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Background: Prior research has reported that integrative medicine (IM) therapies reduce pain in inpatients, but without controlling for important variables. Here, the authors extend prior research by assessing pain reduction while accounting for each patient's pain medication status and clinical population. Methods: The initial data set consisted of 7,106 inpatient admissions, aged ≥18 years, between July 16, 2012, and December 15, 2014. Patients' electronic health records were used to obtain data on demographic, clinical measures, and pain medication status during IM. Results: The final data set included first IM therapies delivered during 3,635 admissions. Unadjusted average pre-IM pain was 5.33 (95% confidence interval [CI]: 5.26 to 5.41) and post-IM pain was 3.31 (95% CI: 3.23 to 3.40) on a 0-10 scale. Pain change adjusted for severity of illness, clinical population, sex, treatment, and pain medication status during IM was significant and clinically meaningful with an average reduction of -1.97 points (95% CI: -2.06 to -1.86) following IM. Adjusted average pain was reduced in all clinical populations, with largest and smallest pain reductions in maternity care (-2.34 points [95% CI: -2.56 to -2.14]) and orthopedic (-1.71 points [95% CI: -1.98 to -1.44]) populations. Pain medication status did not have a statistically significant association on pain change. Decreases were observed regardless of whether patients were taking narcotic medications and/or nonsteroidal anti-inflammatory drugs versus no pain medications. Conclusions: For the first time, inpatients receiving IM reported significant and clinically meaningful pain reductions during a first IM session while accounting for pain medications and across clinical populations. Future implementation research should be conducted to optimize identification/referral/delivery of IM therapies within hospitals. Clinical Trials.gov #NCT02190240.

Objectives: An important task facing hospitals is improving pain management without raising costs. Integrative medicine (IM), a promising nonpharmacologic pain management strategy, is yet to be examined for its cost implications in an inpatient setting. This institution has had an inpatient IM department for over a decade. The purpose was to examine the relationship between changes in patients' pain, as a result of receiving IM therapy, and total cost of care during an inpatient hospital admission. Design: In this retrospective analysis, data from an EPIC-based electronic health record (EHR) patient demographics, length of stay (LOS), and All Patient Refined Diagnosis Related Groups (APR-DRG) severity of illness measures were utilized. IM practitioners collected and entered patient-reported pain scores into the EHR. The authors regressed the demographic, change in pain, LOS, and APR-DRG variables with changes in pain on total cost for the hospital admission. To estimate cost savings to the hospital, they computed the average reduction in cost associated with reduction in pain by multiplying the coefficient for change in pain by average total cost. Setting/Location: A large, tertiary care hospital in Minneapolis, MN. Subjects: Adult inpatient admissions, 2730, during the study period where patients received IM for pain and met eligibility criteria. Intervention: IM services provided to inpatients. Outcome measures: Change in pain on an 11-point numeric rating scale before and after initial IM sessions; total costs for hospital admissions. Results: Both LOS and age were found to increase cost, as did being white, male, married, and having APR-DRG severity coded as extreme. For patients receiving IM therapies, pain was reduced by an average of 2.05 points and this pain reduction was associated with a cost savings of $898 per hospital admission. Conclusions: For patients receiving IM therapies, pain was significantly reduced and costs were lowered by about 4%.

Objectives To conduct a cost analysis of ambient assisted living technology, which is promising for improving the ability of individuals and care providers to monitor daily activities and gain better awareness through proactive management of health and safety. Design Three-arm cohort study. Setting Homes of enrollees of a state-based healthcare plan for older adults. Participants Enrollees dually eligible for Medicare and Medicaid (N = 268). Intervention Health and safety passive remote patient monitoring (PRPM) systems were installed in enrollees’ homes (the intervention group) with monitoring and proactive intervention of a case manager when deviation from baseline subject behavior was detected. Measurements Claims data were collected over 12 months to assess healthcare use and costs in the intervention group and to compare use and costs with those of two control groups: a concurrent group of enrollees who declined the technology and a historical cohort matched on age to the participation group. Results Although the small sample size precluded cost differences that were statistically significant, the participant group used substantially less custodial care, emergency department (ED) services, inpatient stays, and ED costs than the two control groups. Conclusion In this pilot study, the PRPM system was associated with apparent healthcare cost savings. Although more cost analyses are warranted, ambient assisted living technologies are a potentially valuable investment for older adult care.

Some large employers and healthcare analysts have advocated for retail competition that relies on providers competing on performance metrics to improve care quality. Using publicly available performance measures, we determined whether health systems increased the quality of diabetes care provided by their clinics based on performance relative to competitors.Our analysis examined publicly reported performance measures of diabetes care from 2006 to 2013 for clinics in Minnesota health systems.We obtained data for 654 clinics, of which 572 publicly reported diabetes care performance. Because some clinics did not report performance, we estimated a Heckman selection model. First, we predicted whether or not clinics reported performance. Second, we estimated the effect of relative performance (a clinic's performance minus the mean performance of clinics in competing health systems) on clinic performance using the results of the reporting model to control for selection into the sample of reporting clinics.Although diabetes care performance improved during our study, health systems did not differentially improve the diabetes care performance of their clinics performing worse than clinics in competing systems. This result indicates divergence between high-performing and low-performing clinics. This result does not appear to be due to risk selection.Publicly reporting quality information did not incentivize health systems to increase the performance of their clinics with lower performance than competitors, as would be expected under retail competition. Our results do not support strategies that rely on competition on publicly reported performance measures to improve quality in diabetes care management.

Objective To examine how the relationship between patient characteristics, patient experience with the health care system, and overall satisfaction with care varies with illness complexity. Data Sources/Study Setting Telephone survey in 14 U.S. geographical areas. Study Design Structural equation modeling was used to examine how relationships among patient characteristics, three constructs representing patient experience with the health care system, and overall satisfaction with care vary across patients by number of chronic illnesses. Data Collection/Extraction Methods Random digital dial telephone survey of adults with one or more chronic illnesses. Principal Findings Patients with more chronic illnesses report higher overall satisfaction. The total effects of better patient–provider interaction and support for patient self-management are associated with higher satisfaction for all levels of chronic illness. The latter effect increases with illness burden. Older, female, or insured patients are more satisfied; highly educated patients are less satisfied. Conclusions Providers seeking to improve their patient satisfaction scores could do so by considering patient characteristics when accepting new patients or deciding who to refer to other providers for treatment. However, our findings suggest constructive actions that providers can take to improve their patient satisfaction scores without selection on patient characteristics.

