Do-not-resuscitate and do-not-hospitalize directives of persons admitted to skilled nursing facilities under the Medicare benefit

OBJECTIVES: To determine prevalence and factors associated with do-not-resuscitate (DNR) and do-not-hospitalize (DNH) directives of residents admitted under the Medicare benefit to a skilled nursing facility (SNF). To explore geographic variation in use of DNR and DNH orders. DESIGN: Retrospective cohort study. SETTING: Nursing homes in the United States. PARTICIPANTS: Medicare admissions to SNFs in 2001 (n=1,962,742). MEASUREMENTS: Logistic regression was used to select factors associated with DNR and DNH directives and state variation in their use. RESULTS: Thirty-two percent of residents had DNR directives, whereas less than 2% had DNH directives. Factors associated with having a DNR or DNH directive at the resident level included older age, cognitive impairment, functional dependence, and Caucasian ethnicity. African-American, Hispanic, Asian, and North American Native residents were all significantly less likely than Caucasian residents to have DNR (adjusted odds ratio (OR)=0.35, 0.51, 0.61, and 0.62, respectively) or DNH (adjusted OR=0.26, 0.41, 0.43, and 0.67, respectively) directives. In contrast, residents in rural and government facilities were more likely to have DNR or DNH directives. After controlling for resident and facility characteristics, significant variation between states existed in the use of DNR and DNH directives. CONCLUSION: Ethnic minorities are less likely to have DNR and DNH directives even after controlling for disease status, demographic, facility, and geographic characteristics. Wide variation in the likelihood of having DNR and DNH directives between states suggests a need for better-standardized methods for eliciting the care preferences of residents admitted to SNFs under the Medicare benefit.     

Pneumonia and lower respiratory infections in nursing home residents: predictors of hospitalization and mortality

OBJECTIVES: To compare predictors of hospitalization and death in nursing home residents with pneumonia and other lower respiratory infections (LRIs). DESIGN: A nested cohort study. SETTING: Nine nursing homes in southern Ontario. PARTICIPANTS: Three hundred fifty-three nursing home residents with LRIs (enrolled in the control arm of a clinical trial). MEASUREMENTS: Comorbidities, vaccination status, age, health-related quality of life, functional status, and vital statistics were evaluated as potential predictors of hospitalization and mortality at 30 days. RESULTS: Moderate to high disease severity score on a practical severity scale was a strong independent predictor of hospitalization (odds ratio (OR)=7.12, P<.001) and mortality (OR=5.04, P=.003). Diagnosis of pneumonia, established using chest radiograph, was also associated with hospitalization (OR=2.43, P=.008) and mortality (OR=2.35, P=.02). Oxygen saturation (<90%) was a strong independent predictor of hospitalization (OR=3.02, P=.004) but was not a significant predictor of mortality in multivariable analyses. Diagnosis of congestive heart failure (OR=2.26, P=.02) was an independent predictor of hospitalization, whereas receipt of pneumococcal vaccine (OR=0.36, P=.01) and greater functional independence (OR=0.92, P=.02) were negatively associated with hospitalization. CONCLUSION: In nursing home residents with LRI, severity of illness and radiographically confirmed pneumonia are predictive of death and hospitalization.     

Pneumonia in nursing home residents: factors associated with in-home care of EverCare enrollees

OBJECTIVES: To identify determinants of whether nursing home (NH) residents enrolled in EverCare were admitted to in-home intensive service days (ISDs) rather than a hospital when they were thought to have pneumonia. DESIGN: Retrospective cross-sectional. SETTING: EverCare operations in five metropolitan areas. PARTICIPANTS: EverCare enrollees admitted to ISDs or a hospital for suspected pneumonia in 2002. MEASUREMENTS: Member, nurse practitioner, physician, and NH characteristics extracted from EverCare's administrative data and Online Survey Certification and Reporting NH data. RESULTS: Multivariable logistic regression indicated that admission to ISDs (65% of cases) was positively associated with age (odds ratio (OR)=1.04. 95% confidence interval (CI) 1.03-1.04), advance directives not to hospitalize (OR=2.88, 95% CI=1.76-4.72), or perform cardiopulmonary resuscitation, 3.09 (2.44-3.91), and hours worked by the NH's registered nurses (OR=4.34, 95% CI=1.74-10.8). Admission to ISD was less likely on weekends (OR=0.30, 95% CI=0.21-0.43), when residents had renal insufficiency (OR=0.61, 95% CI=0.49-0.76), and when the resident was covered by Medicaid (OR 0.87, 95% CI=0.82-0.93). CONCLUSION: Exploration of ways to extend services to weekends, increased availability of registered nurse staff, attention to advance directives, and a better understanding of the role of Medicaid might increase the likelihood of caring for EverCare enrollees with suspected pneumonia in their NH.     

