Search

Background Little is known about variation in use of rehabilitation services provided in acute care hospitals for people who have had a stroke. Objective The objective was to examine patient and hospital sources of variation in acute care rehabilitation services provided for stroke. Design This was a retrospective, cohort design. Methods The sample consisted of Medicare fee-for-service beneficiaries with ischemic stroke admitted to acute care hospitals in 2010. Medicare claims data were linked to the Provider of Services file to gather information on hospital characteristics and the American Community Survey for sociodemographic data. Chi-square tests compared patient and hospital characteristics stratified by any rehabilitation use. We used multilevel, multivariable random effect models to identify patient and hospital characteristics associated with the likelihood of receiving any rehabilitation and with the amount of therapy received in minutes. Results Among 104,295 patients, 85.2% received rehabilitation (61.5% both physical therapy and occupational therapy; 22.0% physical therapy only; and 1.7% occupational therapy only). Patients received 123 therapy minutes on average (median [SD] = 90.0 [99.2] minutes) during an average length of stay of 4.8 [3.5] days. In multivariable analyses, male sex, dual enrollment in Medicare and Medicaid, prior hospitalization, ICU stay, and feeding tube were associated with lower odds of receiving any rehabilitation services. These same variables were generally associated with fewer minutes of therapy. Patients treated by tissue plasminogen activator, in limited-teaching and nonteaching hospitals, and in hospitals with inpatient rehabilitation units, were more likely to receive more therapy minutes. Limitation The findings are limited to patients with ischemic stroke. Conclusion Only 61% of patients with ischemic stroke received both physical therapy and occupational therapy services in the acute setting. We identified considerable variation in the use of rehabilitation services in the acute care setting following a stroke. [ABSTRACT FROM AUTHOR]

Background: Medicare Advantage (MA) and Medicare fee-for-service (FFS) plans have different financial incentives. Medicare pays predetermined rates per beneficiary to MA plans for providing care throughout the year, while providers serving FFS patients are reimbursed per utilization event. It is unknown how these incentives affect post-acute care in skilled nursing facilities (SNFs). The objective of this study was to examine differences in rehabilitation service use, length of stay, and outcomes for patients following hip fracture between FFS and MA enrollees.Methods and Findings: This was a retrospective cohort study to examine differences in health service utilization and outcomes between FFS and MA patients in SNFs following hip fracture hospitalization during the period January 1, 2011, to June 30, 2015, and followed up until December 31, 2015. We linked the Master Beneficiary Summary File, Medicare Provider and Analysis Review data, Healthcare Effectiveness Data and Information Set data, the Minimum Data Set, and the American Community Survey. The 6 primary outcomes of interest in this study included 2 process measures and 4 patient-centered outcomes. Process measures included length of stay in the SNF and average rehabilitation therapy minutes (physical and occupational therapy) received per day. Patient-centered outcomes included 30-day hospital readmission, changes in functional status as measured by the 28-point late loss MDS-ADL scale, likelihood of becoming a long-term resident, and successful discharge to the community. Successful discharge from a SNF was defined as being discharged to the community within 100 days of SNF admission and remaining alive in the community without being institutionalized in any acute or post-acute setting for at least 30 days. We analyzed 211,296 FFS and 75,554 MA patients with hip fracture admitted directly to a SNF following an index hospitalization who had not been in a nursing facility or hospital in the preceding year. We used inverse probability of treatment weighting (IPTW) and nursing facility fixed effects regression models to compare treatments and outcomes between MA and FFS patients. MA patients were younger and less cognitively impaired upon SNF admission than FFS patients. After applying IPTW, demographic and clinical characteristics of MA patients were comparable with those of FFS patients. After adjusting for risk factors using IPTW-weighted fixed effects regression models, MA patients spent 5.1 (95% CI -5.4 to -4.8) fewer days in the SNF and received 463 (95% CI to -483.2 to -442.4) fewer minutes of total rehabilitation therapy during the first 40 days following SNF admission, i.e., 12.1 (95% CI -12.7 to -11.4) fewer minutes of rehabilitation therapy per day compared to FFS patients. In addition, MA patients had a 1.2 percentage point (95% CI -1.5 to -1.1) lower 30-day readmission rate, 0.6 percentage point (95% CI -0.8 to -0.3) lower rate of becoming a long-stay resident, and a 3.2 percentage point (95% CI 2.7 to 3.7) higher rate of successful discharge to the community compared to FFS patients. The major limitation of this study was that we only adjusted for observed differences to address selection bias between FFS and MA patients with hip fracture. Therefore, results may not be generalizable to other conditions requiring extensive rehabilitation.Conclusions: Compared to FFS patients, MA patients had a shorter course of rehabilitation but were more likely to be discharged to the community successfully and were less likely to experience a 30-day hospital readmission. Longer lengths of stay may not translate into better outcomes in the case of hip fracture patients in SNFs. [ABSTRACT FROM AUTHOR]

