Yuchi Young

Factors Associated with Potentially Preventable Hospitalization in Nursing Home Residents in New York State: A Survey of Directors of Nursing

OBJECTIVES: To describe characteristics of New York State nursing homes and identify factors associated with potentially preventable hospitalization in nursing home residents.

Clinical and Nonclinical Factors Associated With Potentially Preventable Hospitalizations Among Nursing Home Residents in New York State

OBJECTIVE Identify clinical and nonclinical factors associated with potentially preventable ambulatory care sensitive (ACS) hospitalization among nursing home residents. METHODS Residents (n=26,746) of 147 randomly selected nursing homes in New York State. Data included sociodemographics and clinical and nonclinical related factors. Multivariate linear regression quantified the association between potential determinants and ACS hospitalization. RESULTS Four factors significantly associated with reduction in ACS hospitalization included nursing staff trained to communicate effectively with physicians regarding a residents condition (P < .0001), physicians treat residents within the nursing home and admit to hospital as a last resort (P < .0001), provide better information and support to nurses and aides surrounding end-of-life care (P < .0001), and easy access to stat lab results in <4 hours on weekends (P < .0001). Two factors significantly associated with increased ACS hospitalization are: perceived likelihood illness will cause death (P < .0001) and perceived inadequate access to medical history/lab/EKGs (P < .0001). CONCLUSION Preventable ACS hospitalization reduction depends on effective communication between physicians and nursing staff, providing physicians with easy access to stat results in <4 hours on weekends, and easy access to medical records/lab/EKGs. Use of electronic medical records and providing training to nursing staff on how to communicate effectively with physicians and how to articulate about a residents condition may minimize preventable ACS hospitalizations.

Effect of comorbidity on functional recovery after hip fracture in the elderly.

ObjectiveThe aim of this study was to assess the relationship between self-reported disease burden (stroke, congestive heart failure, diabetes, chronic obstructive pulmonary disease, arthritis, or cancer) and functional improvement during and after inpatient rehabilitation among older adults with hip fractures. DesignThis is a longitudinal study examining 238 community-dwelling adults 65 yrs or older with unilateral hip fractures who underwent surgical repair and inpatient rehabilitation and were followed for 1 yr after discharge from the inpatient rehabilitation facility. The Functional Independence Measure (FIM) instrument was the outcome variable, collected at inpatient rehabilitation facility admission and discharge and at 2, 6, and 12 mos after discharge from the inpatient rehabilitation facility. A mixed-effect model was applied to quantify FIM functional improvement patterns between groups with and without selected preexisting chronic conditions while adjusting for potential confounders. ResultsMaximum functional improvement occurred during rehabilitation and the first 6 mos after rehabilitation for all six chronic conditions under study. In regard to the effect of disease on selected FIM outcomes, compared with patients without the selected preexisting chronic conditions, those who have had a stroke had significantly worse self care (&bgr; = −0.33; P = 0.02), transfer (&bgr; = −0.36; P = 0.03), and locomotion (&bgr; = −0.84; P = 0.0005) ratings, whereas the patients with congestive heart failure had significantly worse transfer (&bgr; = −0.59; P = 0.001) and locomotion (&bgr; = −0.71; P = 0.01) ratings. Significant interactions in stroke with time were seen in self-care (&bgr; = −0. 03; P = 0.04), suggesting that those who have had a stroke before hip fracture had poorer functional improvement over time than those who did not have the conditions. The patients with congestive heart failure demonstrated a faster rate of recovery over time in locomotion than those without (&bgr; = 0.06; P = 0.03). ConclusionsIntervention strategies should monitor the first 6 mos after discharge from inpatient rehabilitation, during which the maximum level of functional improvement is expected. However, the individuals who have had a stroke had poor functional improvement at 1 yr (adjusted mean FIM score, 5.74) than those who have not had a stroke (adjusted mean FIM score, 6.56). The patients who have had a stroke required human supervision at 12 mos after rehabilitation. Therefore, long-term care needs should be monitored in the discharge plan.