Effect of do-not-resuscitate orders on hospitalization of nursing home residents evaluated for lower respiratory infections

OBJECTIVES: To determine resident and facility characteristics associated with do-not-resuscitate (DNR) orders and to test the effect of DNR orders on hospitalization of acutely ill nursing home (NH) residents with lower respiratory tract infections (LRIs). DESIGN: Prospective cohort. SETTING: Thirty-six NHs (almost 4,000 residents) in central and eastern Missouri in the Missouri Lower Respiratory Infection study. PARTICIPANTS: NH residents with a LRI (n=1031). MEASUREMENTS: Data were obtained from new Minimum Data Set evaluations, resident examination, and chart review. Associations between resident, physician, and facility characteristics and the presence of a DNR order and hospitalization within 30 days from evaluation for an LRI were analyzed. RESULTS: Sixty percent of subjects had a DNR order, and 2% had a do-not-hospitalize order. Resident characteristics associated with a DNR order included older age, white race, having a surrogate decision-maker, NH residence for longer than 3 years, and more-impaired cognition. Residents with DNR orders were more likely to live in facilities with more licensed beds, a lower proportion of Medicaid recipients, and a higher prevalence of influenza vaccination. After controlling for potential confounders, residents with a DNR order before the acute illness episode were significantly less likely to be hospitalized (adjusted odds ratio=0.69, 95% confidence interval=0.49-0.97). CONCLUSION: DNR orders independently reduce the risk of hospitalization for LRI and may function as a marker for undocumented care limitations or as a mandate to limit care (unrelated to resuscitation) in NH residents with LRI.     

Risk factors for dehydration among elderly nursing home residents

Dehydration is the most common fluid and electrolyte disorder among the elderly, yet risk factors are not known. This study identifies risk factors for dehydration in acutely ill nursing home residents. All 339 elderly resident of two nursing homes who developed an acute illness requiring hospitalization during 1984 were included in the study. The 173 patients having a serum Na less than 150 mg/dL and blood urea nitrogen to creatinine ratio (BUN:Cre) less than 20 were designated controls; 91 patients having a serum Na greater than 150 mg/dL or a serum BUN:Cre greater than 25 were designated cases. Odds ratios (OR) and confidence intervals were calculated for age, sex, chronic conditions, acute illnesses, medications, functional status measures, and season. Acutely ill dehydrated patients were female (OR, 3.3); over 85 years old (OR, 2.2); had more than four chronic conditions (OR, 4.0); took more than four medications (OR, 2.8); and were bedridden (OR, 2.9). Among the most severely dehydrated (serum Na greater than 150 mg/dL and BUN:Cre greater than 25), the odds ratios for the above factors were strengthened and other factors, such as inability to feed oneself and type of acute diagnosis, emerged as risk factors. Among the variables unrelated to functional status, laxatives (OR, 3.2) and chronic infections (OR, 1.8) were risk factors. We conclude that a group at high risk for dehydration can be defined and that they are better characterized by the number of chronic diseases and debilitated functional status than by acute disease processes.     