Objectives To examine the association between life-space mobility and cognitive decline over a five-year period among older Mexican Americans. Design Longitudinal study. Setting Hispanic Established Population for the Epidemiologic Study of the Elderly survey conducted in the southwestern of United States (Texas, Colorado, Arizona, New Mexico, and California). Participants Four hundred thirty-two Mexican Americans aged 75 and older with normal or high cognitive function at baseline. Measurements Socio-demographic factors, living arrangement, type of household, social support, financial strain, self-reported medical conditions, Mini-Mental State Examination ( MMSE), depressive symptoms, activities of daily living ( ADLs), and Short Physical Performance Battery. Life-space assessment ( LSA) during the past 4 weeks was assessed during in-home interview. Scores ranged from 0 (daily restriction to the bedroom) to 120 (daily trips outside of their own town without assistance) and categorized as 0 to 20, 21 to 40, 41 to 60, 61 to 80, and 81 to 120. Because of the small sample size in the category of 81 to 120, the two highest categories were combined into a single group. Results The mean LSA score and MMSE score of participants at baseline was 44.6 (Standard Deviation [ SD], 20.7) and 25.7 ( SD, 3.2), respectively. Mixed Model analyses showed that participants in the highest life-space category (≥61) experienced slower rates of cognitive decline over time compared to participants in the lowest category (0 to 20) ( β = 1.03, Standard Error [ SE] = 0.29, P = 0.0004), after adjusting for all covariates. Conclusion Greater life-space mobility at baseline was predictor of slower rates of cognitive decline over 5 years in older Mexican Americans. [ABSTRACT FROM AUTHOR]

Objectives To create a risk index (Mexican American Dementia Nomogram ( MADeN)) that predicts dementia over a 10-year period for Mexican Americans aged 65 and older. Design Retrospective cohort study with longitudinal analysis. Setting Texas, New Mexico, Colorado, Arizona, and California. Participants Hispanic Established Populations for the Epidemiologic Study of the Elderly (H- EPESE) participants (n = 1,739). Measurements Dementia was defined as a decline of three or more points per year on the Mini-Mental State Examination and inability to perform one or more daily activities. Candidate risk factors included demographic characteristics, measures of social engagement, self-reported health conditions, ability to perform daily activities, and physical activity. Results The MADeN comprised the following risk factors: age, sex, education, not having friends to count on, not attending community events, diabetes mellitus, feeling the blues, pain, impairment in instrumental activities of daily living, and unable to walk a half-mile. The area under the receiver operating characteristic curve was 0.74 (95% confidence interval ( CI) = 0.70-0.78) and a score of 16 points or higher had a sensitivity of 0.65 (95% CI = 0.59-0.72) and specificity of 0.70 (95% CI = 0.67-0.73) in predicting dementia. Conclusion The MADeN was able to predict dementia in a population of older Mexican-American adults with moderate accuracy. It has the potential to identify older Mexican-American adults who may benefit from interventions to reduce dementia risk and to educate this population about risk factors for dementia. [ABSTRACT FROM AUTHOR]

The amount of irradiated beef in the U.S. market is growing, and a reliable, rapid method is needed to detect irradiated beef and quantify the irradiation dose. The official analytical method (BS EN 1785 2003) that has been adopted by the European Union is time consuming. The objective of this study was to develop a rapid method for the analysis of 2-dodecylcyclobutanone (2-DCB) in irradiated beef. A 5 g sample of commercially irradiated ground beef patty (90/10) was extracted with n-hexane using a Soxhlet apparatus or with acetonitrile via direct solvent extraction. The Soxhlet hexane extract was evaporated to dryness, and the sample was dissolved in a mixture of ethyl acetate and acetonitrile (1:1). The defatted extract was purified with a 1 g silica cartridge. Another 5 g aliquot of the same patty was mixed with 50 mL acetonitrile and either blended for 1 min with a hand blender or crushed for 10 min with a glass rod. The extraction procedure was repeated 3 times, and the acetonitrile was collected and evaporated to dryness. Eluants from both methods were concentrated under nitrogen and injected into a gas chromatography-mass spectrometry. The 2-DCB concentration in the commercial samples was 0.031 ± 0.0026 ppm ( n = 5) for the Soxhlet method and 0.031 ± 0.0025 ppm ( n = 10) for direct solvent extraction. Recovery of 2-DCB from spiked beef samples in the direct solvent extraction method was 93.2 ± 9.0% ( n = 7). This study showed that the direct solvent extraction method is simple and as efficient and reproducible as the Soxhlet method. [ABSTRACT FROM AUTHOR]

