 0.05) and clinicians (adequacy (yes; %): GRU = 78.3%; PACU = 76.0%; GAU = 72.2%; p > 0.05) found MATCH acceptable. Overall, MATCH was implementable, feasible, and acceptable in a GAU, GRU, and PACU. Randomized controlled trials are needed to confirm our results and evaluate the health benefits of MATCH compared with usual care.

"If I Become a Vegetable, Then no": A Thematic Analysis of How Patients and Physicians Refer to Prognosis When Discussing Cardiopulmonary Resuscitation.

Background: Documenting decisions about the relevance cardiopulmonary resuscitation (CPR) is a standard practice at hospital admission yet a complex task. Objective: Our aim was to explore how physicians approach and discuss CPR prognosis with older patients recently admitted to a post-acute care unit. Method: We recorded 43 conversations between physicians and patients about the relevancy of CPR that took place at admission at the geriatric rehabilitation service of a Swiss university hospital. Thematic analysis determined (i) who initiated the talk about CPR prognosis, (ii) at what point in the conversation, and (iii) how prognosis was referred to. Results: Prognosis was mentioned in 65% of the conversations. We categorized the content of references to CPR prognosis in five themes: factors determining the prognosis (general health, age, duration of maneuvers); life (association of CPR with life, survival); proximal adverse outcomes (broken ribs, intensive care); long-term adverse outcomes (loss of autonomy, suffering a stroke, pain, generic, uncertainty); and being a burden. Discussion and conclusion: Discussing CPR is important to all patients, including those for whom it is not recommended. Information about CPR prognosis is essential to empower and support patients in expressing their expectations from life-prolonging interventions and attain shared decision-making.

Musculoskeletal Ultrasound Shows Muscle Mass Changes during Post-Acute Care Hospitalization in Older Men: A Prospective Cohort Study.

This study aimed to prospectively assess changes in muscle thickness (MT) and the cross-sectional area (CSA) of the rectus femoris (RF) muscle in a cohort of older adults, using musculoskeletal ultrasound at admission and at a 2-week follow-up during hospitalization in a post-acute care unit. Differences in frailty status and correlations of MT-RF and CSA-RF with current sarcopenia diagnostic criteria were also studied. Forty adults aged 79.5 (SD 9.5) years (57.5% women) participated, including 14 with frailty and 26 with pre-frailty. In the first week follow-up, men had a significant increase in MT (0.9 mm [95%CI 0.3 to 1.4], p = 0.003) and CSA (0.4 cm2 [95%CI 0.1 to 0.6], p = 0.007). During the second week, men continued to have a significant increase in MT (0.7 mm [95%CI 0.0 to 1.4], p = 0.036) and CSA (0.6 cm2 [95%CI 0.01 to 1.2], p = 0.048). Patients with frailty had lower values of MT-RF and CSA-RF at admission and during the hospitalization period. A moderate-to-good correlation of MT-RF and CSA with handgrip strength, fat-free mass and gait speed was observed. Musculoskeletal ultrasound was able to detect MT-RF and CSA-RF changes in older adults admitted to a post-acute care unit.

Carbapenemase-producing Enterobacteriaceae in an inpatient post-acute care facility: Impact on time to functional recovery.

The carriage of carbapenemase-producing Enterobacteriaceae (CPE) might lengthen the time to functional recovery (TTFR) for inpatients in post-acute care (PAC) units. We aimed to assess the impact of CPE carriage on TTFR in a PAC facility. This 2-year retrospective cohort study included 20 CPE-positive patients and 54 CPE-negative patients admitted to 3 PAC units (general, orthopaedic and neurological rehabilitation units) in a teaching hospital from January 2017 to December 2019. Potential risk factors and demographic data were collected from patients' medical records, the French national hospital discharge database, and the hospital's CPE surveillance database. Functional recovery was defined as the median difference in functional independence measure (FIM) between admission and discharge from each unit. Survival analysis and multiple Cox regression models were used to predict the TTFR and identify factors associated with functional recovery. The overall median [interquartile range] TTFR was 50 days [36-66]. Longer median TTFR was associated with CPE carriage (63 vs 47 days in the CPE-negative group; adjusted hazard ratio (aHR) 0.35, 95% CI 0.13-0.97) and presence of a peripheral venous catheter (aHR 3.51, 1.45-8.46); shorter TTFR was associated with admission to an orthopaedic versus general rehabilitation unit (aHR 3.11, 1.24-7.82). CPE carriage in inpatient PAC facilities was associated with long TTFR. Further studies are needed to explore the mechanisms involved in these adverse events and to identify possible preventive measures.