To define the relationship between vitamin D status and employee presenteeism in a large sample of health care employees.Prospective observation study of 10,646 employees of a Midwestern-integrated health care system who completed an on-line health risk appraisal questionnaire and were measured for 25-hydroxyvitamin D.Measured differences in productivity due to presenteeism were 0.66, 0.91, and 0.75 when comparing employees above and below vitamin D levels of 20 ng/mL, 30 ng/mL, and 40 ng/mL, respectively. These productivity differences translate into potential productivity savings of 0.191%, 0.553%, and 0.625%, respectively, of total payroll costs.Low vitamin D status is associated with reduced employee work productivity. Employee vitamin D assessment and replenishment may represent a low-cost, high-return program to mitigate risk factors and health conditions that drive total employer health care costs.

Background: Optimal inpatient pain management remains a major institutional and therapeutic challenge. Nontoxic, nonpharmacological approaches to treating pain show promise but have not been widely implemented, nor has their effectiveness been evaluated. Aims: To evaluate the effectiveness of an inpatient integrative medicine consult service for pain management in 6 settings across an entire tertiary care hospital. Design: Retrospective, observational study. Setting Abbott Northwestern Hospital, a 629-bed tertiary-care hospital in Minneapolis, Minn, that is part of Allina Hospitals & Clinics. Participants: Approximately 1837 patients hospitalized between January 1, 2008, and June 30, 2009. Measurements: Pretreatment and posttreatment pain scores on a verbal scale of 0 to 10. Results: Most patients (66%) had never previously received integrative services. Provision of integrative services had immediate and beneficial effects on pain scores. The average reduction in pain scores was 1.9 points (on a 10-point scale), and the average percentage in pain reduction was approximately 55%. Conclusions: The formal provision of inpatient integrative medicine had a significant impact on pain scores for hospitalized patients, reducing self-reported pain by more than 50%, without placing patients at increased risk of adverse effects. This was true in all 6 settings. Age, previous use of complementary therapies, and sex did not affect results. Future research must define the appropriate dose of the intervention, the duration of the relief, and the identification of patients most likely to respond to these nonpharmacological treatments. Additionally, future research using the electronic health record will allow quantification of any reduction in total costs, pain medication usage, and adverse events.

Background: Follow-up is critically important for stroke survivors with diabetes, yet there is limited research about the quality of diabetes care that these patients receive. We investigated performance on diabetes quality of care indicators for stroke survivors overall and by race. Methods: Claims data was extracted for 1,460 Medicare beneficiaries with preexisting diabetes who survived hospitalization for acute ischemic stroke in 2000. Adjusted probabilities of receiving HbA1c, LDL and dilated eye exams were estimated using logistic regression. Results: 53% had a dilated eye exam, 60% received an LDL check, 73% percent had their HbA1c checked at least once and only 51% received two or more HbA1c checks. In the unadjusted results, blacks were significantly less likely than whites to receive these tests. Conclusions:Care of stroke survivors, particularly blacks, shows gaps according to guidelines.

SUMMARY Background: “Bounce-backs” (movements from a less intensive to a more intensive care setting) soon after hospital discharge are common, but reasons for bouncing-back remain unknown. Objective: To examine how the primary diagnosis for first rehospitalization relates to thirty-day bounce-back number and initial discharge destination in acute stroke. Population: Administrative data from 5,250 Medicare beneficiaries > 65 years discharged with acute ischemic stroke in 1998–2000 to a rehabilitation center, skilled nursing facility or home with home health care and with at least one thirty day rehospitalization. Analysis: Probability of thirty-day bounce-back was calculated using multivariate models. Results: Infections and aspiration pneumonitis were the most common reasons for rehospitalization, regardless of initial discharge site. Conclusions: Efforts addressing aspirations and infections, the preventable complications of immobility, will be critical in decreasing acute stroke bounce-backs.

Diabetes care has become increasingly complex. We set out to quantify recent trends in the complexity of medication regimens and test ordering for diabetes patients continuously enrolled in health plans affiliated with a large, regional US health maintenance organization, with representation in the South and Midwest.We provide descriptive trends analysis of overall diabetes care complexity (number of components [i.e., glucose, blood pressure, cholesterol control], number of medications/tests) from 1995 to 2003 for adults with diabetes (N = 304,233).The main outcomes were (1) the proportion of patients receiving diabetes-related medications (blood glucose, blood pressure, and cholesterol control agents), (2) the average number of medications, (3) the proportion of patients receiving diabetes-related tests (glycosylated hemoglobin [HbA1c], urine microalbumin, and serum cholesterol), (4) and the average number of tests ordered within the first year that a patient had any indication of diabetes.The proportion of patients on cholesterol lowering drugs (18% --39%, p0.01) and blood pressure lowering drugs (51% --62%, p = 0.04) rose significantly, while the proportion on glucose lowering drugs fell (76% --47%, p0.01). Among patients prescribed medications, the average total number of diabetes-related medications rose from 2.96 to 3.70 medications (p0.01) with smaller increases seen for glucose lowering (1.45 --1.65, p0.01) and blood pressure lowering regimens (2.14 --2.51, p0.01), and no change for cholesterol lowering drugs (1.23 --1.19, p = 0.19). For laboratory tests, the proportion receiving cholesterol (40% --58%), and urine microalbumin (4% --18%) (all p's0.01) rose significantly, while the testing rates for HbA(1c) remained unchanged. The average total number of tests ordered per year increased significantly from 3.34 to 4.10 (p0.01) with more modest increases observed for individual tests.Trends analyses are unadjusted for many clinical characteristics that might influence the complexity of diabetes care.Diabetes care grew more complex with the largest change in the number of patients receiving multi-component diabetes care. While the use of blood pressure and cholesterol lowering drugs rose overall, the proportion of patients using glucose lowering drugs declined and the average number of prescribed glucose lowering drugs did not increase in a clinically significant manner.