The term acute coronary syndrome (ACS) refers to any group of clinical symptoms compatible with acute myocardial ischemia and includes unstable angina (UA), non-ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI). These high-risk manifestations of coronary atherosclerosis are important causes of the use of emergency medical care and hospitalization in the United States. A quick but thorough assessment of the patient's history and findings on physical examination, electrocardiography, radiologic studies, and cardiac biomarker tests permit accurate diagnosis and aid in early risk stratification, which is essential for guiding treatment. High-risk patients with UA/NSTEMI are often treated with an early invasive strategy Involving cardiac catheterization and prompt revascularization of viable myocardium at risk. Clinical outcomes can be optimized by revascularization coupled with aggressive medical therapy that includes anti-ischemic, anti-platelet, anticoagulant, and lipid-lowering drugs. Evidence-based guidelines provide recommendations for the management of ACS; however, therapeutic approaches to the management of ACS continue to evolve at a rapid pace driven by a multitude of large-scale randomized controlled trials. Thus, clinicians are frequently faced with the problem of determining which drug or therapeutic strategy will achieve the best results. This article summarizes the evidence and provides the clinician with the latest information about the pathophysiology, clinical presentation, and risk stratification of ACS and the management of UA/NSTEMI. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic has disproportionately affected racial and ethnic minorities in the United States and has been devastating for residents of nursing homes (NHs). However, evidence on racial and ethnic disparities in COVID-19–related mortality rates within NHs and how that has changed over time has been limited. This study examines the impact of a high proportion of minority residents in NHs on COVID-19–related mortality rates over a 30-week period. Longitudinal study. Centers for Medicare & Medicaid Services Nursing Home COVID-19 Public Use File data from 50 states from June 1, 2020, to December 27, 2020. We linked data from 11,718 NHs to (1) Nursing Home Compare data, (2) the Long-Term Care: Facts on Care in the U.S., and (3) US county-level data on COVID cases and deaths. Our primary independent variable was proportion of minority residents (blacks and Hispanics) in NHs and its association with mortality rate over time. During the first 6 weeks from June 1, 2020, NHs with a higher proportion of black residents reported more COVID-19 deaths per 1000 followed by NHs with a higher proportion of Hispanic residents. Between 7 and 12 weeks, NHs with a higher proportion of Hispanic residents reported more deaths per 1000, followed by NHs with a higher proportion of black residents. However, after 23 weeks (mid-November 2020), NHs serving a higher proportion of white residents reported more deaths per 1000 than NHs serving a high proportion of black and Hispanic residents. The disparities in COVID-19–related mortality for nursing homes serving minority residents is evident for the first 12 weeks of our study period. Policy interventions and the equitable distribution of vaccine are required to mitigate the impact of systemic racial injustice on health outcomes of people of color residing in NHs. [ABSTRACT FROM AUTHOR]

Objectives This study examined the association between hospital participation in Bundled Payments for Care Improvement (BPCI) or Comprehensive Care for Joint Replacement (CJR) and the timely initiation of home health rehabilitation services for lower extremity joint replacements. Furthermore, this study examined the association between the timely initiation of home health rehabilitation services with improvement in self-care, mobility, and 90-day hospital readmission. Method This retrospective cohort study used Medicare inpatient claims and home health assessment data from 2016 to 2017 for older adults discharged to home with home health following hospitalization after joint replacement. Multilevel multivariate logistic regression was used to examine the association between hospital participation in BPCI or CJR programs and timely initiation of home health rehabilitation service. A 2-staged generalized boosted model was used to examine the association between delay in home health initiation and improvement in self-care, mobility, and 90-day risk-adjusted hospital readmission. Results Compared with patients discharged from hospitals that did not have BPCI or CJR, patients discharged from hospitals with these programs had a lower likelihood of delayed initiation of home health rehabilitation services for both knees and hip replacement. Using propensity scores as the inverse probability of treatment weights, delay in the initiation of home health rehabilitation services was associated with lower improvement in self-care (odds ratio [OR] = 1.23; 95% CI = 1.20–1.26), mobility (OR = 1.15; 95% CI = 1.13–1.18), and higher rate of 90-day hospital readmission (OR = 1.19; 95% CI = 1.15–1.24) for knee replacement. Likewise, delayed initiation of home health rehabilitation services was associated with lower improvement in self-care (OR = 1.16; 95% CI = 1.13–1.20) and mobility (OR = 1.26; 95% CI = 1.22–1.30) for hip replacement. Conclusion Hospital participation in BPCI or comprehensive CJR was associated with early home health rehabilitation care initiation, which was further associated with significant increases in functional recovery and lower risks of hospital readmission. Impact Policy makers may consider incentivizing health care providers to initiate early home health services and care coordination in value-based payment models. [ABSTRACT FROM AUTHOR]

