Robert E. Burke

Mental dysfunction and resource use in nursing homes.

The role of dementia and other mental disorders in nursing home case-mix classification systems has been an area of controversy. The role of mental dysfunctions was considered in developing a new case-mix measurement system for facility payment in a national demonstration to understand staff time use in nursing homes. Nursing staff (nurses and aides) time and resident assessment data were collected for 6,663 nursing home residents in 6 states. Measures of signs and symptoms of cognitive impairment (dementia), depression, and delirium were created based on items from the new National Minimum Data Set. These measures then were used to determine whether mental dysfunctions were predictive of resource use (nursing staff times and costs) when controlling for other case-mix variables. Cognitive impairment was associated with slightly higher staff time only in less physically-impaired residents without serious medical conditions and not receiving heavy rehabilitation. Similarly, depression and delirium were associated with higher resource use only in selected types of residents. Based on these findings, the new Resource Utilization Groups Version III (RUG-III) contain a major category of residents who are cognitively impaired but not severely dependent in Activities of Daily Living. Depression is used to differentiate subgroups of residents with major medical conditions such as hemiplegia and aphasia. Delirium, when used together with other resident characteristics, was not found useful in explaining resource use. Case-mix groups defined by mental dysfunctions can foster improved care, but careful consideration must be given to appropriate incentives and documentation requirements for providers.

Rise of Post–Acute Care Facilities as a Discharge Destination of US Hospitalizations

Rise of Post–Acute Care Facilities as a Discharge Destination of US Hospitalizations Medicare’s payment reforms in the 1990s significantly affected hospital length of stay and post–acute care (PAC) (eg, skilled nursing or rehabilitation) facility use.1, 2 H o w e v e r , f e w s t u d i e s d e s c r i b e c o nt e m p o r a r y length of stay and postdisc h a rge c a r e t r e n d s i n a nationally representative sample of Medicare and nonMedicare patients. We sought to understand these trends using the National Hospital Discharge Survey (NHDS) from 1996 to 2010.

Identifying keys to success in reducing readmissions using the ideal transitions in care framework

BackgroundSystematic attempts to identify best practices for reducing hospital readmissions have been limited without a comprehensive framework for categorizing prior interventions. Our research aim was to categorize prior interventions to reduce hospital readmissions using the ten domains of the Ideal Transition of Care (ITC) framework, to evaluate which domains have been targeted in prior interventions and then examine the effect intervening on these domains had on reducing readmissions.MethodsReview of literature and secondary analysis of outcomes based on categorization of English-language reports published between January 1975 and October 2013 into the ITC framework.Results66 articles were included. Prior interventions addressed an average of 3.5 of 10 domains; 41% demonstrated statistically significant reductions in readmissions. The most common domains addressed focused on monitoring patients after discharge, patient education, and care coordination. Domains targeting improved communication with outpatient providers, provision of advanced care planning, and ensuring medication safety were rarely included. Increasing the number of domains included in a given intervention significantly increased success in reducing readmissions, even when adjusting for quality, duration, and size (OR per domain, 1.5, 95% CI 1.1 - 2.0). The individual domains most associated with reducing readmissions were Monitoring and Managing Symptoms after Discharge (OR 8.5, 1.8 - 41.1), Enlisting Help of Social and Community Supports (OR 4.0, 1.3 - 12.6), and Educating Patients to Promote Self-Management (OR 3.3, 1.1 - 10.0).ConclusionsInterventions to reduce hospital readmissions are frequently unsuccessful; most target few domains within the ITC framework. The ITC may provide a useful framework to consider when developing readmission interventions.

Hospital Readmission From Post-Acute Care Facilities: Risk Factors, Timing, and Outcomes

OBJECTIVES Hospital discharges to post-acute care (PAC) facilities have increased rapidly. This increase may lead to more hospital readmissions from PAC facilities, which are common and poorly understood. We sought to determine the risk factors and timing for hospital readmission from PAC facilities and evaluate the impact of readmission on patient outcomes. DESIGN Retrospective analysis of Medicare Current Beneficiary Survey (MCBS) from 2003-2009. SETTING The MCBS is a nationally representative survey of beneficiaries matched with claims data. PARTICIPANTS Community-dwelling beneficiaries who were hospitalized and discharged to a PAC facility for rehabilitation. INTERVENTION/EXPOSURE Potential readmission risk factors included patient demographics, health utilization, active medical conditions at time of PAC admission, and PAC characteristics. MEASUREMENTS Hospital readmission during the PAC stay, return to community residence, and all-cause mortality. RESULTS Of 3246 acute hospitalizations followed by PAC facility stays, 739 (22.8%) included at least 1 hospital readmission. The strongest risk factors for readmission included impaired functional status (HR 4.78, 95% CI 3.21-7.10), markers of increased acuity such as need for intravenous medications in PAC (1.63, 1.39-1.92), and for-profit PAC ownership (1.43, 1.21-1.69). Readmitted patients had a higher mortality rate at both 30 days (18.9% vs 8.6%, P < .001) and 100 days (39.9% vs 14.5%, P < .001) even after adjusting for age, comorbidities, and prior health care utilization (30 days: OR 2.01, 95% CI 1.60-2.54; 100 days: OR 3.79, 95% CI 3.13-4.59). CONCLUSIONS Hospital readmission from PAC facilities is common and associated with a high mortality rate. Readmission risk factors may signify inadequate transitional care processes or a mismatch between patient needs and PAC resources.

