Journal of the American Medical Directors Association最新文献

Objectives: Hospital discharge to a long-term care facility (LTCF) often represents an opportunity to reassess care goals, treatment intensity, and medication use. We examined changes in glucose-lowering medication (GLM) dispensing following first hospital discharge to LTCFs and whether these changes differed by resident frailty status.

Design: Retrospective cohort study.

Setting and participants: Adults aged ≥65 with type 2 diabetes (T2D) newly discharged to LTCFs in Victoria, Australia, from 2012 and 2018.

Methods: Using linked hospital and medication dispensing data, we compared age- and sex-adjusted prevalence of GLM use in the 90-day period prehospitalization and 90-day period postdischarge to LTCF using Poisson regression. Multivariable adjusted relative risks (aRRs) were estimated using generalized estimating equations.

Results: Among 19,704 individuals discharged to an LTCF (78.7% frail, 45.9% aged ≥85 years, 54.6% female), overall GLM use declined from 59.7% (95% CI 58.4-61.0) to 54.8% (95% CI 53.6-56.1) in frail residents, and 59.3% (95% CI 56.9-61.9) to 56.2% (95% CI 53.8-58.7) in robust residents. Changes in age- and sex-adjusted GLM prevalence among frail and robust residents were mainly attributable to decreased use of metformin and sulfonylureas and increased use of insulin. In multivariable-adjusted analyses, frailty was associated with lower likelihood of dispensing metformin monotherapy within 90 days postdischarge (aRR 0.91, 95% CI 0.85-0.97) and metformin plus sulfonylurea at 90 days (aRR 0.89, 95% CI 0.79-0.99). There were no statistically significant differences in aRRs for combination therapy with ≥2 GLMs. In sensitivity analyses, frailty was associated with greater likelihood of no GLM dispensing within 6 months (aRR 1.04, 95% CI 1.02-1.07), but not within 90 days postdischarge (aRR 1.02, 95% CI 1.00-1.05).

Conclusions and implications: There are potential missed opportunities to reassess GLM regimens in the 90-day period postdischarge to LTCFs. Resident frailty status did not appear to be associated with meaningful T2D treatment deintensification. Further initiatives may be needed to promote postdischarge medication reviews to optimize diabetes care in this vulnerable population.

Objectives: Most older adults prefer to recover at home, making home health care (HHC) an important alternative to institutional post-acute care (eg, skilled nursing, inpatient rehabilitation). Understanding factors associated with HHC referral at hospital discharge-relative to other options-can align care with patient preferences and support aging in place. This study examined individual, hospital, and community characteristics associated with HHC referral vs institutional post-acute care among Medicare beneficiaries.

Design: Retrospective observational study.

Settings and participants: Participants included beneficiaries referred to HHC, skilled nursing, or inpatient rehabilitation at hospital discharge in 100% Medicare fee-for-service claims, 2017-2019. Hospital characteristics came from Centers for Medicare & Medicaid Services Hospital Cost Reports, and community-level variables came from the 2017 Agency for Healthcare Research and Quality Social Determinants of Health database.

Methods: Our outcome was discharge to HHC vs institutional post-acute care (eg, skilled nursing, inpatient rehabilitation). Mixed-effects linear probability models estimated associations between individual-, hospital-, and community-level characteristics with HHC referral among Medicare beneficiaries at hospital discharge.

Results: The study population included 11,139,222 hospital discharges among 6,287,660 Medicare beneficiaries. Older age, longer length of stay, urban dwelling, and dual-eligibility were associated with lower rates of HHC referral. Beneficiaries of color had higher rates of HHC referral than non-Hispanic White beneficiaries. Large (>400 beds), nonteaching, and safety net hospitals were associated with higher rates of HHC referral. Communities with higher percentages of racially and ethnically minoritized residents and older adults had higher rates of HHC referral. However, models explained only 13% of the variation in post-acute care referral, underscoring the limited ability of administrative claims data to capture all relevant determinants.

Conclusions and implications: Referral decisions for post-acute care are influenced by individual-, hospital-, and community-level factors. As the use of HHC continues to grow, greater attention is needed to how these decisions are made to ensure equitable access to preferred and appropriate care for older adults.