Coordinating illness and insurance trajectories: Evidence from a post-acute care unit

This article examines how healthcare practitioners incorporate patients' insurance coverage and financial situation into their professional judgment. It does so by introducing the concept of an “insurance trajectory” that healthcare workers must coordinate with their medical management of illness and recovery. Drawing on 15 months of ethnography and 16 in-depth interviews at a post-acute care unit in New York City, this article argues that providers engage in anticipation work to align the tempo of recovery with the timeline of insurance coverage, in order to maximize revenue for the organization and minimize costs for patients. It identifies three modalities of anticipation work from intake to discharge: the creation of roadmaps on which illness and insurance trajectories intersect to predict an ideal discharge date, the synchronization of trajectories to avoid denials of coverage during rehabilitation, and the projection of futures to prevent illness and insurance trajectories from decoupling once patients are discharged. These findings expand our understanding of the effects of managed care on healthcare workers' practices and decision-making.

Prevention Admission into Nursing homes (PAN): study protocol for an explorative, prospective longitudinal pilot study

BackgroundIn Switzerland, there is a lack of adequate rehabilitation services, and effective coordination, that take into account the multifactorial health risks of older people. The literature shows that the hospitalisation rate in rehabilitation facilities has increased in recent years and that a gender bias exists. Additionally, there is little or no evidence available on the effect that a post-acute care programme might have over an extended period on functioning, quality of life and the informal network of older people. Therefore, the aim of this trial is to evaluate the sustainability of post-acute care within three nursing homes in Zurich, Canton of Zurich, Switzerland.MethodsThe Prevention Admission into Nursing homes (PAN) study is a explorative, prospective, longitudinal pilot trial based on a convenience sample of three long-term care facilities in the Swiss Canton of Zurich. The proposed pilot study will examine the effects of a post-acute care programme on people aged ≥65 years with a post-acute care potential ≥ three admitted to any of the three post-acute care units (n = 260). Older people of all sexes admitted to one of the post-acute care units and likely to be discharged to home within 8 weeks will be eligible for participation in the study. The primary endpoint is functionality based on the Barthel Index. The secondary endpoints are independency based on delirium, cognition, mobility, falling concerns, frailty, weight/height/body mass index, post-acute care capability, quality of life, and lastly, the informal network. As part of process evaluation, a qualitative evaluation will be conducted based on constructive grounded theory to specifically analyse how the experience of informal caregivers (n = 30) can contribute to a successful daily life 6 months after discharge.DiscussionWe expect to observe improved functional status and independence after the post-acute care programme. The qualitative evaluation conducted with caregivers will complement our description of the transition of older people towards living at home.Trial registrationThis study is registered in the German Clinical Trials Register under DRKS00016647 (registered on 23.05.2019).

POSA97 Assessment of the Economic IMPACT in Relation with the Use of Sugammadex in the French Hospitals Setting

This study aims to estimate the impact of sugammadex administration as neuromuscular reversal agents on time spent in the operating room (OR) and post-acute care unit (PACU) and the potential economic impact of faster recovery in patients undergoing colectomy, hysterectomy, or bariatric surgery in France.

Mepivacaine vs Bupivacaine Spinal Anesthesia in Total Hip Arthroplasty at an Ambulatory Surgery Center.

Mepivacaine spinal anesthetic may facilitate more rapid postoperative recovery in joint arthroplasty than bupivacaine. This study compared recovery, pain, and complications between the 2 anesthetics in anterior-approach total hip arthroplasty (THA) at a free-standing ambulatory surgery center (ASC). This retrospective cohort study of 282 consecutive patients with mean age 55.7±8.8 years and body mass index 30.6±5.3 who underwent THA at an ASC from November 2018 to July 2020 compares mepivacaine (n= 141) vs bupivacaine (n= 141) spinal anesthesia, a transition made in March 2019. The main outcomes were length of stay in the postoperative unit (post acute care unit) prior to same-day discharge (SDD), time to controlled void, and ambulation. Secondarily, postoperative pain scores (0-10) with morphine equivalents were required and any postoperative complications were compared. Mepivacaine decreased mean post acute care unit stay (4.0 vs 5.7hours, P < .001), time to void (3.1 vs 4.9hours, P < .001), and ambulation (3.2 vs 4.5hours, P < .001). No patients needed urinary catheterization or overnight stay. Two patients in the bupivacaine group had transient neurologic symptoms, consisting of foot drop and spinal headache, compared to none with mepivacaine (P= .498). Mepivacaine patients had increased postoperative pain at 2hours (1.7 vs 0.9, P < .001), at discharge (1.1 vs 0.5, P= .004), and morphine equivalent doses received (7.8 vs 3.7 mg, P < .001). Mepivacaine spinal anesthesia for anterior-approach THA safely facilitated more rapid SDD from the ASC through decreased times to controlled void and ambulation with only minor increase in pain when compared to bupivacaine. Level III - Retrospective comparative cohort study.

