Michael P. Cary

Inpatient Rehabilitation Outcomes in a National Sample of Medicare Beneficiaries With Hip Fracture

Effects of patient characteristics on rehabilitation outcomes (functional status at discharge, discharged home) were assessed in a retrospective study of Medicare beneficiaries admitted to Medicare-certified inpatient rehabilitation facilities (IRFs) following hospitalization for hip fracture in 2009 (N = 34,984). Hierarchical regression analysis showed significantly higher functional status at discharge (p < .0001) for patients with these characteristics: White or Asian, younger, female, lived alone, higher functional status at admission, fewer comorbidities, no tier comorbidities, and longer IRF length of stay (LOS). Likelihood of discharged home was higher for patients with these characteristics: Hispanic (1.49 [1.32, 1.68]), Asian (1.35 [1.04, 1.74]), or Black (1.28 [1.12, 1.47]); younger (0.96 [0.96, 0.96]); female (1.14 [1.08, 1.20]); lived with others (2.12 [2.01, 2.23]); higher functional status at admission (1.06 [1.06, 1.06]); fewer comorbidities, no tier comorbidities; and longer LOS (1.61 [1.56, 1.67]). Functional status at admission, tier comorbidities, and race/ethnicity contributed the most to variance in functional status at discharge. Living with others contributed the most to variance in discharged home.

Sustaining complex interventions in long-term care: a qualitative study of direct care staff and managers

BackgroundLittle is known about the sustainability of behavioral change interventions in long-term care (LTC). Following a cluster randomized trial of an intervention to improve staff communication (CONNECT), we conducted focus groups of direct care staff and managers to elicit their perceptions of factors that enhance or reduce sustainability in the LTC setting. The overall aim was to generate hypotheses about how to sustain complex interventions in LTC.MethodsIn eight facilities, we conducted 15 focus groups with 83 staff who had participated in at least one intervention session. Where possible, separate groups were conducted with direct care staff and managers. An interview guide probed for staff perceptions of intervention salience and sustainability. Framework analysis of coded transcripts was used to distill insights about sustainability related to intervention features, organizational context, and external supports.ResultsStaff described important factors for intervention sustainability that are particularly challenging in LTC. Because of the tremendous diversity in staff roles and education level, interventions should balance complexity and simplicity, use a variety of delivery methods and venues (e.g., group and individual sessions, role-play/storytelling), and be inclusive of many work positions. Intervention customizability and flexibility was particularly prized in this unpredictable and resource-strapped environment. Contextual features noted to be important include addressing the frequent lack of trust between direct care staff and managers and ensuring that direct care staff directly observe manager participation and support for the program. External supports suggested to be useful for sustainability include formalization of changes into facility routines, using “train the trainer” approaches and refresher sessions. High staff turnover is common in LTC, and providing materials for new staff orientation was reported to be important for sustainability.ConclusionsWhen designing or implementing complex behavior change interventions in LTC, consideration of these particularly salient intervention features, contextual factors, and external supports identified by staff may enhance sustainability.Trial registrationClinicalTrial.gov, NCT00636675

Changes in Payment Regulation and Acute Care Use for Total Hip Replacement: Trends in Length of Stay, Costs, and Discharge, 1997-2012.

Purpose: To describe trends in the length of stay (LOS), costs, mortality, and discharge destination among a national sample of total hip replacement (THR) patients between 1997 and 2012. Design: Longitudinal retrospective design Methods: Descriptive analysis of the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample data. Findings: A total of 3,516,636 procedures were performed over the study period. Most THR patients were women, and the proportion aged 44–65 years increased. LOS decreased from 5 to 3 days. Charges more than doubled, from

Relationship Between Chronic Conditions and Disability in African American Men and Women

22,184 to

Effect of promoting high-quality staff interactions on fall prevention in nursing homes: A cluster-randomized trial

53,901. Deaths decreased from 43 to 12 deaths per 10,000 patients. THR patients discharged to an institutional setting declined, while those discharged to the community increased. Conclusion: We found an increase in THR patients, who were younger, women, had private insurance, and among those discharged to community‐based settings. Clinical Relevance: Findings have implications for patient profiles, workplace environments, quality improvement, and educational preparation of nurses in acute and postacute settings.