Objectives: This study compares what matters to residents and how they experience personalized care across nursing facilities, assisted living facilities, residential care facilities, and adult foster homes in Oregon.

Design: Secondary data analysis of qualitative comments collected through validation of the Resident Voicing Importance, Experience, and Well-Being (ResidentVIEW) instrument.

Setting and participants: Residents were from 32 nursing facilities (n = 245), 31 assisted living facilities/residential care facilities (n = 212), and 119 adult foster homes (n = 188) in Oregon (December 2017-September 2019).

Methods: Practical thematic analysis to develop codes consisting of complete phrases, and biweekly meetings to refine themes.

Results: Three key themes emerged from the data. The first, loss, disregard, or limitation of personhood, described how residents across all care settings experienced a restriction in their decision-making. The second, "sometimes" nature of independence and choice, highlighted the inconsistency of autonomy, where choices were overridden by rigid institutional schedules. The third, respecting and including the person behind the "resident," emphasized the importance of staff recognizing residents as individuals, along with residents' value of social inclusion, meaningful engagement, and being part of the community rather than simply existing within it.

Conclusions and implications: Findings reveal the nuanced ways in which person-centered care is experienced and how it can be either fostered or limited by the care setting. Residents' experiences of autonomy and dignity are fluid and shaped by the context of their care setting. Staff training must be supported by consistent staffing practices that actively uphold and reinforce personhood across all types of care environments. There is a clear call from residents to be heard, valued, and seen as integral members in the environment they are living in.

Objectives: Frailty is a common geriatric syndrome associated with adverse health outcomes. Although gait speed is widely recognized as a predictor of frailty, the contribution of other gait parameters remains unclear, particularly among initially robust older adults. This study aimed to examine the associations between multiple gait variables and incident frailty in community-dwelling older adults who were nonfrail at baseline.

Design: A prospective observational study.

Setting and participants: A total of 1898 community-dwelling older adults (mean age: 73.0 ± 4.9 years, age range: 65-92 years, 50.9% women) who were determined to be nonfrail by the Kihon Checklist in the baseline survey were included.

Methods: Gait variables, including gait speed, were measured using the Walkway system. Frailty status was reassessed after 3 years via a mailed Kihon Checklist survey. Participants classified as either pre-frail or frail at follow-up were considered to have incident frailty, in order to capture early functional decline. Logistic regression analyses were conducted to evaluate the associations between gait variables and incident frailty.

Results: In this study, 611 participants (32.2%) were classified into the incident frailty during follow-up (524 pre-frailty and 87 frailty). Logistic regression analysis showed that gait speed [odds ratio (OR), 0.273; 95% confidence interval (CI), 0.152-0.491], step length (OR, 0.947; 95% CI, 0.924-0.970), and cadence (OR, 0.987; 95% CI, 0.976-0.998) were significantly associated with the onset of frailty. Furthermore, step length was independently associated with the onset of frailty, even in models adjusted for gait speed and covariates (OR, 0.945; 95% CI, 0.909-0.982).

Conclusions and implications: Step length was identified as a significant indicator of incident frailty in healthy older adults. For early frailty screening, a comprehensive assessment that includes step length, rather than gait speed alone, may be more informative.

Objectives: To examine whether unionized nursing homes in New York State show different levels of resident voice-measured through formal complaints-and how ownership relates to these patterns.

Design: Cross-sectional analysis of 2022 facility-level data.

Setting and participants: A total of 511 New York State nursing homes categorized by union status and ownership type.

Methods: Resident voice was defined as complaints per 100 residents submitted to the New York State Department of Health Complaint Hotline. Key predictors were union status and ownership, with covariates including facility size, payer mix, occupancy, hospital admissions, and quality rating.

Results: Of the 511 facilities, 361 (70.6%) were unionized. Unionized homes had fewer complaints on average (57.9 vs 64.4 per 100 residents; P = .04). Among unionized facilities, higher Medicaid (β = 0.885; P < .001) and Medicare shares (β = 0.567; P = .003) were positively associated with complaints and higher overall quality ratings were inversely associated (β = -6.77; P < .001).