Opioid Use and Extended Stays in the Post Anesthesia Care Unit (PACU)

<h3>Introduction</h3> Opioid abuse has become an epidemic. By reducing opioid administration in the post-acute care unit (PACU) and utilizing a multi modal approach of non-narcotic intravenous (IV) acetaminophen and non-steroidal anti-inflammatory (NSAID) we can demonstrate the benefits of alternatives to opioids. <h3>Identification of the problem</h3> Using non-opioid medications, IV acetaminophen and NSAID's, patients will require less IV opioids thus less nausea and vomiting that leads to extended stays in PACU. <h3>Purpose of the Study</h3> Determine whether utilizing IV acetaminophen and NSAID would reduce IV narcotic administration post operatively thereby decreasing side effects of nausea, vomiting and length of stay. <h3>Methodology</h3> Analysis involved a retrospective review of 250 surgical patient charts having either hernia or gynecological procedure sub-divided into 4 groups: 1) NSAID only; 2) non-acetaminophen/NSAID; 3) acetaminophen with NSAID; 4) acetaminophen only. Data collected included narcotic medications, treatment for nausea and vomiting, and length of stay in PACU. <h3>Results</h3> Data analysis revealed statistically significant results. Study groups 2 and 3 required less opioids (25.8% and 30.8%) compared to 1 and 4 (46.2% and 54.0%). Less PACU interventions occurred in 2 and 3 (35.5% and 35.0%) than 1 and 4 (60% and 66%). Adverse events that could lead to increased length of stay occurred less in 2 and 3 (0% and 4.2%) vs. 1 and 4 (7.7% and 10.0%). <h3>Discussion</h3> By utilizing acetaminophen with an NSAID this will decrease the need for antiemetic treatment which will improve patient and staff satisfaction. More time can be spent at the patient's bedside educating on postoperative care and alternatives to opioids. <h3>Conclusion</h3> The multi-modal approach using non-narcotic medications are beneficial to decreasing opioid use, nausea, vomiting, and adverse events in postoperative patients. <h3>Implications for perianesthesia nurses and future research</h3> Progress and outcomes were shared with our hospital opioid committee and helped validate prescribing acetaminophen prior to surgery. Staff education improved in the periop setting and led to improved partnership with anesthesia. Discharge handouts regarding opioids were established, verbiage for pain are being updated and a new project undertaken led to exploring cost and benefits of IV verses by mouth acetaminophen.

Using the Kano Model Survey for Quality of Life Improvement in the Long-Term Care Setting During COVID-19

A quality improvement project was conducted within this facility’s post-acute and long-term care unit to determine which provided services are related to quality of life. The Kano model was utilized to assess a service by using questionnaires with antagonistic questions to assess function and satisfaction. The services are then categorized as performance, attractive, must-have, indifferent, and reverse. If more of the attractive and performance services are performed well, satisfaction will increase.

A randomized controlled trial of resistance and balance exercise for sarcopenic patients aged 80\u201399\xa0years

We compared a mixed exercise program (i.e., balance exercise plus resistance exercise) with resistance exercise in a single-blind, randomized controlled trial in a post-acute care unit. In total, 60 sarcopenic patients were randomly assigned to an intervention group (12-week mixed exercise) and a control group (12-week resistance exercise). The primary outcomes were the change of the Barthel Index and the number of fallers. The intervention group showed a mean increase of 9.5 points on the Barthel Index (95% confidence interval (CI) 3.9–15.1), while the control group showed a mean increase of 6.3 points (95% CI 2.3–10.4). The mixed exercise program provided a significant benefit over resistance exercise (adjusted mean difference of the change of Barthel Index: 6.8 points; 95% CI 1.4–12.1). The number of fallers was 13.3% and 23.3% in the intervention and control groups, respectively, but the difference was not significant (risk ratio (RR) 0.89, 95% CI 0.69–1.13, p = 0.506). In conclusion, compared with resistance exercise, the mixed exercise program appears to further improve the activities of daily living and physical performance in our study population. Under the monitoring of experienced physiotherapists, both exercise programs are feasible and safe for this population.