Improving Nursing Facility Care Through an Innovative Payment Demonstration Project: Optimizing Patient Transfers,Impacting Medical Quality,and Improving Symptoms: Transforming Institutional Care Phase 2

Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) is a 2‐phase Center for Medicare and Medicaid Innovations demonstration project now testing a novel Medicare Part B payment model for nursing facilities and practitioners in 40 Indiana nursing facilities. The new payment codes are intended to promote high‐quality care in place for acutely ill long‐stay residents. The focus of the initiative is to reduce hospitalizations through the diagnosis and on‐site management of 6 common acute clinical conditions (linked to a majority of potentially avoidable hospitalizations of nursing facility residents 1 ): pneumonia, urinary tract infection, skin infection, heart failure, chronic obstructive pulmonary disease or asthma, and dehydration. This article describes the OPTIMISTIC Phase 2 model design, nursing facility and practitioner recruitment and training, and early experiences implementing new Medicare payment codes for nursing facilities and practitioners. Lessons learned from the OPTIMISTIC experience may be useful to others engaged in multicomponent quality improvement initiatives.     

Race and mental health disorders’ impact on older patients’ nursing home admissions upon hospital discharge

IntroductionDespite policy efforts to reduce unwanted nursing home (NH) admissions, NH residents increasingly are being admitted from hospitals, with a significant share diagnosed with mental health disorders.ObjectivesWe examined interactive effect of Black race and mental health disorder's impact on older patients' (age 65 and older) NH admission upon hospital discharge.Material and methodsWe analyzed 186,646 older patients using pooled data from the 2007 through 2010 National Hospital Discharge Survey. Logistic regression analyses were used to examine the risk factors for NH admission.ResultsDiagnosis of mental health disorders increased the odds of NH admission among the older sample patients (OR = 1.15, 95%CI[1.04,1.28]). Black race was not associated with higher odds, whereas black patients experienced higher odds if they were diagnosed with mental health disorders (OR = 1.60, 95%CI[1.43,1.79]). Medicare as primary payer was associated with greater odds of NH admission. Admission from nursing facilities substantially increased the odds of NH admission upon hospital discharge. Patients discharged with diagnoses of stroke, lower-limb fractures, and a chronic ulcer, as well as those with a longer length-of-stay (> 5 days) experienced increased odds of NH admission. Being discharged from a larger hospital (with >200 beds) decreased the odds for NH admission; as did being discharged from a government-owned hospital.ConclusionsOlder Black patients with mental health disorder experienced significantly greater odds of NH admission after adjusting for other factors. Public policy initiatives are needed to address the specific needs in the vulnerable population to avoid unwanted NH admission.     

Hospice enrollment and hospitalization of dying nursing home patients.

PURPOSE: This study's purpose was to evaluate whether Medicare hospice care provided in nursing homes is associated with lower hospitalization rates. SUBJECTS AND METHODS: This retrospective cohort study included nursing home residents in five states who enrolled in hospice between 1992 and 1996 (n = 9202), and who died before 1998. For each hospice patient, 3 nonhospice residents (2 in 106 instances) were chosen (n = 27,500). Medicare claims identified hospice enrollment and acute care hospitalizations. RESULTS: Twenty-four percent of hospice and 44% of nonhospice residents were hospitalized in the last 30 days of life. Adjusting for confounders, hospice patients were less likely than nonhospice residents to be hospitalized (odds ratio 0.43; 95% confidence interval [CI]: 0.39 to 0.46). Considering all of nonhospice residents who died (n = 226,469), those in facilities with no hospice had a 47% hospitalization rate, whereas rates were 41% in facilities with low hospice use and 39% in facilities with moderate hospice use (5%+ of patients in hospice). Hospitalization was less likely for nonhospice residents in facilities with low hospice use (odds ratio 0.82; 95% CI: 0.80 to 0.84) and moderate hospice use (odds ratio 0.71; 95% CI: 0.69 to 0.74), compared with those in facilities with no hospice. CONCLUSIONS: When integrated into the nursing home care processes, hospice care is associated with less hospitalization for Medicare hospice patients. Additionally, possibly through diffusion of palliative care philosophy and practices, nonhospice residents who died in nursing homes having a hospice presence had lower rates of end-of-life hospitalizations.     

Prediction of hospital readmission for heart failure: development of a simple risk score based on administrative data.