Conclusions and implications: Nursing homes with unionized workforces display distinct patterns of resident voice. These findings suggest that workforce organization may influence the institutional environment in ways that either facilitate or constrain residents' ability to advocate for improved care. Understanding how labor structures intersect with ownership and quality conditions can inform future policy efforts aimed at strengthening resident-centered care and guide research on mechanisms linking workforce organization to resident advocacy behaviors.

Objective: To examine the association between individual characteristics and type of initial long-term services and supports (LTSS) among older adults receiving Medicaid home- and community-based services (HCBS) or nursing home (NH) care.

Design: Cohort study of traditional Medicare beneficiaries surveyed between 2002 and 2009 linked with Medicare and Medicaid administrative files through 2018.

Setting and participants: The study population includes 581 dual-eligible individuals aged ≥65 at the time of initial LTSS use. Study population was predominantly Black (67.1%), female (69.0%), and with a household income below $15,000/year (78.3%).

Methods: Initial HCBS and long-term NH use were identified using Medicaid data and Minimum Data Set (MDS) nursing home assessments. Sociodemographic factors were identified using the Southern Community Cohort Study (SCCS) survey dataset. Chronic conditions and prior health care use were identified using traditional Medicare claims. A multivariate logistic model predicted whether individuals initiated LTSS with HCBS use, adjusting for individual-level covariates and state and year fixed effects.

Results: Half of the sample (N = 291) initiated LTSS with HCBS and the other half (N = 290) initiated with NH use between 2008 and 2018. Factors associated with a higher likelihood of initiating LTSS with HCBS included Black race (marginal effect [ME], 0.13; 95% CI, 0.05-0.21) and female sex (ME, 0.19; 95% CI, 0.12-0.26). Factors associated with higher likelihood of initiating LTSS with NH instead of HCBS included older age, Alzheimer's disease and related dementias (ADRD) diagnosis, recent hospitalization, and higher education levels. Among individuals with ADRD, several factors-Black race, living with others, and prior emergency room use-were associated with higher likelihood of initiating LTSS with HCBS and prior hospitalization was associated with initial NH use.

Conclusion and implications: Among dual-eligible older adults initiating LTSS, factors related to more complex medical needs were associated with a higher likelihood of NH use rather than HCBS use as their initial LTSS option.

Objectives: To compare the prevalence of vaccination programs between nursing homes (NHs) and assisted living communities (ALs) and examine how these programs relate to perceived hospitalization risk and temporary admission suspensions due to outbreaks.

Design: Descriptive analysis of facility-level survey data from the 2023 Ohio Biennial Survey of Long-Term Care Facilities, which has a >90% response rate.

Setting and participants: All licensed NHs and ALs in Ohio were surveyed and answered questions related to vaccination programs (n = 736; n = 623).

Methods: Three measures were analyzed: presence of a vaccination program for 7 vaccine-preventable illnesses [influenza; COVID-19; respiratory syncytial virus (RSV); pneumococcal; hepatitis B; shingles; and tetanus, diphtheria, and pertussis (Tdap)], perceived risk of transferring residents to the hospital for these illnesses, and temporary suspension of admissions due to outbreaks. All measures were binary and sample averages were calculated separately for NHs and ALs. Facility characteristics associated with COVID-19-related admission suspensions were compared.

Results: NHs had a higher prevalence of vaccination programs for all 7 vaccine-preventable illnesses compared with ALs. The largest differences were observed for RSV, pneumococcal, hepatitis B, shingles, and Tdap. ALs reported higher perceived risk of transferring residents to the hospital for all illnesses, whereas NHs reported the highest perceived risk for respiratory illnesses. Temporary admission suspensions due to outbreaks were uncommon; when reported, they were primarily associated with COVID-19. Facilities with COVID-19-related suspensions were more likely to be smaller and not-for-profit/government owned. NHs with outbreaks were more often located in rural areas, and ALs with outbreaks were more often located in urban areas.

Conclusions and implications: Significant disparities exist in vaccination program implementation between NHs and ALs. Expanding vaccination programs in ALs may reduce hospitalization risk and strengthen outbreak prevention. Targeted policy efforts, improved education, and resource allocation are needed to ensure equitable access to comprehensive vaccination programs across long-term care settings.