Hip Fractures Among Elderly Women: Longitudinal Comparison of Physiological Function Changes and Health Care Utilization

OBJECTIVE To compare physiological and functional impairments and their impact on health care use patterns among disabled older women with and without hip fracture. METHODS Data from the 3-year longitudinal Womens Health and Aging Study I (WHAS-I) and Medicare Current Beneficiaries Survey (MCBS) were used for this comparison study. Outcome variables include physiological measures (eg, hip and knee strength, functional reach), functional impairments (ADLs, IADLs), and health care use (physician visits). Generalized Estimation Equation (GEE) models were used to examine the differences between groups on physiological and functional change and health service use over time. RESULTS Three-year crude mortality rates were significantly higher in the hip fracture group (25%) than in the comparison group (18%); however, statistical significance did not persist after adjusting for age, race, education, living arrangement, depression, and comorbidity (RR = 1.5; P = .17). All physiological and functional measures deteriorated over time, regardless of presence or absence of hip fractures. After adjusting for covariates, the fracture group was significantly worse in knee strength (beta = -0.91; P = .01), usual walking speed (beta = -0.04; P = .01) and rapid walking speed (beta = -0.05; P = .02), and worse IADL function (beta = 0.26; P = .002) than the non-hip fracture group. The rate of additional impairment for both hip fracture group and non-hip fracture group was 0.013 IADL units per month (P = .001). However, there were no significant differences in health care use between the groups. CONCLUSION In spite of worse physiological and IADL impairments, once the women recovered from hip fracture surgery, they did not necessarily use more health care resources than non-hip fracture patients. To prevent functional deterioration, interventions need to focus on knee strength and mobility training.

Validation of a Novel Successful Aging Construct

PURPOSE Assess the validity of our previously published multidimensional concept of Successful Aging that integrates physiological, psychological, and sociological domains of health. DESIGN Three distinctly different populations were used to assess the discriminant and predictive validity. METHODS Data included 1438 women age 65 and older who participated in the Womens Health and Aging Studies I and II (WHAS-I and WHAS-II) and 302 participants in a continuing care retirement community (CCRC) study. Outcome measures included ADL and IADL function, self-reported health status, and number of hospitalizations. RESULTS Within the CCRC, the Successful Aging construct discriminated participants with regard to ADL and IADL function and self-reported health status. In both WHAS-I and WHAS- II samples, the construct predicted functional ADL and IADL change over time, and in WHAS-I, it predicted hospitalizations. IMPLICATIONS The Successful Aging construct appears valid and warrants further research and refinement among the general population.

Factors Associated With Permanent Transition From Independent Living to Nursing Home in a Continuing Care Retirement Community

OBJECTIVE Identify risk factors for and time to permanent transition from independent living units to nursing home among residents in a continuing care retirement community (CCRC). METHODS Prospective cohort study (n=298) among residents at least 75 years of age living independently at baseline. Proportional hazard regression identified risk factors associated with permanent transition from sociodemographic and health status data. RESULTS During the 3-year follow-up, 11% of the subjects were permanently transferred. Predictive factors were depression (relative risk [RR] 3.9; 95% CI 1.5-9.8), incontinence (RR 3.8; 95% CI 1.3-11.4), impaired cognition (RR 3.6; 95% CI 1.1-11.3), and dependence on activities of daily living disability (RR 1.5; 95% CI 1.3-1.8). Compared with those with no risk factors, presence of all 4 increased the relative risk to 74-fold and shortened the time to permanent transition by 32 months. CONCLUSION Prevention and treatment for depression, incontinence, and programs to improve or maintain cognitive function and ability to perform activities of daily living among CCRC residents may prolong their independent living life.

Examining Heterogeneity of Functional Recovery Among Older Adults With Hip Fractures

