Abstract Background Thousands of health systems have been recognized as “Age‐Friendly” for implementing geriatric care practices aligned with the “4Ms” (What Matters, Medication, Mentation, and ...Mobility). However, the effect of Age‐Friendly recognition on patient outcomes is largely unknown. We sought to identify this effect in the Veterans Health Administration (VHA)—one of the largest Age‐Friendly integrated health systems in the United States. Methods There were 50 VA medical centers (VAMCs) recognized as Age‐Friendly by December 2021. We used a time‐event difference‐in‐difference analysis to identify the association of a VAMC's recognition as Age‐Friendly on the change in facility‐free days (days outside the hospital or nursing home) among Veterans treated at that facility. We also evaluated this association in three subgroups: Veterans at particularly high risk of nursing home entry, Veterans who lived within 10 miles of a medical center, and facilities that had reached Level 2 Age‐Friendly recognition. We also evaluated individual components of the endpoint in terms of change in hospital and nursing home days separately. Results We found Age‐Friendly recognition was associated with small statistically significant improvements in facility‐free days (0.2% on a base of 97% facility‐free days on average per year, or an additional 0.73 days per year on a base of 354 days). There were no differences in any subgroup, or any individual component of the endpoint across all groups. Conclusions At the individual level, an increase of 0.2% in facility‐free days is a weak effect. However, sites were early in implementation, and facility‐free days may not be a responsive outcome measure. However, across an entire population, small changes in facility‐free days may accrue large cost savings. Future evaluations should consider a broader variety of process and outcome measures.
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Abstract
Background
More than 600,000 Medicare beneficiaries with a diagnosis of dementia are discharged to skilled nursing facilities (SNFs) after hospitalization annually. However, it is unclear ...how their risks and benefits of a SNF stay compare to beneficiaries without a diagnosis of dementia.
Design
Retrospective analysis comparing SNF outcomes for Medicare beneficiaries with and without a diagnosis of dementia.
Setting
One hundred percent sample of Medicare beneficiaries from 2015 to 2016.
Participants
Dementia was identified using validated diagnosis codes. In beneficiaries who had an acute hospitalization followed by SNF stay, we used propensity score matching to balance demographics, comorbidities, characteristics of the index hospital stay, prior hospital and SNF utilization, and cognitive status on SNF admission.
Measurements
Outcomes included unplanned hospital readmission, community discharge rate, and mortality during the SNF stay. Multivariate models were adjusted for hospital and SNF characteristics.
Results
Our sample included 2,418,853 Medicare beneficiaries discharged from hospital to SNF; 830,524 (34.3%) carried a diagnosis of dementia. Overall, 14.7% of the sample had a hospital readmission, 5.0% died, and 61.5% were successfully discharged to the community. In the propensity‐matched cohort, beneficiaries with a diagnosis of dementia had a lower odds ratio of mortality (OR 0.87; 95% confidence interval CI 0.86–0.89), similar odds of hospital readmission (OR 0.99; 95% CI 0.98–1.00), and reduced odds of discharge to the community (OR 0.92; 95% CI 0.91–0.93). However, these findings varied by the severity of cognitive impairment on SNF admission: in beneficiaries with no impairment, those with a diagnosis of dementia had higher odds of adverse outcomes. In beneficiaries with severe impairment, beneficiaries with a diagnosis of dementia had lower odds of adverse outcomes.
Conclusions
Cognitive dysfunction on SNF admission is a stronger predictor of outcomes than a diagnosis of dementia, suggesting the need to individualize decisions about the benefits and risks of SNF care in populations with cognitive impairment.