Patient and Hospitalization Characteristics Associated With Increased Postacute Care Facility Discharges From US Hospitals.

Background/Objectives:The number of patients discharged to postacute care (PAC) facilities after hospitalization increased by 50% nationally between 1996 and 2010. We sought to describe payors and patients most affected by this trend and to identify diagnoses for which PAC facility care may be substituting for continued hospital care. Design:Retrospective analysis of the National Hospital Discharge Survey from 1996 to 2010. Setting:Adult discharges from a national sample of non-Federal hospitals. Participants/Exposures:Adults admitted and discharged to a PAC facility between 1996 and 2010. Our analysis includes 2.99 million sampled discharges, representative of 386 million discharges nationally. Measurements:Patient demographic and hospitalization characteristics, including length of stay (LOS) and diagnoses treated. Results:More than half (50.7%) of all patients discharged to PAC facilities were 80 years old or older in 2010; 40% of hospitalizations in this age group ended with a PAC stay. Decreases in LOS and increases in PAC facility use were consistent across payors and patient demographics. PAC facilities may be substituting for continued inpatient care for patients with pneumonia, hip fracture, and sepsis as these diagnoses demonstrated the clearest trends of decreasing LOS and increasing discharges to PAC facilities. Conclusions:The rise in discharges to PAC facilities is occurring in all age groups and payors, though the predominant population is the very old Medicare patient, for whom successful rehabilitation may be most unsure. PAC facility care may be increasingly substituted for prolonged hospitalizations for patients with pneumonia, hip fracture, and sepsis.

Contribution of psychiatric illness and substance abuse to 30‐day readmission risk

BACKGROUND Little is known about the contribution of psychiatric illness to medical 30-day readmission risk. OBJECTIVE To determine the independent contribution of psychiatric illness and substance abuse to all-cause and potentially avoidable 30-day readmissions in medical patients. DESIGN Retrospective cohort study. SETTING Patients discharged from the medicine services at a large teaching hospital from July 1, 2009 to June 30, 2010. MEASUREMENTS The main outcome of interest was 30-day all-cause and potentially avoidable readmissions; the latter determined by a validated algorithm (SQLape) in both bivariate and multivariate analysis. Readmissions were captured at 3 hospitals where the majority of these patients are readmitted. RESULTS Of 6987 discharged patients, 1260 were readmitted within 30 days (18.0%); 388 readmissions were potentially avoidable (5.6%). In multivariate analysis, 2 or more prescribed outpatient psychiatric medications (odds ratio [OR]: 1.1, 95% confidence interval [CI]: 1.01-1.20) or any prescription of anxiolytics (OR: 1.16, 95% CI: 1.00-1.35) were associated with increased all-cause readmissions, whereas discharge diagnoses of anxiety (OR: 0.82, 95% CI: 0.68-0.99) or substance abuse (OR: 0.80, 96% CI: 0.65-0.99) were associated with fewer all-cause readmissions. These findings were not replicated as predictors of potentially avoidable readmissions; rather, patients with discharge diagnoses of depression (OR: 1.49, 95% CI: 1.09-2.04) and schizophrenia (OR: 2.63, 95% CI: 1.13-6.13) were at highest risk. CONCLUSIONS Our data suggest that patients treated during a hospitalization for depression and for schizophrenia are at higher risk for potentially avoidable 30-day readmissions, whereas those prescribed more psychiatric medications as outpatients are at increased risk for all-cause readmissions. These populations may represent fruitful targets for interventions to reduce readmission risk.

Increasing Home Healthcare Referrals upon Discharge from U.S. Hospitals: 2001–2012

