Daryl J. Caudry

Nursing Home Capabilities and Decisions to Hospitalize: A Survey of Medical Directors and Directors of Nursing

OBJECTIVES: To obtain information from decision makers about attitudes toward hospitalization and the factors that influence their decisions to hospitalize nursing home residents.

Diagnostic agreement in the evaluation of image-guided breast core needle biopsies: results from a randomized clinical trial.

BackgroundImage-guided core needle biopsies (CNBs) are commonly used as the initial sampling method for nonpalpable, mammographically detected breast lesions. Although prior studies have shown that this procedure is a highly sensitive and accurate method for the detection of breast cancer, the level of diagnostic agreement between pathologists in the analysis of CNB has not been previously studied in detail. MethodsTo address this, we reviewed the pathologic findings in 2004 CNB from patients enrolled in the Radiologic Diagnostic Oncology Group 5 study, a randomized, multicenter trial designed to determine the role of CNB and fine needle aspiration biopsy in the evaluation of nonpalpable breast lesions. Slides of CNB specimens were initially diagnosed by pathologists at the 22 participating institutions (local diagnosis) and were then sent to the study pathologists for central review (central diagnosis). Local and central diagnoses were compared. ResultsOverall, the central diagnosis and local diagnosis were concordant in 1925 cases (96%), indicating an excellent level of agreement by kappa statistic analysis (&kgr; = 0.90; 95% confidence interval 0.88–0.92). The level of agreement between local and central pathologists did not vary with the image guidance system (stereotactic mammography vs. ultrasound) or with the mammographic findings (soft tissue density vs. microcalcifications). The level of diagnostic agreement observed for CNB was comparable to that observed among 596 open surgical biopsies obtained from patients in this study and subjected to central pathology review (93% agreement; &kgr; = 0.89, 95% confidence interval 0.86–0.92). ConclusionsThe level of diagnostic agreement in interpretation of breast CNB is extremely high among pathologists and is comparable to that seen for open surgical biopsy.

Predictors of Nursing Home Residents' Time to Hospitalization

Objectives To model the predictors of the time to first acute hospitalization for nursing home residents, and accounting for previous hospitalizations, model the predictors of time between subsequent hospitalizations. Data Sources Merged file from New York State for the period 1998–2004 consisting of nursing home information from the minimum dataset and hospitalization information from the Statewide Planning and Research Cooperative System. Study Design Accelerated failure time models were used to estimate the model parameters and predict survival times. The models were fit to observations from 50 percent of the nursing homes and validated on the remaining observations. Principal Findings Pressure ulcers and facility-level deficiencies were associated with a decreased time to first hospitalization, while the presence of advance directives and facility staffing was associated with an increased time. These predictors of the time to first hospitalization model had effects of similar magnitude in predicting the time between subsequent hospitalizations. Conclusions This study provides novel evidence suggesting modifiable patient and nursing home characteristics are associated with the time to first hospitalization and time to subsequent hospitalizations for nursing home residents.

Deriving a Model of the Necessity to Hospitalize Nursing Home Residents

Although often important to recover from acute medical problems and exacerbations of chronic illness, hospitalizations can be traumatic for nursing home residents and costly for payers. It is important that unnecessary hospitalizations are avoided wherever possible. The authors derived and validated a diagnosis-based model to estimate the clinical necessity of hospitalizing nursing home residents with common conditions using data from an expert panel survey. Model validation involved a linked minimum data set—hospitalization claims data set. The expert panel of 12 experienced geriatricians rated the necessity of hospitalization for 1,948 clinical scenarios containing diagnoses, cognitive and functional status, age, gender, and advance directives. Primary diagnoses with the highest average necessity scores were respiratory failure, acute myocardial infarction, hip fracture, and brain injury. The secondary diagnosis-primary diagnosis interaction with the greatest impact was gastrointestinal bleed on gastroenteritis. Poor cognitive function and presence of an advance directive lowered the risk of hospitalization.

Health Insurance Status and the Care of Nursing Home Residents With Advanced Dementia

IMPORTANCE Nursing home residents with advanced dementia commonly experience burdensome and costly hospitalizations that may not extend survival or improve the quality of life. Fragmentation in health care has contributed to poor coordination of care for acutely ill nursing home residents. OBJECTIVE To compare patterns of care and quality outcomes for nursing home residents with advanced dementia covered by managed care with those covered by traditional fee-for-service Medicare. DESIGN, SETTING, AND PARTICIPANTS Choices, Attitudes, and Strategies for Care of Advanced Dementia at the End-of-Life (CASCADE) was a prospective cohort study including 22 nursing homes in the Boston, Massachusetts, area that monitored 323 nursing home residents for 18 months to better understand the course of advanced dementia at or near the end of life. Data from CASCADE and Medicare were linked to determine the health insurance status of study participants. EXPOSURES The health insurance status of the resident, either managed care or traditional fee for service. MAIN OUTCOMES AND MEASURES The outcomes included survival, symptoms related to comfort, treatment of pain and dyspnea, presence of pressure ulcers, presence of a do-not-hospitalize order, treatment of pneumonia, hospital transfer (admission or emergency department visit) for an acute illness, hospice referral, primary care visits, and family satisfaction with care. RESULTS Residents enrolled in managed care (n = 133) were more likely to have do-not-hospitalize orders compared with those in traditional Medicare fee for service (n = 158) (63.7% vs 50.9%; adjusted odds ratio, 1.9; 95% CI, 1.1-3.4), were less likely to be transferred to the hospital for acute illness (3.8% vs 15.7%; adjusted odds ratio, 0.2; 95% CI, 0.1-0.5), had more primary care visits per 90 days (mean [SD], 4.8 [2.6] vs 4.2 [5.0]; adjusted rate ratio, 1.3; 95% CI, 1.1-1.6), and had more nurse practitioner visits (3.0 [2.1] vs 0.8 [2.6]; adjusted rate ratio, 3.0; 95% CI, 2.2-4.1). Survival, comfort, and other treatment outcomes did not differ significantly across groups. CONCLUSIONS AND RELEVANCE Medicare managed-care programs may offer a promising approach to ensure that nursing homes are able to provide appropriate, less burdensome, and affordable care, especially at the end of life.