Performance-Based Outcomes of Inpatient Rehabilitation Facilities Treating Hip Fracture Patients in the United States

BACKGROUND Race differences in chronic conditions and disability are well established; however, little is known about the association between specific chronic conditions and disability in African Americans. This is important because African Americans have higher rates and earlier onset of both chronic conditions and disability than white Americans. METHODS We examined the relationship between chronic conditions and disability in 602 African Americans aged 50 years and older in the Baltimore Study of Black Aging. Disability was measured using self-report of difficulty in activities of daily living (ADL). Medical conditions included diagnosed self-reports of asthma, depressive symptoms, arthritis, cancer, diabetes, cardiovascular disease (CVD), stroke, and hypertension. RESULTS After adjusting for age, high school graduation, income, and marital status, African Americans who reported arthritis (women: odds ratio (OR)=4.87; 95% confidence interval(CI): 2.92-8.12; men: OR=2.93; 95% CI: 1.36-6.30) had higher odds of disability compared to those who did not report having arthritis. Women who reported major depressive symptoms (OR=2.59; 95% CI: 1.43-4.69) or diabetes (OR=1.83; 95% CI: 1.14-2.95) had higher odds of disability than women who did not report having these conditions. Men who reported having CVD (OR=2.77; 95% CI: 1.03-7.41) had higher odds of disability than men who did not report having CVD. CONCLUSIONS These findings demonstrate the importance of chronic conditions in understanding disability in African Americans and how it varies by gender. Also, these findings underscore the importance of developing health promoting strategies focused on chronic disease prevention and management to delay or postpone disability in African Americans. PUBLICATION INDICES Pubmed, Pubmed Central, Web of Science database.

Successful Community Discharge Following Postacute Rehabilitation for Medicare Beneficiaries: Analysis of a Patient‐Centered Quality Measure

Importance New approaches are needed to enhance implementation of complex interventions for geriatric syndromes such as falls. Objective To test whether a complexity science–based staff training intervention (CONNECT) promoting high-quality staff interactions improves the impact of an evidence-based falls quality improvement program (FALLS). Design, Setting, and Participants Cluster-randomized trial in 24 nursing homes receiving either CONNECT followed by FALLS (intervention), or FALLS alone (control). Nursing home staff in all positions were asked to complete surveys at baseline, 3, 6, and 9 months. Medical records of residents with at least 1 fall in the 6-month pre- and postintervention windows (n = 1794) were abstracted for fall risk reduction measures, falls, and injurious falls. Interventions CONNECT taught staff to improve their connections with coworkers, increase information flow, and use cognitive diversity in problem solving. Intervention components included 2 classroom sessions, relationship mapping, and self-monitoring. FALLS provided instruction in the Agency for Healthcare Research and Quality’s Falls Management Program. Main Outcomes and Measures Primary outcomes were (1) mean number of fall risk reduction activities documented within 30 days of falls and (2) median fall rates among residents with at least 1 fall during the study period. In addition, validated scales measured staff communication quality, frequency, timeliness, and safety climate. Results Surveys were completed by 1545 staff members, representing 734 (37%) and 811 (44%) of eligible staff in intervention and control facilities, respectively; 511 (33%) respondents were hands-on care workers. Neither the CONNECT nor the FALLS-only facilities improved the mean count of fall risk reduction activities following FALLS (3.3 [1.6] vs 3.2 [1.5] of 10); furthermore, adjusted median recurrent fall rates did not differ between the groups (4.06 [interquartile range {IQR}, 2.03-8.11] vs 4.06 [IQR, 2.04-8.11] falls/resident/y). A modest improvement in staff communication measures was observed overall (mean, 0.03 [SE, 0.01] points on a 5-point scale; P = .03) and for communication timeliness (mean, 0.8 [SE, 0.03] points on a 5-point scale; P = .02). There was wide variation across facilities in intervention penetration. Conclusions and Relevance An intervention targeting gaps in staff communication and coordination did not improve the impact of a falls quality improvement program. New approaches to implementing evidence-based care for complex conditions in the nursing home are urgently needed. Trial Registration clinicaltrials.gov Identifier: NCT00636675