Background and Purpose: Stroke patients appear to have improved outcomes when cared for by neurologists, but the mechanism by which improved outcome is achieved is unclear. This study compares 30-day cause-specif ic rehospitalization, 30-day mortality, and specific processes of care for patients treated by a neurologist only, a generalist only, a neurologist and a generalist (i.e., collaborative care), or by another specialist during the index hospitalization.Methods: This study uses Cox regression to analyze claims and enrollment data from 44,099 Medicare beneficiaries 65 years of age and older and discharged with acute ischemic stroke from 1998 to 2000 in 11 US metropolitan regions. Results: Patients seen by neurologists had more severe strokes than patients seen by generalists, though patients seen by generalists had more comorbidities. Patients seen by neurologists (alone or collaboratively) had a 10 and 16% lower risk of 30-day mortality, respectively. Patients seen by a neurologist only had a 12% lower risk of rehospitalization for infections and aspiration pneumonitis. In contrast, patients seen by neurologists had a higher risk of rehospitalization for atherosclerotic (cardiovascular and non-acute cerebrovascular) disease. Patients seen by neurologists were more likely to be discharged to inpatient rehabilitation, had longer lengths of stay, and were more likely to receive warfarin after discharge. Conclusions: Results support the hypothesis that neurologists improve outcomes specifically by reducing the potential for aspiration (through increased swallowing evaluations) or by improving functioning (through use of rehabilitation therapy). Future studies should continue to examine the mechanisms by which neurologists may achieve better outcomes in stroke care.

Objective Given the risks of opioid medications, nonpharmacological strategies should be considered for total joint replacement patients. We investigated acupuncture as an adjunct therapy for postsurgical pain management in a total joint replacement program by examining which total hip and knee replacement patients elected to receive acupuncture and the effect of acupuncture on short-term pain. Design A total joint replacement program using fast-track physiotherapy offered elective postsurgical acupuncture to all patients, at no additional cost, as an adjunct therapy to opioids for pain management. Setting The Joint Replacement Center at Abbott Northwestern Hospital, a 630-bed teaching and specialty hospital in Minneapolis, Minnesota from 2010 to 2012. Subjects Our sample included 2,500 admissions of total hip (THR) and total knee replacement (TKR) patients. Methods Self-reported pain was assessed before and after acupuncture using a 0–10 scale and categorized as none/mild (0–4) and moderate/severe pain (5–10). Results Seventy-five percent of admissions included acupuncture. Women (Odds Ratio: 1.48, 95% Confidence Interval (CI): 1.22, 1.81) had higher odds of receiving acupuncture compared to men, and nonwhite patients (Odds Ratio: 0.55, 95% CI: 0.39, 0.78) had lower odds of receiving acupuncture compared to white patients. Average short-term pain reduction was 1.91 points (95% CI: 1.83, 1.99), a 45% reduction from the mean prepain score. Forty-one percent of patients reported moderate/severe pain prior to receiving acupuncture, while only 15% indicated moderate/severe pain after acupuncture. Conclusions Acupuncture may be a viable adjunct to pharmacological approaches for pain management after THR or TKR.

Few studies have investigated the effectiveness of integrative medicine (IM) therapies on pain and anxiety among oncology inpatients.Retrospective data obtained from electronic medical records identified patients with an oncology International Classification of Diseases-9 code who were admitted to a large Midwestern hospital between July 1, 2009 and December 31, 2012. Outcomes were change in patient-reported pain and anxiety, rated before and after individual IM treatment sessions, using a numeric scale (0-10).Of 10948 hospital admissions over the study period, 1833 (17%) included IM therapy. Older patients had reduced odds of receiving any IM therapy (odds ratio [OR]: 0.97, 95% confidence interval [95% CI] = 0.96 to 0.98) and females had 63% (OR: 1.63, 95% CI = 1.38 to 1.92) higher odds of receiving any IM therapy compared with males. Moderate (OR: 1.97, 95% CI = 1.61 to 2.41), major (OR: 3.54, 95% CI = 2.88 to 4.35), and extreme (OR: 5.96, 95% CI = 4.71 to 7.56) illness severity were significantly associated with higher odds of receiving IM therapy compared with admissions of minor illness severity. After receiving IM therapy, patients averaged a 46.9% (95% CI = 45.1% to 48.6%, P.001) reduction in pain and a 56.1% (95% CI = 54.3% to 58.0%, P.001) reduction in anxiety. Bodywork and traditional Chinese Medicine therapies were most effective for reducing pain, while no significant differences among therapies for reducing anxiety were observed.IM services to oncology inpatients resulted in substantial decreases in pain and anxiety. Observational studies using electronic medical records provide unique information about real-world utilization of IM. Future studies are warranted and should explore potential synergy of opioid analgesics and IM therapy for pain control.

Background Pain and anxiety occurring from cardiovascular disease are associated with long-term health risks. Integrative medicine (IM) therapies reduce pain and anxiety in small samples of hospitalized cardiovascular patients within randomized controlled trials; however, practice-based effectiveness research has been limited. The goal of the study is to evaluate the effectiveness of IM interventions (i.e., bodywork, mind-body and energy therapies, and traditional Chinese medicine) on pain and anxiety measures across a cardiovascular population. Methods Retrospective data obtained from medical records identified patients with a cardiovascular ICD-9 code admitted to a large Midwestern hospital between 7/1/2009 and 12/31/2012. Outcomes were changes in patient-reported pain and anxiety, rated before and after IM treatments based on a numeric scale (0-10). Results Of 57,295 hospital cardiovascular admissions, 6,589 (11.5%) included IM. After receiving IM therapy, patients averaged a 46.5% (p-value