OBJECTIVES: The purpose of this study was to develop a convenient and inexpensive method for identifying an individual's risk for hospital readmission for congestive heart failure (CHF) using information derived exclusively from administrative data sources and available at the time of an index hospital discharge. BACKGROUND: Rates of readmission are high after hospitalization for CHF. The significant determinants of rehospitalization are debated. METHODS: Administrative information on all 1995 hospital discharges in New York State which were assigned International Classification of Diseases-9-Clinical Modification codes indicative of CHF in the principal diagnosis position were obtained. The following were compared among hospital survivors who did and did not experience readmission: demographics, comorbid illness, hospital type and location, processes of care, length of stay and hospital charges. RESULTS: A total of 42,731 black or white patients were identified. The subgroup of 9,112 patients (21.3%) who were readmitted were distinguished by a greater proportion of blacks, a higher prevalence of Medicare and Medicaid insurance, more comorbid illnesses and the use of telemetry monitoring during their index hospitalization. Patients treated at rural hospitals, those discharged to skilled nursing facilities and those having echocardiograms or cardiac catheterization were less likely to be readmitted. Using multiple regression methods, a simple methodology was devised that segregated patients into low, intermediate and high risk for readmission. CONCLUSIONS: Patient characteristics, hospital features, processes of care and clinical outcomes may be used to estimate the risk of hospital readmission for CHF. However, some of the variation in rehospitalization risk remains unexplained and may be the result of discretionary behavior by physicians and patients.     

Quality of care of nursing home residents hospitalized with heart failure

OBJECTIVES: To determine whether the quality of heart failure (HF) care of hospitalized nursing home (NH) residents is different from that of patients admitted from other locations. DESIGN: Retrospective chart review. SETTING: Nursing home residents discharged from hospitals. PARTICIPANTS: Medicare beneficiaries aged 65 and older. MEASUREMENTS: Subjects were discharged with a primary discharge diagnosis of HF in Alabama in 1994. They were categorized as having been admitted from a NH or other locations. Bivariate logistic regression analysis was used to estimate crude odds ratios (ORs) and 95% confidence intervals (CIs) for left ventricular function (LVF) evaluation and angiotensin-converting enzyme (ACE) inhibitor use for NH residents relative to nonresidents. Multivariate generalized linear models were developed to determine independence of associations. RESULTS: Subjects (N = 1,067 years) had a mean age +/- standard deviation of 79 +/- 7.4, 60% were female, and 18% were African Americans. Fewer NH residents (n = 95) received LVF evaluation (39% vs 60%, P <.001) and ACE inhibitors (50% vs 72%, P =.111). NH residents had lower odds for LVF evaluation (OR = 0.42, 95% CI = 0.27-0.64). The odds for ACE inhibitor use, although of similar magnitude, did not reach statistical significance (OR = 0.40, 95% CI = 0.12-1.28). After adjustment of patient and care characteristics, admission from a NH was significantly associated with lower LVF evaluation (adjusted OR = 0.64, 95% CI = 0.49-0.82) but not with ACE inhibitor use (adjusted OR = 0.59, 95% CI = 0.16-2.14). CONCLUSIONS: Quality of HF care received by hospitalized NH residents was lower than that received by others. Further studies are needed to determine reasons for the lack of appropriate evaluation and treatment of NH patients with HF who are admitted to hospitals.     

Use of Postacute Care by Nursing Home Residents Hospitalized for Stroke or Hip Fracture: How Prevalent and to What End?

OBJECTIVES: To examine nursing home (NH) residents' use of Medicare‐paid skilled nursing facility (SNF) services and the outcomes of that care and to identify clinical and non‐clinical factors associated with that care. DESIGN: Retrospective cohort. SETTING: United States. PARTICIPANTS: NH residents aged 65 and older with Medicare claims for a hospitalization for hip fracture or stroke during 2001 to 2003. MEASUREMENTS: Resident diagnoses and use of SNF postacute care were measured using Medicare hospital claims. Market and provider characteristics were drawn from the Provider of Services file. Baseline characteristics, institutionalization, and mortality outcomes were drawn from the Minimum Data Set and Medicare Denominator File. RESULTS: Of the NH population hospitalized for hip fracture (49,903) or stroke (23,084), 79.7% and 64.1%, respectively, used the SNF benefit. Residents not using the SNF benefit had poorer baseline health status; their mortality rates and rates of resuming long‐term care were similar to the rates of residents who used the SNF benefit. CONCLUSION: NH residents used postacute SNF benefits at high rates yet had similar mortality and institutionalization outcomes as those without SNF care.     