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Braak and colleagues have proposed that, within the central nervous system, Parkinson's disease (PD) begins as a synucleinopathy in nondopaminergic structures of the lower brainstem or in the ...olfactory bulb. The brainstem synucleinopathy is postulated to progress rostrally to affect the substantia nigra and cause parkinsonism at a later stage of the disease. In the context of a diagnosis of PD, made from current clinical criteria, the pattern of lower brainstem involvement accompanying mesencephalic synucleinopathy is often observed. However, outside of that context, the patterns of synucleinopathy that Braak described are often not observed, particularly in dementia with Lewy bodies and when synucleinopathy occurs in the absence of neurological manifestations. The concept that lower brainstem synucleinopathy represents “early PD” rests on the supposition that it has a substantial likelihood of progressing within the human lifetime to involve the mesencephalon, and thereby cause the substantia nigra pathology and clinical parkinsonism that have heretofore defined the disease. However, the predictive validity of this concept is doubtful, based on numerous observations made in populations of aged individuals who, despite the absence of neurological signs, have brain synucleinopathy ranging up to Braak stages 4 to 6 at postmortem. Furthermore, there is no relation between Braak stage and the clinical severity of PD. We conclude that the relation between patterns of abnormal synuclein immunostaining in the human brain and the disease entity now recognized as PD remains to be determined. Ann Neurol 2008;64:485–491
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Hospitals began paying financial penalties for high-risk–adjusted 30-day readmission rates for certain diagnoses in October 2012. Physician leaders seeking to reduce readmission rates will find that ...proven interventions often require substantial up-front financial and organizational investment. To reduce readmissions while minimizing the investment, leaders need to develop new and creative strategies guided by the evidence. This article describes 5 proposed strategies or “best practices” derived from critical evaluation of prior interventions and experience in the field. These practices include matching the intensity of the intervention to the patient's risk of readmission, avoiding commonly used but unproven interventions, using interventions with a durable effect, creating an effective team before selecting an intervention, and focusing on previously unrecognized high-risk patient groups.
Objective
To understand how hospital‐based clinicians evaluate older adults in the hospital and decide who will be transferred to a skilled nursing facility (SNF) for postacute care.
Design
...Semistructured interviews paired with a qualitative analytical approach informed by Social Constructivist theory.
Setting
Inpatient care units in three hospitals. Purposive sampling was used to maximize variability in hospitals, units within hospitals, and staff on those units.
Participants
Clinicians (hospitalists, nurses, therapists, social workers, case managers) involved in evaluation and decision‐making regarding postacute care (N = 25).
Measurements
Central themes related to clinician evaluation and discharge decision‐making.
Results
Clinicians described pressure to expedite evaluation and discharge decisions, resulting in the use of SNFs as a “safety net” for older adults being discharged from the hospital. The lack of hospital‐based clinician knowledge of SNF care practices, quality, or patient outcomes resulted in lack of a standardized evaluation process or a clear primary decision‐maker.
Conclusion
Hospital clinician evaluation and decision‐making about postacute care in SNFs may be characterized as rushed, without a clear system or framework for making decisions and uninformed by knowledge of SNF or patient outcomes in those discharged to SNFs. This leads to SNFs being used as a “safety net” for many older adults. As hospitals and SNFs are increasingly held jointly accountable for outcomes of individuals transitioning between hospitals and SNFs, novel solutions for improving evaluation and decision‐making are urgently needed.
See related article by Gadbois et al.
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Identifying disease-causing pathways and drugs that target them in Parkinson's disease (PD) has remained challenging. We uncovered a PD-relevant pathway in which the stress-regulated heterodimeric ...transcription complex CHOP/ATF4 induces the neuron prodeath protein Trib3 that in turn depletes the neuronal survival protein Parkin. Here we sought to determine whether the drug adaptaquin, which inhibits ATF4-dependent transcription, could suppress Trib3 induction and neuronal death in cellular and animal models of PD. Neuronal PC12 cells and ventral midbrain dopaminergic neurons were assessed in vitro for survival, transcription factor levels and Trib3 or Parkin expression after exposure to 6-hydroxydopamine or 1-methyl-4-phenylpyridinium with or without adaptaquin co-treatment. 6-hydroxydopamine injection into the medial forebrain bundle was used to examine the effects of systemic adaptaquin on signaling, substantia nigra dopaminergic neuron survival and striatal projections as well as motor behavior. In both culture and animal models, adaptaquin suppressed elevation of ATF4 and/or CHOP and induction of Trib3 in response to 1-methyl-4-phenylpyridinium and/or 6-hydroxydopamine. In culture, adaptaquin preserved Parkin levels, provided neuroprotection and preserved morphology. In the mouse model, adaptaquin treatment enhanced survival of dopaminergic neurons and substantially protected their striatal projections. It also significantly enhanced retention of nigrostriatal function. These findings define a novel pharmacological approach involving the drug adaptaquin, a selective modulator of hypoxic adaptation, for suppressing Parkin loss and neurodegeneration in toxin models of PD. As adaptaquin possesses an oxyquinoline backbone with known safety in humans, these findings provide a firm rationale for advancing it towards clinical evaluation in PD.