Single assessment of delirium severity during postacute intensive care of chronically critically ill patients and its associated factors: post hoc analysis of a prospective cohort study in Germany

ObjectivesTo assess the delirium severity (DS), its risk factors and association with adverse patient outcomes in chronically critically ill (CCI) patients.DesignA prospective cohort study.SettingA tertiary care hospital with postacute intensive...

Labile PT-INR in a Covid-19 Patient Under Long-term Vitamin K Antagonist Therapy: a Case Report.

The COronaVIrus Disease-19 (COVID-19) has been associated with thromboembolic complications, but evidence on its impact on hemorrhagic risk are still scarce. We describe a case of COVID-19 with hemorrhagic complication in the post-acute phase of the disease. The patient was a 93-year-old woman admitted to a post-acute care unit for COVID-19 patients in northern Italy. The patient’s medical history included moderate cognitive impairment, atrial fibrillation under oral anticoagulation (warfarin 2.5 mg and 3.75 mg on alternate days, showing stable PT-INR values since October 2018), and arterial hypertension. The patient was affected by COVID-19, treated with supportive therapy. In the post-acute phase of the disease, the patient presented with melena and showed a marked elevation of PT-INR of 25.1. She was treated with venous infusion of three-factor prothrombin complex concentrate and vitamin K until PT-INR reduction. After 5 days, blood analyses revealed normal hemoglobin, PT-INR 2.15, and a slight alteration of liver function. This case supports a strong impact of the infection on the coagulative pattern not only pro-thrombotically but also by increasing hemorrhagic risk. Special attention should therefore be paid to COVID-19 patients under anticoagulation with vitamin K antagonist and a shift to heparin treatment until illness resolution may be a safe option in these individuals.

Effectiveness of a Short-Term Mixed Exercise Program for Treating Sarcopenia in Hospitalized Patients Aged 80 Years and Older: A Prospective Clinical Trial.

To assess the effectiveness of short-term exercise for treating sarcopenia in hospitalized older patients aged 80 years and over. Prospective clinical trial. A post-acute care unit. Sarcopenic patients aged 80 years or over. The participants were allocated to the intervention group (to receive a mixed exercise program with 10 sessions over two weeks) or the control group (usual care) based on the sequence of admission. The primary outcome was the improvement in activities of daily living (ADL) estimated by the change in Barthel Index (BI) score from the baseline to the end of the 2-week intervention. The secondary outcomes were the changes in gait speed, handgrip strength, the time "UP and GO" test (TUG) score, and the Short Physical Performance Battery (SPPB) score. We included 121 participants (intervention group: n = 62; control group: n = 59). All participants in the intervention group finished all 10 exercise sessions. After the 2-week intervention, patients in the mixed exercise group achieved a significant improvement in ADL compared with their counterparts in the control group (the adjusted mean difference of the change in BI score was 7.8 points, 95% confidence interval (CI) 4.0 to 11.8 points). The mixed exercise program significantly but slightly improved gait speed (adjusted group difference in mean change: 0.06 m/s, 95% CI 0.02 to 0.11 m/s). However, the mixed exercise program did not significantly improve the handgrip strength, SPPB score, or TUG score compared with usual care. Very old inpatients with sarcopenia can benefit from a mixed exercise program (even as short as two weeks) by improving their ADL and gait speed. However, the long-term effects of exercise on important clinical outcomes need to be further evaluated.

Frailty, underweight and impaired mobility are associated with institutionalisation after post-acute care.