Improving Quality and Safety Through Use of Secondary Data: Methods Case Study:

OBJECTIVE To examine the influence of facility and aggregate patient characteristics of inpatient rehabilitation facilities (IRFs) on performance-based rehabilitation outcomes in a national sample of IRFs treating Medicare beneficiaries with hip fracture. DESIGN Secondary data analysis. SETTING U.S. Medicare-certified IRFs (N=983). PARTICIPANTS Data included patient records of Medicare beneficiaries (N=34,364) admitted in 2009 for rehabilitation after hip fracture. INTERVENTION Not applicable. MAIN OUTCOME MEASURES Performance-based outcomes included mean motor function on discharge, mean motor change (mean motor score on discharge minus mean motor score on admission), and percentage discharged to the community. RESULTS Higher mean motor function on discharge was explained by aggregate characteristics of patients with hip fracture (lower age [P=.009], lower percentage of blacks [P<.001] and Hispanics [P<.001], higher percentage of women [P=.030], higher motor function on admission [P<.001], longer length of stay [P<.001]) and facility characteristics (freestanding [P<.001], rural [P<.001], for profit [P=.048], smaller IRFs [P=.014]). The findings were similar for motor change, but motor change was also associated with lower mean cognitive function on admission (P=.008). Higher percentage discharged to the community was associated with aggregate patient characteristics (lower age [P<.001], lower percentage of Hispanics [P=.009], higher percentage of patients living with others [P<.001], higher motor function on admission [P<.001]). No facility characteristics were associated with the percentage discharged to the community. CONCLUSIONS Performance-based measurement offers health policymakers, administrators, clinicians, and consumers a major opportunity for securing health system improvement by benchmarking or comparing their outcomes with those of other similar facilities. These results might serve as the basis for benchmarking and quality-based reimbursement to IRFs for 1 impairment group: hip fracture.

Benefits and Challenges of Delivering Tele-rehabilitation Services to Rural Veterans

OBJECTIVE To determine the sociodemographic and clinical characteristics as well as health services use associated with successful community discharge. DATA SOURCE Inpatient Rehabilitation Facility-Patient Assessment Instrument and Medicare Provider Analysis and Review files. STUDY DESIGN We retrospectively examined 167,664 Medicare beneficiaries discharged from inpatient rehabilitation facilities (IRFs) in 2013 to determine the sociodemographic and clinical characteristics as well as health services use associated with successful community discharge. PRINCIPAL FINDINGS In the multivariable model, sociodemographic (younger age, no disability, social support), clinical (higher motor and cognitive functional status at admission), and health services use (fewer acute care days and longer IRF days) variables were associated with successful community discharge. CONCLUSIONS Remaining in the community is an important patient-centered outcome that could complement other postacute rehabilitation quality measures.

Home-time Following Discharge from Post-Acute Rehabilitation for Medicare Fee-for-Service Patients

Researchers need to evaluate the strengths and weaknesses of data sets to choose a secondary data set to use for a health care study. This research method review informs the reader of the major issues necessary for investigators to consider while incorporating secondary data into their repertoire of potential research designs and shows the range of approaches the investigators may take to answer nursing research questions in a variety of context areas. The researcher requires expertise in locating and judging data sets and in the development of complex data management skills for managing large numbers of records. There are important considerations such as firm knowledge of the research question supported by the conceptual framework and the selection of appropriate databases, which guide the researcher in delineating the unit of analysis. Other more complex issues for researchers to consider when conducting secondary data research methods include data access, management and security, and complex variable construction.