BACKGROUND: Hip fracture is a common problem among older Americans. Two types of procedures are available for repairing hip fractures: hip replacement and open or closed reduction with or without internal fixation. The assumption has been that hip replacement produces better functional outcomes. Although that is the common wisdom, outcome studies evaluating hip replacement for treatment of hip fracture are few and have not clearly documented its superiority. OBJECTIVES: To compare outcomes of hip fracture patients who receive hip replacement versus another stabilizing procedure (open or closed reduction with or without internal fixation). DESIGN: Prospective cohort study. PARTICIPANTS: We studied 332 patients (age, > 65) who were hospitalized for a femoral neck fracture and discharged alive. MEASUREMENTS: We examined 2 treatment groups, hip replacement versus another procedure, on 6 outcomes [Activities of Daily Living (ADLs), walking, living situation (institutionalized or not), perceived health (excellent/good vs. fair/poor), rehospitalization, and mortality] at 3 postdischarge times (6 weeks, 6 months and 1 year). RESULTS: Mean age was 80, 80% were female, 96% White, 28% married, and 71% had a hip replacement. The treatment groups were similar at baseline (3 months before admission as reported at discharge) on ADLs, walking, living situation, and perceived health (all P > 0.24). After adjusting for demographics, clinical characteristics, fracture characteristics, and prior ADLs, walking ability, living situation, and perceived health, patients with a hip replacement did not do better at 6 weeks, 6 months, or 1 year post-discharge on any of the 6 outcome measures (all 18 P > 0.10). A global test of all 6 outcomes finds hip replacement patients doing less well at one year (P = 0.02). CONCLUSIONS: Despite the commonly held belief that hip replacement is a superior treatment for hip fracture, we found no suggestion of better outcomes for hip replacement on any of 6 key outcomes. Language: en

The ratings of the importance of functional status items among geriatric experts and consumers in Europe and the United States differed in many cases between experts and consumers in both countries; the differences were more frequent among the U.S. samples. The overall correlation between consumer and expert rankings was .82 for both groups. In general consumers, rated instrumental activities of daily living (IADL) items more highly, whereas the experts rated the most dysfunctional activities of daily living (ADL) items higher than did consumers. This study suggests the gap in doctor–patient communication. As function is increasingly used as a clinical outcome, agreement is needed on how to weight the components. The differences uncovered in this study suggest a need for more dialogue about what ends are truly sought by various parties.

OBJECTIVES This study investigates the degree of substitutability of adult foster care for nursing home care in Oregon. METHODS Using three tests, the authors determined (1) the extent to which an additional adult foster care resident in a county reduces the number of nursing home residents in that county, (2) which characteristics of residents and facilities are important in sorting residents into either nursing homes or adult foster care facilities, and (3) the price elasticity of demand for adult foster care, using the county as the unit of observation. RESULTS It was found that for every additional foster care resident in a county, a nursing home loses 0.85 residents-almost a one-to-one substitution ratio. CONCLUSIONS Despite the high degree of substitutability, residents perceive important differences in the characteristics of the two forms of care. Indeed, private residents are, on average, willing to pay twice as much for nursing home care as for adult foster care, suggesting that these differences are important. Finally, private consumers are sensitive to price differences among adult foster care facilities. The implications for policy are discussed.

The informal care networks of 242 impaired older people were examined in terms of the primary caregiver and secondary helpers. Most primary caregivers had at least one secondary helper; 88% identified helpers who provided hands-on help, 19% reported that helpers contributed financially, and 44% had helpers involved in care decisions. The size of the network was larger for direct care compared to financial or decision-making assistance. Almost half of primary caregivers reported that their spouse helped. It was expected that after controlling for characteristics of the primary caregiver and of the older person, that characteristics of the secondary caregiver network would influence the amount and type of primary caregiver assistance and formal care used by the older person. However, both hours and type of care by the primary caregiver were independent of size, scope, and composition of the secondary helper network. This independence suggests that efforts to alter the secondary caregiver network may have limited effects on the primary caregiver.

purpose To measure the quality of care for hypertensive and diabetic elderly Medicaid beneficiaries enrolled in managed care versus fee-for-service (FFS) plans. methods Individuals enrolled in the Medicaid Demonstration Project in Hennepin County, Minnesota, were randomly assigned to receive their care either in one of seven managed care health plans in which the Medicaid payment for their care was capitated or in an FFS plan. Two hundred ninety-one hypertensives and 96 diabetics who were aged 65 years or over at the beginning of the evaluation were interviewed at baseline and followed for 1 year. Drug and nondrug therapy, monitoring, monthly medication costs, and access to medications were assessed. results The prepaid and FFS did not differ in drug or nondrug therapy, with the exception that slightly more FFS enrollees were on human insulin after 1 year. Mean monthly medication costs and access to medications were similar for both groups. conclusions In this randomized trial, we were unable to detect differences in the process of care for hypertensive and diabetic Medicaid enrollees.

The importance of assessing functional status in the hospitalized patient is gaining recognition. However, the availability and accuracy of medical record functional status data are uncertain. We collected data on 2,504 patients greater than 65 years of age discharged alive. A personal interview conducted 2 days before discharge recorded the patient's self-reported ability to perform 5 activities of daily living scales. Medical record abstraction was used independently to determine ability to perform the same activities of daily living scales. Patients who required any human assistance to perform a function were considered dependent. Patients were also contacted after discharge to determine the site of posthospital care (28% discharged to a nursing home). The amount of missing medical record functional status data varied by function from 20% for bathing to 50% for dressing. Ten percent of patients had no medical record functional status documentation concerning any of the five functions. The prevalence of self-reported dependence at discharge varied by function from 24% for feeding to 93% for bathing. The total number of dependencies differed between the two methods (medical records, 2.3 +/- 1.9; self-report data, 3.2 +/- 1.5). There was exact agreement between the two methods on the total number of dependencies in 28% of cases and differences of greater than or equal to 3 in 20%. In a stepwise logistic model predicting discharge to a nursing home and adjusting for other relevant variables, the number of dependencies as determined by self-report and medical record data each remained significant (Odds Ratios = 1.6). Self-report and medical record functional status data differ substantially, and the medical record data remain independently associated with nursing home placement. Several possible explanations for this finding are explored.