Post-acute care (PAC) is intended for older adult patients who are unable to return home directly after acute hospitalisation but who do not otherwise qualify for specific rehabilitation. However, data on potential predictors of PAC outcomes remain limited. Our aim was to identify patient characteristics upon admission to PAC that are associated with subsequent institutionalisation. Prospective cohort study enrolling 140 former acute care inpatients aged 60 and older who were referred to PAC units at nursing homes in Zurich, Switzerland. Geriatric assessment at admission included Barthel Index (BI), Short Physical Performance Battery (SPPB), frailty status (Fried phenotype), nutrition and cognitive status. Logistic regression was used to determine statistically significant associations. Mean age was 84.1 (standard deviation [SD] 8.6) years; 62.9% of participants were women. Mean body mass index (BMI) was 25.0 (SD 5.8) kg/m2, with 12.1% being underweight (BMI &lt;20 kg/m2). Mean BI at admission was 62.1 (SD 19.1), mean SPPB score was 5.2 (SD 2.8), and 55% were frail (&ge;3 Fried criteria present). After a mean length of stay in PAC of 30.9 (SD 16.5) days, 48.6% were institutionalised. Patients who were frail at admission had a 2.97-fold higher (odds ratio [OR] 2.9,7 95% confidence interval [CI] 1.04&ndash;8.42), and patients who were underweight had a 4.94-fold higher (OR 4.94, 95% CI 1.11&ndash;22.01) chance of institutionalisation. Conversely, each points increment on the SBBP score lowered the likelihood of institutionalisation by 23% (OR 0.77, 95% CI 0.65&ndash;0.92). Frailty, low Short Physical Performance Battery score and being underweight at admission to PAC were significantly associated with a higher chance of subsequent institutionalisation. Strategies to improve these factors could improve post-acute care outcomes.

The Montreal Cognitive Assessment in Veteran Postacute Care: Implications of Cut Scores.

The Montreal Cognitive Assessment (MoCA) is often used for cognitive screening across health care settings, especially in rehabilitation centers, where assessment and treatment of cognitive function is considered key for successful multidisciplinary treatment. Although the original MoCA validation study suggested a cut score of <26 to identify cognitive impairment, recent studies have suggested that lower cut scores should be applied. To examine the percentage of positive screens for cognitive impairment using the MoCA in a veteran postacute care (PAC) rehabilitation setting and to identify the most accurate MoCA cut score based on criterion neuropsychological measures. We obtained data from 81 veterans with diverse medical diagnoses who had completed the MoCA during their admission to a PAC unit. A convenience subsample of 50 veterans had also completed four criterion neuropsychological measures. Depending on the cut score used, the percentage of individuals classified as impaired based on MoCA performance varied widely, ranging from 6.2% to 92.6%. When predicting performance using a more comprehensive battery of criterion neuropsychological tests, we identified <22 as the most accurate MoCA cut score to identify a clinically relevant level of impairment and <24 to identify milder cognitive impairment. Our findings suggest that a MoCA cut score of <26 carries a risk of misdiagnosis of cognitive impairment, and scores in the range of <22 to <24 are more reliable for identifying cognitive impairment.

Postoperative Serum Cytokine Levels Are Associated With Early Stiffness After Total Knee Arthroplasty: A Prospective Cohort Study

BackgroundInflammatory cytokines have been implicated in organ fibrosis; however, their role in the development of arthrofibrosis after total knee arthroplasty (TKA) has not been well explored. The purpose of this study is to assess whether perioperative synovial fluid or blood plasma cytokine levels are associated with reduced early post-TKA range of motion. MethodsA total of 179 patients with end-stage idiopathic osteoarthritis undergoing TKA were enrolled in this prospective cohort study. Synovial fluid and blood plasma were collected prearthrotomy and plasma was collected longitudinally in the postacute care unit and on postoperative days (PODs) 1 and 2. Stiffness was defined as ≤95° range of motion measured with a goniometer at 6 weeks (±2 weeks). ResultsThirty-two of 162 (19.8%) patients analyzed were stiff at 6 weeks postoperatively. Postoperative plasma levels of 9 cytokines (Eotaxin3, IL-5, IL12_23p40, IP10, VEGF, IL-7, IL-12p70, IL-16, IL-17a) were significantly different between stiff and nonstiff patients on POD1 and/or POD2. An association between preoperative plasma and synovial fluid cytokine levels and the development of postoperative stiffness was not detected. ConclusionThe results of this study suggest that there is a distinct acute postoperative cytokine response profile in patients who develop stiffness 6 weeks after TKA. This profile was characterized by significant differences in levels of 9 cytokines over the first 2 postoperative days. These results identify cytokines that are potential biomarkers for risk of early stiffness after TKA and may play a role in the pathophysiology of this outcome.