Asian and Pacific Islander Americans face cultural, linguistic, and financial barriers to accessing health care. APA Health CARE (APAHC), a UCLA student-led organization, attempts to bridge these disparities through free community health screenings, health education seminars, and follow-up procedures. From 2011 to 2018, participants' demographic and health-related information were recorded during health fairs and follow-up phone calls. Trends in participant characteristics were analyzed over time. Health fair data were compared to data from follow-up phone calls to assess the effectiveness of health fair education and referral practices. 5635 participants from 69 health fairs were screened over the 8-year period. Follow-up contact was attempted for 2258 participants, of which 555 responded. Over time, a greater proportion of participants reported higher income, health insurance, and access to a regular doctor. Of those contacted at follow-up, 32.3% reported visiting a doctor, 50.2% reported making lifestyle changes, and 68.0% of those who were uninsured at health fairs reported obtaining health insurance within 1 month of attendance. Despite an observed increase in the proportion of participants having insurance and a regular doctor, health fair attendance remained consistent, possibly due to Asian American immigrants' preference for services that are convenient and linguistically and culturally accessible. Attendees reported visiting a physician, making lifestyle changes, and obtaining health insurance based on health fair referrals, suggesting measurable success with referral uptake and follow through. Student-led initiatives similar to APAHC can serve as catalysts to increase health literacy and motivate communities to seek health insurance and care. [ABSTRACT FROM AUTHOR]

Background: Recent reports show substantial geographic variation in postacute health care spending. Little is known about variation in functional outcomes after postacute rehabilitation for patients with hip fracture. We examined variation in mobility and self-care after hip fracture rehabilitation across inpatient rehabilitation facilities (IRFs), hospital referral regions (HRRs) and states.Methods: Retrospective cohort study using data from the Centers for Medicare and Medicaid Services (CMS) from 2006 to 2009. Study sample included 149,258 records from patients 66 years and older at 1,166 IRFs located within 292 HRRs and across 50 states. Hip fracture cases were defined by CMS impairment group codes (08.11, 08.12). Hierarchical generalized linear models were used to assess discharge mobility and self-care functional status, adjusting for individual patient characteristics and the random effect of IRFs, HRRs, and states.Results: Variation in discharge mobility status as assessed by the intraclass correlation percentage (ICC%) was 8.8% across IRFs, 4.0% across HRRs, and 1.8% across states. For self-care, the ICCs were 10.2% across IRFs, 4.8% across HRRs, and 2.4% across states. The range of discharge mobility scores (maximum functional status rating to minimum functional status rating) showed a 9.6-point difference for IRFs, 6.5 for regions, and 2.6 for states. Range of discharge self-care scores were 13.1 for IRFs, 6.8 for HRRs, and 3.4 for states.Conclusion: Variation in functional status following postacute hip fracture rehabilitation appears to occur primarily at the level of facilities rather than geographic location. [ABSTRACT FROM AUTHOR]

Objective: To examine changes in facility-level risk-standardized rehospitalization rankings for postacute inpatient rehabilitation facilities after modifying two model parameters.Data Sources: We used national Medicare enrollment, claims, and assessment data to study 522,260 patients discharged from inpatient rehabilitation in fiscal years 2010-2011.Study Design: We calculated risk-standardized 30-day unplanned rehospitalization rates for 1,135 inpatient rehabilitation facilities using four approaches. The first model replicated the current postacute risk-standardization methodology and included patients discharged from acute hospitals up to 30 days prior to postacute admission and excluded patients transferred directly back to acute hospitals following rehabilitation. Our alternative models excluded patients with delayed admissions (>1 day between acute discharge and postacute admission) and counted direct transfers back to acute as rehospitalizations.Principal Findings: Excluding patients with delayed admissions and counting direct transfers back to acute care as rehospitalizations substantially impacted rankings of more than half the postacute providers: 29 percent had better and 27 percent had worse quintile rankings.Conclusions: Changing the timeframes for duration to admission and rehospitalization will have profound effects on postacute provider quality performance ratings. Reporting rehospitalization rates is an important issue with the explicit goal of improving the quality of postacute care. Research is needed to understand and minimize potential unintended consequences of this quality metric. [ABSTRACT FROM AUTHOR]