Variations in hospitalization rates among nursing home residents: the role of facility and market attributes

PURPOSE: This study examined the contribution of facility-level and area market-level attributes to variations in hospitalization rates among nursing home residents. DESIGN AND METHODS: Three years (1991-1994) of state quarterly Medicaid case-mix reimbursement data from 527 nursing homes (NH) in Massachusetts were linked with Medicare Provider Analysis and Review hospital claims and nursing facility attribute data to produce a longitudinal, analytical file containing 72,319 person-quarter observations. Logistic regression models were used to estimate the influence of facility-level and market-level factors on hospital use, after controlling for individual-level resident attributes, including: NH diagnoses, resident-level quality of care indicators, and diagnostic cost grouping classification from previous hospital stays. RESULTS: Multivariate findings suggest that resident heterogeneity alone does not account for the wide variations in hospitalization rates across nursing homes. Instead, facility characteristics such as profit status, nurse staffing patterns, NH size, chain affiliation, and percentage of Medicaid and Medicare reimbursed days significantly influence NH residents' risk of hospitalization. Broader area market factors also appear to contribute to variations in hospitalization rates. IMPLICATIONS: Variations in hospitalization rates may reflect underutilization, as well as overutilization. Continued efforts toward identifying medically necessary hospitalizations are needed.     

Causes and risk factors for rehospitalization of patients hospitalized with community-acquired pneumonia.

BACKGROUND: Rehospitalization after inpatient treatment of community-acquired pneumonia occurs in one-tenth of all hospitalizations, but the clinical circumstances surrounding readmission to the hospital have not been well studied. The objective of this study was to identify the causes and risk factors for rehospitalization of inpatients with community-acquired pneumonia. METHODS: This project was performed as part of a randomized, multicenter, controlled trial of the implementation of practice guidelines to reduce the duration of intravenous antibiotic therapy and duration of hospitalization for patients who have received a clinical and radiographic diagnosis of pneumonia. The trial was conducted at 7 hospitals in Pittsburgh, Pennsylvania, from February 1998 through March 1999. The primary outcome for these analyses was rehospitalization within 30 days after the index hospitalization. Two physicians independently assigned the cause of rehospitalization as pneumonia related, comorbidity related, or both; consensus was reached for all assignments. Patient demographic characteristics and clinical factors independently associated with rehospitalization were identified using multiple logistic regression analysis. RESULTS: Of the 577 patients discharged after hospitalization for community-acquired pneumonia, 70 (12%) were rehospitalized within 30 days. The median time to rehospitalization was 8 days (interquartile range, 4-13 days). Overall, 52 rehospitalizations (74%) were comorbidity related, and 14 (20%) were pneumonia related. The most frequent comorbid conditions responsible for rehospitalization were cardiovascular (n = 19), pulmonary (n = 6) and neurological (n = 6) in origin. Less than a high school education (odds ratio, 2.0; 95% confidence interval, 1.1-3.4), unemployment (odds ratio, 3.7; 95% confidence interval, 1.1-12.3), coronary artery disease (odds ratio, 2.7; 95% confidence interval, 1.5-4.7), and chronic obstructive pulmonary disease (odds ratio, 2.3; 95% confidence interval, 1.3-4.1) were independently associated with rehospitalization. CONCLUSIONS: The majority of rehospitalizations following pneumonia are comorbidity related and are the result of underlying cardiopulmonary and/or neurologic diseases. Careful attention to the clinical stability of patients with these coexisting conditions at and following hospital discharge may decrease the frequency of rehospitalization of patients with community-acquired pneumonia.     

Discretionary hospitalization of nursing home residents with and without Alzheimer's disease: a multilevel analysis

This study analyzes facility variations in hospital admission rates of nursing home (NH) residents with and without Alzheimer's disease (AD) or related dementia with the aim of better understanding how facility-level contextual factors differentially affect hospitalization risks. METHOD: The sample population consists of 19,217 and 18,399 Medicaid residents with and without AD, respectively, from 546 NHs in Massachusetts between 1991 and 1993. Hospital use is measured as annual nonpsychiatric discretionary hospital admissions to short-term general hospitals. Multilevel estimation methods are used to obtain facility and market area parameter estimates. RESULTS: There was greater interfacility variation in discretionary hospital admission rates of AD residents than residents without AD, particularly among more vulnerable subgroups of AD residents. DISCUSSION: The findings underscore the importance of licensed nursing personnel in reducing discretionary hospitalizations among NH residents with AD.     