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•ATF4-CHOP-Trib3 death signaling is activated in multiple Parkinson's disease models.•Adaptaquin (AQ) is a drug that inhibits hypoxia inducible factor prolyl hydroxylases.•AQ suppresses ATF4-CHOP-Trib3 signaling in in vitro and in vivo PD models.•AQ blocks ATF4-CHOP-Trib3 dependent Parkin loss in PD models.•In PD models, AQ is neuroprotective in vitro and in vivo and rescues function in vivo.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Background
The Veterans Administration (VA) provides several post‐acute care (PAC) options for Veterans, including VA‐owned nursing homes (called Community Living Centers, CLCs). In 2016, the VA ...released CLC Compare star ratings to support decision‐making. However, the relationship between CLC Compare star ratings and Veterans CLC post‐acute outcomes is unknown.
Methods
Retrospective observational study using national VA and Medicare data for Veterans discharged to a CLC for PAC. We used a multivariate regression model with hospital random effects to examine the association between CLC Compare overall star ratings and PAC outcomes while controlling for patient, facility, and hospital factors. Our sample included Veteran enrollees age 65+ who were community‐dwelling, experienced a hospitalization, and were discharged to a CLC in 2016–2017. PAC outcomes included 30‐day unplanned hospital readmission, 30‐day mortality, 100‐day successful community discharge, and a secondary composite outcome of unplanned readmission or death within 30‐days of the hospital discharge.
Results
Of the 25,107 CLC admissions, 4088 (16.3%) experienced an unplanned readmission, 4069 (16.2%) died within 30‐days of hospital discharge, and 12,093 (48.2%) had a successful 100‐day community discharge. Admission to a lower‐quality (1‐star) facility was associated with lower odds of successful community discharge (OR 0.78; 95% CI 0.66, 0.91) and higher odds of a combined endpoint of 30‐day mortality and readmission (OR 1.27; 95% CI 1.09, 1.49), compared to 5‐star facilities. However, outcomes were not consistently different between 5‐star and 2, 3, or 4‐star facilities. Star ratings were not associated with individual readmission or mortality outcomes when considered separately.
Conclusion
These findings suggest comparisons of 1‐star and 5‐star CLCs may provide meaningful information for Veterans making decisions about post‐acute care. Identifying ways to alter the star ratings so they are differentially associated with outcomes meaningful to Veterans at each level is essential. We found that 1‐star facilities had higher rates of 30‐day unplanned hospital readmission/death, and lower rates of 100‐day successful community discharges compared to 5‐star facilities. Yet, like past work on CMS Nursing Home Compare ratings, these relationships were found to be inconsistent or not meaningful across all star levels. CLC Compare may provide useful information for discharge and organizational planning, with some limitations.
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Older adult Veterans are at high risk for adverse health outcomes following hospitalization. Since physical function is one of the largest potentially modifiable risk factors for adverse health ...outcomes, our purpose was to determine if progressive, high-intensity resistance training in home health physical therapy (PT) improves physical function in Veterans more than standardized home health PT and to determine if the high-intensity program was comparably safe, defined as having a similar number of adverse events.
We enrolled Veterans and their spouses during an acute hospitalization who were recommended to receive home health care on discharge because of physical deconditioning. We excluded individuals who had contraindications to high-intensity resistance training. A total of 150 participants were randomized 1:1 to either (1) a progressive, high-intensity (PHIT) PT intervention or (2) a standardized PT intervention (comparison group). All participants in both groups were assigned to receive 12 visits (3 visits/week over 30 days) in their home. The primary outcome was gait speed at 60 days. Secondary outcomes included adverse events (rehospitalizations, emergency department visits, falls and deaths after 30 and 60-days), gait speed, Modified Physical Performance Test, Timed Up-and-Go, Short Physical Performance Battery, muscle strength, Life-Space Mobility assessment, Veterans RAND 12-item Health Survey, Saint Louis University Mental Status exam, and step counts at 30, 60, 90, 180 days post-randomization.
There were no differences between groups in gait speed at 60 days, and no significant differences in adverse events between groups at either time point. Similarly, physical performance measures and patient reported outcomes were not different at any time point. Notably, participants in both groups experienced increases in gait speed that met or exceeded established clinically important thresholds.
Among older adult Veterans with hospital-associated deconditioning and multimorbidity, high-intensity home health PT was safe and effective in improving physical function, but not found to be more effective than a standardized PT program.
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