OBJECTIVE To examine heterogeneity in 1-year functional recovery following postacute rehabilitation among older adults with hip fracture. METHODS Two hundred twenty-five community-dwelling older adults with hip fracture who received postacute rehabilitation in 5 rehabilitation facilities in Baltimore, Maryland, were recruited during postacute rehabilitation (baseline) and follow-up at 2, 6, and 12 months following postacute rehabilitation discharge. Functional recovery was measured by the activities of daily living (ADL) and instrumental activities of daily living (IADL) scores. A mixed-effect model was used to examine factors associated with postacute rehabilitation functional recovery; fixed and random effects estimates from the models were used to demonstrate heterogeneity in functional recovery. RESULTS Results indicated that there was an overall trend in both ADL and IADL functional improvement at 2 months following postacute rehabilitation, with continued improvement to 6 months, after which functional recovery slowed down and remained constant through the year. Individuals whose functional recovery did not conform to these patterns were identified and their functional recovery that deviated substantially from the group mean was demonstrated. CONCLUSIONS Functional recovery patterns in elderly hip fracture patients are heterogeneous. To foster functional independence, health care professionals should consider individual recovery trajectories using a modeling approach appropriate for longitudinal or repeated measurement data such as a linear mixed-effects model when designing individualized rehabilitation and postacute rehabilitation care plans.

Preventable hospitalization among nursing home residents: varying views between medical directors and directors of nursing regarding determinants.

Objectives: To compare the perception of the determinants of preventable hospitalization among nursing home residents by surveying medical directors (MDs) and directors of nursing (DONs). Methods: A survey (N = 52) was completed in January 2008. Data included resource availability, determinants of hospitalization, and nursing home practice. Multivariate linear regression examined the associations between potential determinants and preventable hospitalization. Results: Four significant determinants perceived by MDs to influence preventable hospitalization: MD/nurse practitioner (NP) access by pager, family preferences, access to medical history and lab/ electrocardiograph (EKG) reports, and physicians better paid to manage acutely ill residents (R 2 = .58). None of these factors were echoed by DONs (R 2 = .15). Whereas DONs perceived stat lab results on weekends were associated with increased hospitalization (p = .03), MDs did not (p = .28). Conclusions: Our analysis showed that communication and consensus are important factors in the hospital transfer decision and that the discord in perceptions among MDs and DONs may complicate interventions to reduce preventable hospitalization.

Comparison Study: The Impact of On-site Comprehensive Service Access on Self-Reported Health and Functional Status of Older Adults

OBJECTIVE To evaluate the impact of on-site comprehensive service access by comparing functional outcomes and self-rated health between 2 older adult samples. METHODS Data came from 131 randomly selected residents living independently in 2 retirement communities that provided on-site comprehensive service access and 1723 community-dwelling older adults from the second Longitudinal Study on Aging, Wave 3 (LSOA II), who did not have compatible services access. All subjects were age 70+, white, with intact cognitive function, and had 12 or more years of education. We applied regressed measures of functional status and self-rated health on on-site comprehensive service access (yes versus no) in multivariate models that adjusted for covariates. RESULTS After adjusting for covariates, results indicated that residents with access to on-site comprehensive service settings is significantly associated with less risk for activities of daily living (ADL) limitations (beta = -0.40, P < .001) and Nagi impairments (beta = -0.62, P <or= .001), and better self-rated health (OR = 4.3; 95% CI 2.03-9.15) than the comparison group. CONCLUSION On-site comprehensive service access appears to have positive association on functional outcomes and self-rated health. Future studies should explore specific components of on-site comprehensive service access (eg, home health, social activities) that may account for these desirable outcomes.

Work-Related Injuries An Old Problem Revisited in the First Representative U.S. Sample of Home Health Aides

Objective: To examine whether certain personal and workplace factors increase risk for work-related injuries among home health aides. Method: A cross-sectional analysis was conducted using data from the 2007 National Survey of Home Health Aides among workers who provided formal caregiving to older adults or people with disabilities (N = 3,377, weighted sample = 160,720). Results: Multivariate logistic regression identified six factors associated with injury: White race (OR = 2.07, 95% CI 1.18, 3.63); inappropriate workload (OR = 3.27, 95% CI 1.55, 6.93); having multiple jobs (OR = 2.73, 95% CI 1.30, 5.71); job dissatisfaction (OR = 2.71, 95% CI 1.23, 5.96); higher hourly pay rate (OR = 2.38, 95% CI 1.31, 4.33); and working in two locations (inpatient facility and patient’s home) compared with working in patient’s home only (OR = 2.57, 95% CI 1.51, 4.40). Discussion: Interventions should be developed to address preventable risk factors. Evaluations of candidate interventions should control for other related factors that are not modifiable.