Kind AJH, Smith MA, Liou J-I, Pandhi N, Frytak JR, Finch MD. Discharge destination's effect on bounce-back risk in black, white, and Hispanic acute ischemic stroke patients. Objective To determine whether racial and ethnic effects on bounce-back risk (ie, movement to settings of higher care intensity within 30d of hospital discharge) in acute stroke patients vary depending on initial posthospital discharge destination. Design Retrospective analysis of administrative data. Setting Four hundred twenty-two hospitals, southern/eastern United States. Participants All Medicare beneficiaries 65 years or more with hospitalization for acute ischemic stroke within one of the 422 target hospitals during the years 1999 or 2000 (N=63,679). Interventions Not applicable. Main Outcome Measures Adjusted predicted probabilities for discharge to and for bouncing back from each initial discharge site (ie, home, home with home health care, skilled nursing facility [SNF], or rehabilitation center) by race (ie, black, white, and Hispanic). Models included sociodemographics, comorbidities, stroke severity, and length of stay. Results Blacks and Hispanics were significantly more likely to be discharged to home health care (blacks=21% [95% confidence interval (CI), 19.9–22.8], Hispanic=19% [17.1–21.7] vs whites=16% [15.5–16.8]) and less likely to be discharged to SNFs (blacks=26% [95% CI, 23.6–29.3], Hispanics=28% [25.4–31.6] vs whites=33% [31.8–35.1]) than whites. However, blacks and Hispanics were significantly more likely to bounce back when discharged to SNFs than whites (blacks=26% [95% CI, 24.2–28.6], Hispanics=28% [24–32.6] vs whites=21% [20.3–21.9]). Hispanics had a lower risk of bouncing back when discharged home than either blacks or whites (Hispanics=14% [95% CI, 11.3–17] vs blacks=20% [18.4–22.2], whites=18% [16.8–18.3]). Patients discharged to home health care or rehabilitation centers demonstrated no significant differences in bounce-back risk. Conclusions Racial/ethnic bounce-back risk differs depending on initial discharge destination. Additional research is needed to fully understand this variation in effect.

This paper examines the three-way relationships among patient characteristics, type of care (admission to a nursing home or community setting), and 6-month outcomes of 352 long-term care patients. The study found that patient characteristics influenced the type of care received and that substantial portions of the variance in the outcomes were attributable to initial differences among patients in the two types of care. Controlling for the effect of selective admission, type of care had no significant impact on patients' ADL scores, mobility scores, or disposition after 6 months in the long-term care setting.

BACKGROUND. In Oregon, adult foster care (AFC) homes, which are private residences where a live-in manager cares for one to five disabled residents, have been covered by Medicaid since 1981 and seem to offer a mainstream alternative to nursing homes. They house almost 6000 older people, two thirds of which pay privately. METHODS. In a cross-sectional study, we interviewed 400 AFC and 400 nursing home residents. Data analyses included descriptive cross-tabulations; hierarchial loglinear models for judging the effects of care setting and payment status on resident characteristics; and logit analyses for predicting care setting and payment status within care settings. RESULTS. On average, nursing home residents were more physically and cognitively impaired than AFC residents, but there was considerable overlap in patterns of frailty in the two settings. Medicaid AFC residents were less disabled than privately paying AFC residents. AFC residents reported more social activity, even when we controlled for disability status. AFC residents and their families were more likely to value privacy and homelike settings when choosing a care setting, whereas nursing home residents were more likely to value rehabilitation and organized activity programs. CONCLUSIONS. Both AFC and nursing homes are viable components of a long-term care repertoire. The greater disability levels of private-pay AFC residents refutes the criticisms that disabled Medicaid residents were being inappropriately channeled to AFC.

Hospice is considered to be underutilized, particularly among patients with noncancer diagnoses such as stroke. The highest mortality among stroke patients occurs within the first 30 days; however, we know little about the hospice enrollment decision for this population during this critical time frame.To determine hospice enrollment rates and to describe sociodemographic and clinical predictors of hospice utilization among patients who die within 30 days of their stroke.Retrospective analysis of administrative data.Medicare beneficiaries 65 years and older discharged with ischemic stroke from 422 hospitals and 11 metropolitan regions during the year 2000 who died within 30 days of their stroke.Hospice utilization within 30 days.The overall hospice enrollment rate in our study was 23%. Using multivariable logistic regression, factors predicting increased hospice enrollment included older age, female gender, health management organization (HMO) membership, length of stay more than 3 days, and dementia. Factors predicting decreased enrollment included African American race, mechanical ventilation, gastrostomy tube placement, uncomplicated diabetes mellitus, and valvular disease. When in-hospital deaths were excluded, overall enrollment increased to 44%, and mechanical ventilation and dementia ceased to predict enrollment.Hospice enrollment rates among patients who die within the first 30 days of their stroke, particularly among those who survive to discharge, are much higher than prior estimates suggest. Although overall enrollment rates were higher than anticipated, there remain important sociodemographic and clinical characteristics unique to this population that predict low hospice utilization that should serve as targets for further research and intervention.

To examine 1-year mortality and healthcare payments of stroke patients experiencing zero, one and two or more bounce-backs within 30 days of discharge.Retrospective analysis of administrative data.Four hundred twenty-two hospitals in the southern and eastern United States.Eleven thousand seven hundred twenty-nine Medicare beneficiaries aged 65 and older surviving at least 30 days with acute ischemic stroke in 2000.One-year mortality and predicted total healthcare payments were calculated using log-normal parametric survival analysis and quantile regression, respectively. Models included sociodemographics, prior medical history, stroke severity, length of stay, and discharge site.Crude survival at 1 year for the zero, one and two or more bounce-back groups was 83%, 67%, and 55%, respectively. The one bounce-back group had 49% shorter (time ratio (TR)=0.51, 95% confidence interval (CI)=0.46-0.56) and the two or more bounce-backs group had 68% shorter (TR=0.32, 95% CI=0.27-0.38) adjusted 1-year survival time than the zero bounce-back group. For high- and low-cost patients, adjusted predicted payments were greater with each additional bounce-back experienced.Acute stroke patients experiencing bounce-backs within 30 days have strikingly poorer survival and higher healthcare payments over the subsequent year than their counterparts with no bounce-backs. Bounce-backs may serve as a simple predictor for identifying stroke patients at extremely high risk for poor outcomes.