1. Charlson F, Degenhardt L, McLaren J et al. A systematic review of research examining benzodiazepine-related mortality. Pharmacoepidemiol Drug Saf 2009;18:93–103. 2. Weich S, Pearce HL, Croft P et al. Effect of anxiolytic and hypnotic drug prescriptions on mortality hazards: Retrospective cohort study. BMJ 2014;348:g1996. 3. Belleville G. Mortality hazard associated with anxiolytic and hypnotic drug use in the National Population Health Survey. Can J Psychiatry 2010;55:558–567. 4. Kripke DF, Langer RD, Kline LE. Hypnotics’ association with mortality or cancer: A matched cohort study. BMJ open 2012;2:e000850. 5. Kripke DF, Klauber MR, Wingard DL et al. Mortality hazard associated with prescription hypnotics. Biol Psychiatry 1998;43:687–693. 6. Vinkers DJ, Gussekloo J, van der Mast RC et al. Benzodiazepine use and risk of mortality in individuals aged 85 years or older. JAMA 2003;290:2942–2943. 7. Hogan DB, Maxwell CJ, Fung TS et al. Prevalence and potential consequences of benzodiazepine use in senior citizens: Results from the Canadian Study of Health and Aging. Can J Clin Pharmacol 2003;10:72–77. 8. Gisev N, Hartikainen S, Chen TF et al. Mortality associated with benzodiazepines and benzodiazepine-related drugs among community-dwelling older people in Finland: A population-based retrospective cohort study. Can J Psychiatry 2011;56:377–381. 9. Jaussent I, Ancelin ML, Berr C et al. Hypnotics and mortality in an elderly general population: A 12-year prospective study. BMC Med 2013; 11:212.

Effect of a hospitalist‐run postdischarge clinic on outcomes

BACKGROUND New post-discharge strategies to reduce adverse events are needed. OBJECTIVE To determine whether follow-up in a hospitalist-run post-discharge clinic (PDC) decreases post-discharge adverse events when compared to follow-up in a primary care clinic (PCP) or urgent care clinic (UC). DESIGN Retrospective cohort study using propensity scoring in multivariate analysis. PATIENTS Consecutive Veterans discharged home after a nonscheduled admission seen in PDC, UC, or PCP within 30 days of discharge. INTERVENTIONS Recently discharged patients are seen by housestaff who cared for them during the index admission and staffed with a rotating hospitalist in PDC; UC and PCP patients are seen by housestaff or attending ambulatory physicians. MAIN MEASURES The primary outcome was a composite of hospital readmissions, Emergency Department visits, and mortality 30 days after discharge. KEY RESULTS 5085 patients met criteria; 538 followed up in PDC (10.6%), 1848 with their PCP (36.3%), and 2699 in UC (53.1%). Patients following up in PDC were older and had a higher comorbidity burden. ICU exposure was similar between groups. Patients seen in PDC had shorter length of stay (LOS) (PDC, 3.8 days, UC, 5.0 days, PCP, 6.2 days; p = 0.04) and time to first post-discharge visit (PDC, 5.0 days, UC, 9.4 days, PCP, 13.7 days; p < 0.01). There were no differences between groups in the primary outcome in unadjusted or propensity-adjusted multivariate analysis. CONCLUSIONS Patients seen in a hospitalist-run PDC had similar 30-day post-discharge adverse outcome rates despite a 2.4-day shorter LOS compared to patients seen by their PCP. Prospective testing of PDCs is warranted.

Postdischarge clinics: Hospitalist attitudes and experiences

Novel methods for improving transitions of care are needed. Hospitalist-run postdischarge clinics (PDCs) may improve access to postdischarge care, but require practice change from providers. We conducted a Web-based cross-sectional survey of hospitalists at 37 academic medical centers across the United States and a large private employer of hospitalists to assess the attitudes of hospitalists toward postdischarge care and PDCs. Two hundred twenty-eight of 814 hospitalists responded to the survey (28%). Responding hospitalists commonly (55%) experienced difficulty arranging outpatient follow-up, and felt that lack of access was responsible for most patient problems after discharge (61%). Despite this, 62% felt hospitalists should not provide postdischarge care in a clinic, and 77% felt they would require extra compensation for work in a PDC. However, 74% thought such a clinic would decrease emergency department visits. Practicing in a PDC was associated with a trend toward positive attitudes about providing postdischarge care (P = 0.054). Responding hospitalists expressed difficulty arranging appropriate postdischarge care, confidence that PDCs would reduce postdischarge utilization, and reservations about working in a PDC, perhaps because of practical or financial concerns. These results are important given the current emphasis on reducing hospital readmissions. Further work evaluating the experience of hospitalists in PDCs is needed.

Impact of the New York Long-Term Home Health Care Program.

The Long-Term Home Health Care Program (LTHHCP), also known as the Nursing Homes Without Walls, is an innovative, comprehensive Medicaid program in New York State that provides nursing home level of care to patients at home. This paper evaluates the performance of the first nine LTHHCP sites over the first 2 years of operation. Across all sites there is clear evidence that the program has been extremely successful in reducing levels of nursing home utilization. In the five upstate sites, considerable cost savings have also been achieved while improving patient survival. In the four New York City sites, patient outcomes have also been favorable, but health care costs for clients have been higher than would have been the case had clients not enrolled in the LTHHCP. Across the entire state, results could have been better if enrollment had been targeted to subsets of the eligible patient groups for whom the LTHHCP is most cost effective.