Utility of pulse oximetry in diagnosing pneumonia in nursing home residents

BACKGROUND: The differential diagnosis of acute infection in elderly nursing home patients is often difficult. This study evaluated pulse oximetry in pneumonia in this population. METHODS: A case-control study was performed in a veteran's nursing home involving 2 analyses: (1) pneumonia patients (case subjects) were compared with patients with nonpulmonary infections (control subjects) at time of acute infection; (2) differences in paired values measured at time of infection versus a noninfected baseline were compared for pneumonia patients and control subjects. Vital signs including pulse oximetry were obtained routinely (at least monthly) and with acute illness. RESULTS: Oxygen saturations were lower in 45 pneumonia patients than in 22 patients with acute nonpulmonary infections (P < 0.001). An oxygen saturation < 94 gave a sensitivity for pneumonia of 80%, specificity of 91%, and positive predictive value of 95%. The drop in oxygen saturation from the last baseline value was greater in pneumonia patients than in control subjects (P < 0.001). The sensitivity of an oxygen saturation drop >3% from baseline for pneumonia was 73% with specificity and positive predictive values of 100%. CONCLUSIONS: Pulse oximetry may be very helpful in evaluating acutely infected nursing home residents. The present study suggests that in acutely infected nursing home patients, a decrease in oxygen saturation of >3% from baseline, as well as a single oxygen saturation of <94, should suggest pneumonia. A decrease from baseline of <4% or a single oxygen saturation of 94 or higher suggests that pneumonia is unlikely.     

Length of hospital stay among oldest-old patients in acute geriatric ward

PurposeTo examine risk factors for prolonged hospital length of stay (LOS) in the oldest-old inpatients aged ≥ 90.MethodsThis retrospective cross-sectional study was performed in acute Geriatrics Department at Kaplan Medical Center. The target population was the oldest-old inpatients aged ≥ 90 hospitalized with acute illness. In total 1536 admissions of 987 patients admitted between January 2007 and December 2010 from the emergency room were included in the study. We retrieved from the electronic hospital records the following data: demographics, admission diagnosis, comorbidities, laboratory tests, drugs, functional and cognitive status, Charlson Comorbidity Index (CCI) score and age-adjusted CCI score.ResultsThe risk factors for a prolonged LOS were tube-feeding, consumption of ≥ 5 drugs, non-independent functional status, diagnosis of urinary tract infection (UTI), pneumonia and malignancy on admission, and comorbidities of congestive heart failure (CHF) and hypoalbuminemia. Multiple linear regression analysis found that UTI, hypoalbuminemia, elevated troponin, pneumonia, number of drugs, malignancy, CHF and number of comorbidities explain a higher risk for a longer LOS.ConclusionHospital LOS in the oldest-old patients in acute geriatric ward was associated with admission diagnosis and comorbidities. Awareness of the risk factors for a longer LOS might contribute to reducing hospitalization stay and its related negative consequences. Accurate prediction of prolonged LOS in this age group of patients may be more challenging and require variables that were not included in our study. Future research is warranted.     

An evaluation of increased mortality rates in Wisconsin nursing homes

We reviewed mortality data from 80 nonprofit and government-owned skilled nursing facilities (SNFs) to evaluate previously reported increases in deaths occurring in Wisconsin nursing homes since 1983. Comparing nursing home mortality data for 1982 and 1985, we found a 16.6% increase in overall nursing home mortality rates. The increased mortality rates occurred in the sample SNFs regardless of ownership, Medicare certification, bed size, metropolitan area and hospital affiliation. There were two explanations for the increased mortality rates. First, the number of residents dying within 30 days after nursing home admission increased 59%. The majority of these short-lived residents had been discharged from hospitals indicating a transfer of terminally ill patients into nursing homes just prior to death. Second, there was a 27% increase in the mortality rate of residents living in the nursing home for 1 to 5 years suggesting that the population had become sicker between 1982 and 1985. These data reflect both the impact of Medicares Prospective Payment System (PPS) on the study nursing homes and an increase in the severity of illness of Wisconsin's nursing home population between 1982 and 1985. The findings document an increased role for nursing homes in caring for more acutely ill patients since the passage of the PPS, and have implications for nursing home reimbursement policies and quality of care.     