To identify predictors of complicated transitions within 30 days after discharge from hospitalization for acute stroke.Retrospective analysis of administrative data.Four hundred twenty-two hospitals in the southern and eastern United States.Thirty-nine thousand three hundred eighty-four Medicare beneficiaries aged 65 and older discharged after acute ischemic stroke from 1998 to 2000.Complicated transition, defined as movement from less- to more-intensive care setting after hospital discharge, with hospital being most intensive and home without home health care being least intensive.Twenty percent of patients experienced at least one complicated transition; 16% of those experienced more than one complicated transition. After adjustment using logistic regression, factors predicting any complicated transition included older age, African-American race, Medicaid enrollment, prior hospitalization, gastrostomy tube, chronic disease, length of stay, and discharge site. Patients with multiple complicated transitions were more likely to be African American (odds ratio (OR)=1.38, 95% confidence interval (CI)=1.13-1.68), be male (OR=1.21, 95% CI=1.04-1.40), have a prior diagnosis of fluid and electrolyte disorder (e.g., dehydration) (OR=1.23, 95% CI=1.07-1.43), have a prior hospitalization (OR=1.18, 95% CI=1.01-1.36), and be initially discharged to a skilled-nursing facility or long-term care (OR=1.22, 95% CI=1.04-1.44) than patients with only one complicated transition. They were less likely to be initially discharged to a rehabilitation center (OR=0.71, 95% CI=0.57-0.89).Significant numbers of stroke patients experience complicated transitions soon after hospital discharge. Sociodemographic factors and initial discharge site distinguish patients with multiple complicated transitions. These factors may enable prospective identification and targeting of stroke patients at risk for "bouncing back."

Background: Stroke affects more than 500,000 older persons each year in the United States, but no studies have compared older stroke patients in Medicare health maintenance organizations (HMOs) and fee-for-service (FFS) after recent changes in FFS reimbursement. Objectives: We sought to compare utilization and outcomes after stroke in Medicare HMO and FFS. Design: We reviewed administrative data in 11 regions from Medicare and a large national health plan. Subjects: We studied Medicare beneficiaries 65 years and older discharged with ischemic stroke during 1998-2000, ie, 4816 HMO patients and a random sample of 4187 FFS patients from 422 hospitals. Measures: We measured survival, rehospitalization, length of stay, discharge destination, and warfarin use. Results: Overall, HMO patients were younger, male, non-Caucasian, and had fewer comorbid conditions. When compared with FFS patients, HMO patients were more likely to be rehospitalized within 30 days for a primary diagnosis of ischemic stroke (Adjusted Hazard Ratio = 1.45, 95% Confidence Interval [CI] 1.14-1.83) or ill-defined conditions (eg, rehabilitation services) (2.87, 95% CI 1.85-4.46) and less likely to be rehospitalized for fluid and electrolyte disorders (0.54, 95% CI 0.34-0.87) or circulatory/respiratory problems (0.77, 95% CI 0.60-0.98). There were no consistent differences in 30-day mortality or in 1-year rehospitalization or mortality for 30-day survivors. HMO patients also were much less likely to be discharged to rehabilitation facilities, slightly less likely to be discharged to skilled nursing facilities and to have a shorter length of stay, and did not differ in the use of home care services or warfarin use when compared with FFS patients. Conclusions: Traditional measures of quality such as 30-day rehospitalization may not be valid when comparing HMO and FFS patients if differences might reflect an alternative service mix. Utilization of postacute care for FFS patients appears similar to HMO patients except for discharge to rehabilitation facilities.

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.Retrospective cross-sectional.EverCare operations in five metropolitan areas.EverCare enrollees admitted to ISDs or a hospital for suspected pneumonia in 2002.Member, nurse practitioner, physician, and NH characteristics extracted from EverCare's administrative data and Online Survey Certification and Reporting NH data.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).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.

BACKGROUND: Medicare's introduction of the Prospective Payment System for hospitals has led to tremendous growth in ways of providing posthospital care. Despite substantial differences in costs per episode of care, the type of posthospital care that produces the best results for specific types of patients is not clear. This study analyzed the outcomes of different types of posthospital care for a cohort of older Medicare patients (who had diagnoses associated with the use of a range of posthospital care modalities) for up to a year after hospital discharge. METHODS: Medicare patients hospitalized with strokes and hip fractures were enrolled consecutively just before discharge from 52 hospitals in three cities in 1988–1989. These diagnosis-related groups were chosen because patients were discharged to all three major types of Medicare-supported posthospital care. Patients were interviewed in-person before discharge and again at 6 weeks, 6 months, and 1 year after discharge. The functional outcomes of posthospital care were evaluated by the instrumental variables estimation approach to correct for selection bias caused by nonrandom treatment assignment The impacts of discharge locations on the functional outcomes were examined by one-way analyses of variance (ANOVA). RESULTS: In general, the more disabled patients went to nursing homes and rehabilitation, but the overlap in distribution was sufficient to conduct the analyses. Stroke patients discharged to nursing homes had the highest mortality rate (P < .01). Stroke patients discharged to home health had the lowest rehospitalization rates (P < .05) Hip fracture discharged to home health care had the highest adjusted rehospitalization rate, whereas those discharged to nursing homes had the lowest adjusted rehospitalization rate (P < .05). For stroke patients, posthospital care in rehabilitation facilities or home health care was associated with significantly better functional improvement compared with stroke patients discharged elsewhere. However, functional outcomes deteriorated by 1 year posthospitalization among stroke patients who received their posthospital care at nursing homes or received no formal posthospital care. For hip fracture patients, all four types of posthospital care were associated with functional improvement, but patients discharged to rehabilitation facilities experienced the most functional improvement. CONCLUSIONS: The choice of posthospital care can influence the course of Medicare patients. Careful attention should be paid to how hospital discharge decisions are made and to the financial incentives for different types of posthospital care provided under the current payment system. The current supply of nursing homes is not well suited to the demands of posthospital care.