The purpose of this study was to determine independent influences of functional level and lower limb amputation type on inpatient rehabilitation outcomes. We conducted a secondary data analysis for patients with lower limb amputation who received inpatient medical rehabilitation (N = 26,501). The study outcomes included length of stay, discharge functional status, and community discharge. Predictors included the 3-level case mix group variable and a 4-category amputation variable. Age of the sample was 64.5 years (13.4) and 64% were male. More than 75% of patients had a dysvascular-related amputation. Patients with bilateral transfemoral amputations and higher functional severity experienced longest lengths of stay (average 13.7 days) and lowest functional rating at discharge (average 79.4). Likelihood of community discharge was significantly lower for those in more functionally severe patients but did not differ between amputation categories. Functional levels and amputation type are associated with rehabilitation outcomes in inpatient rehabilitation settings. Patients with transfemoral amputations and those in case mix group 1003 (admission motor score less than 36.25) generally experience poorer outcomes than those in other case mix groups. These relationships may be associated with other demographic and/or health factors, which should be explored in future research. [ABSTRACT FROM AUTHOR]

Human biomonitoring data show that exposure to perchlorate is widespread in the United States. The predominant source of intake is food, whereas drinking water is a less frequent and far smaller contributor. We used spot urine samples for over 2700 subjects and estimated 24 h intake using new creatinine adjustment equations. Merging data from surveys of national health (NHANES) with drinking water monitoring (UCMR), we categorized survey participants according to their potential exposure through drinking water or food. By subtracting daily food doses of perchlorate from the oral reference dose (RfD), we derive an allowances for perchlorate in tap water for several populations. The calculated mean food perchlorate dose in the United States was 0.081 μg/kg/day compared to 0.101 μg/kg/day for those who also had a potential drinking water component. The calculated 95th percentile doses, typically falling between 0.2 and 0.4 μg/kg/day, were well below the RfD (0.7 μg/kg/day) in all populations analyzed. Children aged 6-11 years had the highest mean perchlorate doses in food (0.147 μg/kg/day), with an additional water contribution of only 0.003 μg/kg/day representing just 2% of exposure. Pregnant women had a mean food dose of 0.093 vs 0.071 μg/kg/day for all women of reproductive age. At the 95th percentile intake for both the total population and women of child-bearing age (15-44), the perchlorate contribution from food was 86% and from drinking water 14% (respectively, 30% and 5% of the RfD). At the mean for the same groups, the food to water contribution ratio is approximately 80:20. We calculate that an average 66 kg pregnant woman consuming a 90th percentile food dose (0.198 μg/kg/day) could also drink the 90th percentile of community water for pregnant women (0.033 l/kg/day) containing 15 μg/l perchlorate without exceeding the 0.7 μg/kg/day reference dose. [ABSTRACT FROM AUTHOR]

The purpose of the study is to contribute to the literature regarding post-acute nursing home utilization and quality indicators among Medicare beneficiaries in Puerto Rico compared with the US mainland. Medicare data from 2015 to 2017 was used to identify new discharges to skilled nursing facilities (SNFs) using the Minimum Data Set and the Medicare Provider Analysis and Review. Post-acute care patients admitted to SNFs in Puerto Rico and the United States. Our final cohort included 4,732,222 beneficiaries from Puerto Rico and the United States enrolled in Medicare fee-for-service or Medicare Advantage programs admitted to an SNF (N = 15,197) following an acute hospital stay. We compared demographic, clinical, and facility-level characteristics among patients in Puerto Rico and the United States. We also described 2 quality indicators among these groups: (1) 30-day rehospitalization rates and (2) successful discharge from the facility to the community. Medicare patients in Puerto Rico were physically and cognitively healthier than patients in the United States. Puerto Ricans were also more likely to be admitted to lower quality nursing homes than US patients (2.5 vs 3.4). Finally, Puerto Ricans had higher rates of successful discharge to the community [17.6, 95% confidence interval (CI) 13.0-22.3], but higher 30-day rehospitalization rates compared with US patients (11.2, 95% CI 6.2-16.3). These differences were consistent even when comparing these quality outcomes among Puerto Ricans to US Hispanics only. SNFs in the United States and Puerto Rico are now receiving financial penalties for high readmission rates. Currently, Medicare does not measure readmission rates for Medicare Advantage patients—even though some states, including Puerto Rico, have a high proportion of Medicare Advantage beneficiaries. As Medicare Advantage enrollment continues to increase, our results highlight the importance of measuring performance among Medicare Advantage patients and assessing disparities in quality of post-acute care among patients in Puerto Rico and the United States. [ABSTRACT FROM AUTHOR]