Derivation and Confirmation of Scales Measuring Medical Directors’ Attitudes About the Hospitalization of Nursing Home Residents

Objectives: To derive and confirm scales measuring medical director’s attitudes about hospitalization of nursing home residents. Method: The authors surveyed nursing facility medical directors about the necessity of hospitalizing residents for eight clinical conditions and compared the ratings to those obtained from an expert panel to derive a relative hospitalization score. They also asked about factors that might influence hospitalization decisions. They performed a factor analysis to derive scales that measure attitudinal determinants of hospitalization and used the relative hospitalization score to confirm the scales. Results: The survey had a 79% response rate. The relative hospitalization score demonstrated that medical directors were slightly less likely to recommend hospitalization than expert panel physicians. Factor analyses yielded 10 scales focusing on nursing home functioning, economics, resident specific considerations, and physician attitudes. Eight of the 10 scales had significant bivariable associations with the relative hospitalization score, and 6 had significant multivariable associations. Discussion: Medical directors identify multiple determinants of hospitalization for nursing facility residents across several domains. Hospitalization decisions for nursing facility residents are complex and involve clinical and nonclinical factors.

The Care Continuum for Hospitalized Medicare Beneficiaries Near Death

Background: Rising use of postacute care (PAC) facilities over the past 2 decades has contributed to increased transitions of care in the last year of life (1, 2). Medicare PAC facility benefits cover rehabilitation from acute illness in skilled nursing facilities, inpatient rehabilitation facilities, or long-term acute care hospitals. Amid pressure to reduce length of stay, hospitals often use PAC facilities as a stopgap and send elderly patients near the end of life to facilities designed more for rehabilitation than palliative care. The role of PAC facilities as a discharge destination for patients in the last days or weeks of life has been underappreciated, particularly because the alternative choice of hospice care may improve their quality of life (3). Objective: To assess the use of PAC facilities, overall and by hospice use, as well as hospital readmissions from these facilities in patients near death. Methods and Findings: We studied Medicare fee-for-service beneficiaries who died between 2006 and 2011 using the beneficiary summary files, data from the Medicare Provider Analysis and Review, and hospice base claims. We described use of PAC facilities and acute hospitals overall and by hospice status, dichotomized as any versus no hospice claims in the last year of life. Among 8216193 Medicare beneficiaries who died, 23.3% received care in a PAC facility in the last 90 days of life. Further, 16.1% received care in a PAC facility in the last 14 days of life and 9.9% received care in in a PAC facility on the day of or day before death. Among patients using a PAC facility within the last 30 and 90 days of life, 50.1% and 60.4%, respectively, returned to an acute hospital before death; most of these readmissions were transferred directly from PAC facilities (Table 1). Table 1. Readmissions in the Last 30 and 90 Days of Life Among Medicare Beneficiaries With> =1 PAC Facility Stay* Among all Medicare beneficiaries who died during the study period, 39.0% used hospice services in the last year of life. Those who did not had higher use of acute care hospitals and PAC facilities in the days and weeks before death (Table 2). Table 2. Medicare Fee-for-Service Beneficiaries Who Used Acute Care Hospitals or PAC Facilities Before Death, by Hospice Status* Discussion: Patients who used PAC facilities in the last month of life were frequently readmitted to an acute care hospital before death, and patients who did not use hospice services had higher use of acute care hospitals and PAC facilities before death. Given the lack of palliative care expertise in PAC facilities and the key contribution of such facilities to Medicare spending growth (4), these transitions may lead to lower-quality end-of-life care for patients and increased cost to the health system. Many potential explanations exist for high use of PAC facilities and hospital readmissions near the end of life. Although some patients may have unrealistic hopes for rehabilitation, many frail elderly patients hospitalized for serious illness may be unable to return home because of functional decline, lack of caregiver support, or difficulty controlling such symptoms as pain or dyspnea. Postacute care facilities can meet some of these needs; however, such patients are often rehospitalized when their clinical status changes, leading to potentially burdensome transitions. Other patients interested in hospice may be unable to receive home-based hospice care because of functional decline or lack of a caregiver. Hospice facility fees for room and board for such patients can cost hundreds of dollars per day (5), because fully funded general inpatient hospice care is limited to those who require intravenous pain medication and intensive symptom management. That many of these patients may be discharged to Medicare-funded PAC facilities is thus not surprising. These findings suggest future interventions and research questions and could inform conversations with patients near the end of life about their setting and goals of care. Policies that require documentation of advanced care planning before transfer to a PAC facility, including discussion of do-not-hospitalize orders, could help facilitate these conversations. Further, financial incentives for PAC facilities to reduce hospital readmissions could help fund interventions, such as having palliative care clinicians on call to answer questions about managing acute symptoms or training the staff of PAC facilities in palliative care. This study was limited by its retrospective, claims-based approach and lack of patient-reported data. Future studies should explore why patients use PAC facilities near the end of life and prospectively assess how doing so affects the quality of end-of-life care.