OBJECTIVES: This study examined the importance that nursing home residents and nursing assistants ascribed to control and choice over everyday issues, the satisfaction of residents with their control and choice over these issues, and the nursing assistants' impressions of the extent to which control and choice exist for nursing home residents on everyday matters. DESIGN: Cross-sectional in-person interviews with a stratified representative sample of nursing home residents and nursing assistants using semi-structured interview protocols with both fixed-choice and open-ended questions. SETTING: A random sample of 25 nursing homes in the Twin Cities, MN area; a random sample of five nursing homes in North Little Rock, AR; all five nursing homes in Sante Fe, NM; and five purposively selected nursing homes in each of New York City and Los Angeles, CA. PARTICIPANTS: One hundred thirty-five cognitively intact residents, three from each facility, were selected and included the resident council chair, one randomly selected short-stay resident, and one randomly selected long-stay resident from each facility. Also participating were 134 nursing assistants (1 selected randomly from each shift from those employed at least two-thirds time and who had worked in the facility for at least 3 months). MEASUREMENTS: The most important measurements were ordinal-level ratings of the importance of choice and control for nursing home residents over 10 selected areas of everyday life; ordinal measures of residents' satisfaction with their choice and control over these areas; and nursing assistants' ratings of the extent to which they thought it possible for residents to achieve choice and control. Open-ended comments were also elicited. Also measured were demographic data, ADL status, frequency of trips away from the nursing home, frequency of receiving visitors, and (for nursing assistants) length of employment, wages, job satisfaction, and extent to which they knew the residents under their care. MAJOR RESULTS: Cognitively intact nursing home residents attach importance to choice and control over matters such as bedtime, rising time, food, roommates, care routines, use of money, use of the telephone, trips out of the nursing home, and initiating contact with a physician. Nursing assistants view such control as important to residents. Residents and staff differ significantly in the importance attached to particular items, with staff placing lower importance than residents on use of the telephone and personal expenditures and higher importance on control and choice over visitors and formal nursing home activities. Residents were not very satisfied with their control and choice, and nursing assistants viewed them as unlikely to experience control and choice. Nursing home, resident, and staff characteristics were not associated with the patterns of results. CONCLUSIONS: A self-defeating cycle has been identified where neither resident nor staff are optimistic about achieving more resident control and choice, which both groups perceive as desirable. To end this cycle, suggestions are offered for structuring the role of the nursing assistant, physician and nurse leadership, changes in nursing home routines and practices, and public policy changes.

OBJECTIVES. The authors examine the relationship between three dimensions of patient satisfaction (quality of care, hospital care, and physician time) and two ways of looking at outcomes: absolute (status at 6 months after surgery) and relative (difference between baseline and follow-up status). METHODS. A total of 2,116 patients undergoing cholecystectomy were interviewed before surgery and again at 6 months. The baseline interview addressed health status (general functioning and specific symptoms) and risk factors. The follow-up interview included health status and a series of satisfaction questions. Outcomes included both overall health status and specific symptoms. Potential confounding factors, in addition to baseline status, such as demographics, casemix, and procedure type, were accounted for in the analysis. RESULTS. Each of the outcomes was related significantly to each of the satisfaction scales; however, the relative outcomes were related more strongly to satisfaction than were the absolute versions. Although the regression coefficients were highly significant, none of the outcomes measures accounted for more than 8% of the explained variance in the several satisfaction scores. CONCLUSIONS. Although outcomes and satisfaction are related, more goes into satisfaction than just outcomes. When determining their satisfaction with the care they have received, patients are more likely to focus on their present state of health than to consider the extent of improvement they have enjoyed.

OBJECTIVES: To describe and compare outcomes for men and women discharged alive following a hospitalization for congestive heart failure (CHF). DESIGN: Prospective cohort study PARTICIPANTS: A total of 519 patients, aged ≥ 65, who were discharged alive after a hospitalization for CHF (DRG = 127). MEASUREMENTS: Outcomes (Activities of Daily Living (ADLs), shortness of breath when walking, perceived health, living situation, rehospitalization, and mortality) were measured at 3 times (6 weeks, 6 months, and 1 year) post-discharge. RESULTS: The 205 men were, on average, younger (77 ± 7 vs 80 ± 8, P < .001), wealthier (46% vs 21% earned ≥ $10,000, P < .001), and more often married (50% vs 19%, P < .001). Men were more likely than women to have a previous history of CHF (71% vs 63%, P = .052). Men also had higher 1-year mortality than women (48% vs 35%, P = .009), even after adjusting for age, comorbidity, physiological severity (APACHE II APS and RAND discharge instability), radiological evidence of CHF, prior ADLs, walking ability, living situation, and perceived health. Men and women survivors at 1-year had similar and substantial impairment for all non-fatal outcomes considered (all P values ≥ .489). Their adjusted mean ADL scores were consistent with complete dependence on one essential activity (range 0–6 dependencies); 35% were short of breath walking less than 1 block; 62% had fair or poor perceived health; 32% received some formal care; and 46% were rehospitalized within 1 year of discharge. CONCLUSIONS: Men with CHF have a higher mortality than women with CHF. Men and women who survive have similar and substantial impairment for all non-fatal outcomes (ADLs, shortness of breath upon walking, perceived health, living situation, and rehospitalization).

Hip replacement is the preferred treatment for displaced femoral neck fractures, whereas other less expensive procedures are preferred for nondisplaced fractures. The authors determined whether there was geographic variation in the use of hip replacement to treat displaced and nondisplaced fractures.The authors studied 332 patients, age 65 years or older, hospitalized with a femoral neck fracture in three cities.The population was 55% over age 80, 80% female, and lived in Houston (17%), Pittsburgh (29%), and Minneapolis (54%). Rates of hip replacement varied by city (Houston-84%, Pittsburgh-77%, Minneapolis-63%; P = 0.002), with great variability among patients with nondisplaced fractures (Houston-88%, Pittsburgh-77%, and Minneapolis-56%; P = 0.0001), and no variation among those with displaced fractures (P = 0.72). Other factors associated with hip replacement are history of hip fracture (P = 0.003) and cerebrovascular disease (Por = 0.10), APACHE II-APS score (P = 0.09), and impacted fracture (P = 0.001). Sociodemographic and functional status (perceived health; activities of daily living and instrumental activities of daily living dependencies) were not associated with hip replacement (P0.10). In a logistic model controlling for prior history, APACHE II-APS, and fracture characteristics, city remained a significant predictor of hip replacement (P0.001).Despite an absence of evidence supporting its appropriateness and a much higher cost, hip replacement is used to treat nondisplaced fractures much more frequently in Houston and Pittsburgh than in Minneapolis.