Nursing homes as acute care providers. A pilot study of incentives to reduce hospitalizations

This program was designed to encourage treatment of episodes of acute illness in skilled nursing facilities in order to avoid costly and potentially traumatic admission to hospital. It is part of the Monroe County Long Term Care Program, Inc, system of case management and Medicare and Medicaid waivers, and consists of financial incentives, paid by Medicare, to facilities and to responsible physicians to evaluate and care for acutely ill patients in the SNF's when medically safe and feasible. A retrospective evaluation using a physician assessment committee concluded that among the first 112 patients in the program, 76% were very probably saved hospitalization or at least an emergency room visit. Acute bacterial infection was the most common category of episode, occurring in 46% of cases. Considerable savings to both Medicare and Medicaid were estimated to have resulted.     

Clinical characteristics and outcomes among older nursing home residents hospitalized with pneumonia

Background: Due to population aging, the number of cases of pneumonia in nursing homes in South Korea has been increasing. This study investigated the characteristics and clinical outcomes in nursing home residents with pneumonia admitted to a tertiary hospital.Methods: A retrospective cohort study was conducted of patients transferred to the tertiary hospital from nursing homes between August 2009 and October 2016. The in-hospital mortality, Pneumonia Severity Index, bacterial pathogens in sputum cultures, and antibiotic sensitivity profile were assessed.Results: The analysis included a total of 174 patients hospitalized with pneumonia. Their median age was 78 years, and 109 patients (62.6%) were male. 108 patients (62.1%) were admitted to the intensive care unit. The in-hospital mortality rate was 12.6% (22/174). Culture of a multidrug-resistant (MDR) pathogen was an independent risk factor for mortality (odds ratio [OR]: 3.72, 95% confidence interval [CI]: 1.16–11.89). Male sex and a history of antibiotic use within the previous 3 months were independent risk factors for MDR pathogen isolation (OR: 3.32, 95% CI, 1.38–7.98 and OR: 3.93, 95% CI: 1.82–8.49, respectively).Conclusions: Detection of an MDR pathogen, rather than host factors such as old age, bedridden status, and comorbidities, was the most important risk factor for in-hospital mortality in patients with nursing home pneumonia. Patients with a history of antibiotic use within the previous 3 months had a higher probability of MDR pathogen identification. Identifying MDR pathogens is important in treating older nursing home residents with pneumonia.     

Hospitalization and death associated with potentially inappropriate medication prescriptions among elderly nursing home residents

BACKGROUND: This study examines the association of potentially inappropriate medication prescribing (PIRx) with hospitalization and death among elderly long-stay nursing home residents. METHODS: We defined PIRx using the combined version of the Beers criteria. Data were from the 1996 Medical Expenditure Panel Survey Nursing Home Component. The study sample included 3372 residents, 65 years and older, who had nursing home stays of 3 consecutive months or longer in 1996. We performed multivariate logistic regression analyses of longitudinal data using generalized estimating equations. RESULTS: Residents who received any PIRx had greater odds (odds ratio [OR], 1.27; P = .002) of being hospitalized in the following month than those receiving no PIRx. Residents with PIRx exposure for 2 consecutive months were at increased risk (OR, 1.27; P = .004) of hospitalization, as were those receiving PIRx in the second month only (OR, 1.80; P = .001), compared with those receiving no PIRx. Residents who received PIRx were at greater risk of death (OR, 1.28; P = .01) that month or the next. Residents with intermittent PIRx exposures were at greater odds of death (OR, 1.89; P<.001), compared with those with no PIRx exposure. CONCLUSIONS: The association of PIRx with subsequent adverse outcomes (hospitalization and death) provides new evidence of the importance of improving prescribing practices in the nursing home setting.