Disparities in 30-day readmission rates among Medicare enrollees with dementia

Background

Readmissions contribute to excessive care costs and burden for people living with dementia. Assessments of racial disparities in readmissions among dementia populations are lacking, and the role of social and geographic risk factors such as individual-level exposure to greater neighborhood disadvantage is poorly understood. We examined the association between race and 30-day readmissions in a nationally representative sample of Black and non-Hispanic White individuals with dementia diagnoses.

Methods

This retrospective cohort study used 100% Medicare fee-for-service claims from all 2014 hospitalizations nationwide among Medicare enrollees with dementia diagnosis linked to patient, stay, and hospital factors. The sample consisted of 1,523,142 hospital stays among 945,481 beneficiaries. The relationship between all cause 30-day readmissions and the explanatory variable of self-reported race (Black, non-Hispanic White) was examined via generalized estimating equations approach adjusting for patient, stay, and hospital-level characteristics to model 30-day readmission odds.

Results

Black Medicare beneficiaries had 37% higher readmission odds compared to White beneficiaries (unadjusted OR 1.37, CI 1.35–1.39). This heightened readmission risk persisted after adjusting for geographic factors (OR 1.33, CI 1.31–1.34), social factors (OR 1.25, CI 1.23–1.27), hospital characteristics (OR 1.24, CI 1.23–1.26), stay-level factors (OR 1.22, CI 1.21–1.24), demographics (OR 1.21, CI 1.19–1.23), and comorbidities (OR 1.16, CI 1.14–1.17), suggesting racially-patterned disparities in care account for a portion of observed differences. Associations varied by individual-level exposure to neighborhood disadvantage such that the protective effect of living in a less disadvantaged neighborhood was associated with reduced readmissions for White but not Black beneficiaries. Conversely, among White beneficiaries, exposure to the most disadvantaged neighborhoods associated with greater readmission rates compared to White beneficiaries residing in less disadvantaged contexts.

Conclusions

There are significant racial and geographic disparities in 30-day readmission rates among Medicare beneficiaries with dementia diagnoses. Findings suggest distinct mechanisms underlying observed disparities differentially influence various subpopulations.     

Violence against emergency medical services personnel: A systematic review of the literature

Background

Violence against emergency medical services (EMS) personnel is a growing concern. The aim of this systematic review is to synthesize the current literature on violence against EMS personnel.

Methods

We examined literature from 2000 to 2016. Eligibility criteria included English‐language, peer‐reviewed studies of EMS personnel that described violence or assaults. Sixteen searches identified 2655 studies; 25 studies from nine countries met the inclusion criteria.

Results

The evidence from this review demonstrates that violence is a common risk for EMS personnel. We identified three critical topic areas: changes in risk over time, economic impact of violence and, outcomes of risk‐reduction interventions. There is a lack of peer reviewed research of interventions, with the result that current intervention programs have no reliable evidence base.

Conclusions

EMS leaders and personnel should work together with researchers to design, implement, evaluate and publish intervention studies designed to mitigate risks of violence to EMS personnel.

     

A Survey of Workplace Violence Across 65 U.S. Emergency Departments

Objectives: Workplace violence is a concerning issue. Healthcare workers represent a significant portion of the victims, especially those who work in the emergency department (ED). The objective of this study was to examine ED workplace violence and staff perceptions of physical safety. Methods: Data were obtained from the National Emergency Department Safety Study (NEDSS), which surveyed staff across 69 U.S. EDs including physicians, residents, nurses, nurse practitioners, and physician assistants. The authors also conducted surveys of key informants (one from each site) including ED chairs, medical directors, nurse managers, and administrators. The main outcome measures included physical attacks against staff, frequency of guns or knives in the ED, and staff perceptions of physical safety. Results: A total of 5,695 staff surveys were distributed, and 3,518 surveys from 65 sites were included in the final analysis. One‐fourth of surveyed ED staff reported feeling safe sometimes, rarely, or never. Key informants at the sampled EDs reported a total of 3,461 physical attacks (median of 11 attacks per ED) over the 5‐year period. Key informants at 20% of EDs reported that guns or knives were brought to the ED on a daily or weekly basis. In multivariate analysis, nurses were less likely to feel safe “most of the time” or “always” when compared to other surveyed staff. Conclusions: This study showed that violence and weapons in the ED are common, and nurses were less likely to feel safe than other ED staff.     

“My Older Clients Fall Through Every Crack in the System”: Geriatrics Knowledge of Legal Professionals

With the number of older adult arrestees and prisoners increasing rapidly, legal professionals increasingly provide front‐line identification and response to age‐related health conditions (including cognitive and physical impairments) that may affect legal outcomes, such as the ability to participate in one's defense or stay safe in jail. The goals of this study were to assess the ability of legal professionals to recognize and respond to age‐related conditions that could affect legal outcomes and to identify recommendations to address important knowledge gaps. This was a mixed quantitative–qualitative study. Legal professionals (N = 72) in the criminal justice system were surveyed to describe their demographic characteristics, expertise, and prior aging‐related training and to inform the qualitative interview guide. Those surveyed included attorneys (district attorneys (25%), public defenders and legal advocates (58%)), judges (6%), and court‐affiliated social workers (11%). In‐depth qualitative interviews were then conducted with a subset of 10 legal professionals who worked with older adults at least weekly. Results from the surveys and interviews revealed knowledge deficits in four important areas: age‐related health, identification of cognitive impairment, assessment of safety risk, and optimization of services upon release from jail. Four recommendations to close these gaps emerged: educate legal professionals about age‐related health, train professionals to identify cognitive and sensory impairment, develop checklists to identify those at risk of poor health or safety, and improve knowledge of and access to transitional services for older adults. These findings suggest that geriatrics knowledge gaps of legal professionals exist that may contribute to adverse medical or legal outcomes for older adults involved in the criminal justice system and that partnerships between healthcare and legal professionals are needed to address these challenges.