BACKGROUND: Medicare's introduction of the Prospective Payment System for hospitals has shortened hospital stays and, as a consequence, has increased the use of post-hospital care. Medicare coverage provides for various types of post-hospital care. This paper examines the characteristics of patients, cities, and hospitals associated with discharge to these different types of post-hospital care. METHODS: A total of 2248 consecutive Medicare patients having one of five diagnosis related groups (DRGs), who were about to be discharged from 52 hospitals in three cities in 1988–1989, were enrolled in the study. These DRGs comprised approximately one-eighth of all Medicare hospital discharges and 40% of all Medicare-paid post-hospital care. Patients were interviewed in person before discharge and again 6 weeks after discharge. Clinical severity measures were developed from information abstracted from each patient's medical record. For each DRG, multinomial logit regression equations were developed to identify factors associated with the choice of one of four possible discharge locations: home with no formal care, home health care, nursing home care, or rehabilitation. RESULTS: Discharge location could be predicted correctly in 52 to 71% of cases, depending on the DRG. This level of predictive accuracy was significantly greater than relying on the modal discharge location, which accounted for 33 to 62% of cases. Most of the predictive power came from information gathered at the discharge interview. The variables associated significantly with the discharge location varied with the DRG and location examined. Living alone and functional dependency at discharge were the significant predictors found most often. CONCLUSIONS: Rather than assuming that everyone is discharged to the modal location, patient discharge location can be predicted. Much of the the explanation can be traced to a few variables such as functional status and living situation. The lack of greater accuracy suggests that factors other than those identified as important by clinical panels are involved in discharge planning for Medicare patients. J Am Geriatr Soc 44:242–250, 1996.

This study tested the effects on physical functioning of substituting adult foster care (AFC) for nursing home care. Secondary data from Oregon's Medicaid agency were used to compare change in ADL functioning of 1,032 nursing home and 279 AFC residents. Maximum likelihood estimation was used to analyze selection of long-term care setting and change in functioning. One-third of surviving AFC residents would have been better off in a nursing home, whereas almost all nursing home residents were placed appropriately. Further research on outcomes that clients value most along with efforts to support functioning are needed.

BACKGROUND: Most ADL summary measures add up the number of dependencies. They assume an equal weighting among items and require an arbitrary definition of dependency. METHODS: A panel of experts in geriatrics was asked to rate a set of ADL and IADL components in terms of the contribution of each to overall dependency using a magnitude estimation (ME) technique. The ratings were done for both domains and for levels of function within each domain. The resultant scores were compared with the usual dependency count approach. RESULTS: The distribution of weighted items appears to have face validity. The pattern of dependency traced by the ME model was intermediate between those created by simple counts with two different definitions of dependency. The ME approach has stronger statistical properties than the ordinal scoring approach. CONCLUSIONS: The ME approach appears to be a reasonable and workable method for creating a measure that permits meaningful statements about the mean value of functional dependencies. This result can be used for any comparison of means, such as across individuals, across aggregates of individuals, or across time. J Am Geriatr Soc 43:877–884, 1995.

This paper examines the relationship between characteristics of Medicare beneficiaries and their choice of health plan in the Twin Cities during 1988. This analysis provides the first comparison of beneficiaries in the basic fee-for-service (FFS) Medicare sector (without a supplementary policy) to beneficiaries in the FFS sector with a supplementary policy, enrollees in independent practice associations (IPAs), and network health maintenance organizations (HMOs). The site and time period are important because there were five large, mature HMOs with TEFRA-risk contracts operating at that time, enrolling 50% of Medicare beneficiaries in the market area. We find that the oldest, poorest and, to a lesser extent, the sickest Medicare beneficiaries were most likely to have basic FFS Medicare coverage without supplementary insurance. The youngest enrollees are found in network HMOs. The availability of group coverage and premium subsidies are positively associated with choice of FFS with a supplementary policy. Government policy concerning Medicare HMO premiums appears to contribute to the poorest beneficiaries facing the highest out-of-pocket costs.

PURPOSE To determine the effect on health and functional status outcomes of enrollment of noninstitutionalized elderly Medicaid recipients in prepaid plans compared with traditional fee-for-service Medicaid. DESIGN A randomized controlled trial. Beneficiaries were randomly assigned to prepaid care in one of seven capitated health plans compared with fee-for-service care. Only the Medicaid portion of their care was capitated. Patients were followed for 1 year. SETTING The Medicaid Demonstration Project in Hennepin County, Minnesota, which includes Minneapolis. PATIENTS 800 Medicaid beneficiaries who were 65 years or older at the beginning of the evaluation. Beneficiaries were interviewed at baseline (time 1) and 1 year later (time 2). Ninety-six percent of beneficiaries were available for follow-up interviews at time 2. MAIN OUTCOME MEASURES General health status, physical functioning, mental health status, activities of daily living, instrumental activities of daily living, corrected visual acuity, and blood pressure and glycosylated hemoglobin measurements for hypertensive and diabetic persons, respectively. RESULTS There were no differences between prepaid and fee-for-service groups in the number of deaths (20 compared with 24, P > 0.2), the proportion in fair or poor health (56.5% compared with 59.7%, P > 0.2), physical functioning, activities of daily living, visual acuity, or blood pressure or diabetic control. Patients in the prepaid group reported a trend toward better general health rating scores (10.2 compared with 9.8, P = 0.06) and well-being scores (10.0 compared with 9.7, P = 0.07) than patients in the fee-for-service group. The difference in the likelihood of a patient in the prepaid group having a physician visit relative to the fee-for-service group was -16.5% (adjusted odds ratio, 0.46; 95% CI, 0.29 to 0.74) and for an inpatient visit was -11.2% (adjusted odds ratio, 0.55; CI, 0.32 to 0.94). CONCLUSIONS There was no evidence of harmful effects of enrolling elderly Medicaid patients in prepaid plans, at least in the short run. Whether these findings also apply to settings in which health maintenance organizations are formed exclusively for Medicaid patients should be studied further.