Opioid use is associated with fall-related injuries (FRI) among older adults, especially those with dementia. We examined FRI following changes in national opioid safety initiatives over 3 regulatory ...periods preinitiatives baseline (period 1): October 2012 to June 2013; post-Veteran Affairs (VA) opioid safety initiative (period 2): January 2014 to November 2015; post-VA and CDC opioid prescribing guidelines (period 3): March 2017 to September 2018 among Department of VA Community Living Center (CLC) long-stay residents with dementia.
VA provided and purchased care records, Medicare claims, CLC Minimum Data Set (MDS) assessments. VA bar-code medication administration data, VA outpatient prescription refill data, and Medicare Part D data were used to capture medication from inpatient, outpatient, and Medicare sources.
A total of 12,229 long-stay CLC residents with dementia between October 2012 and September 2018.
We applied Veteran-regulatory period level (1) generalized linear model to examine the unadjusted and adjusted trends of FRI, and (2) difference-in-difference model with propensity score weighting to examine the relationship between opioid safety initiatives and FRI in 3 regulatory periods. We applied propensity score weighting to enable the cohorts in periods 2 and 3 had similar indications for opioid administration as in period 1.
FRI prevalence per month among CLC residents with Alzheimer disease and related dementias decreased from 3.1% in period 1 to 1.6% and 1.2% in periods 2 and 3, and the adjusted probability of FRI was 17% and 40% lower in periods 2 and 3 compared with period 1. The any, incident, and continued opioid administration were significantly associated with higher FRI, whereas the differences in FRI probabilities between opioid and nonopioid users had no significant changes over the 3 regulatory periods.
FRI was reduced among CLC residents with Alzheimer disease and related dementias receiving care in VA CLCs over the 3 regulatory periods, but the FRI reduction was not significantly associated with opioid safety initiatives. Other interventions that potentially targeted falls are likely to have helped reduce these fall events. Future studies could examine whether opioid use reduction ultimately benefitted nursing home residents by focusing on other possible outcomes or whether such reduction only resulted in more untreated pain.
IMPORTANCE It is important to understand the relationship between sleep medication use and injurious falls in nursing home residents. OBJECTIVE To conduct a case-crossover study to estimate the ...association between nonbenzodiazepine hypnotic drug use (zolpidem tartrate, eszopiclone, or zaleplon) and the risk for hip fracture among a nationwide sample of long-stay nursing home residents, overall and stratified by individual and facility-level characteristics. DESIGN AND SETTING Case-crossover study performed in an academic research setting. PARTICIPANTS The study participants included 15 528 long-stay US nursing home residents 50 years or older with a hip fracture documented in Medicare Part A and Part D fee-for-service claims between July 1, 2007, and December 31, 2008. MAIN OUTCOME MEASURES Odds ratios (ORs) of hip fracture were estimated using conditional logistic regression models by comparing the exposure to nonbenzodiazepine hypnotic drugs during the 0 to 29 days before the hip fracture (hazard period) with the exposure during the 60 to 89 and 120 to 149 days before the hip fracture (control periods). Analyses were stratified by individual and facility-level characteristics. RESULTS Among the study participants, 1715 (11.0%) were dispensed a nonbenzodiazepine hypnotic drug before the hip fracture, with 927 exposure-discordant pairs included in the analyses. The mean (SD) age of participants was 81.0 (9.7) years, and 77.6% were female. The risk for hip fracture was elevated among users of a nonbenzodiazepine hypnotic drug (OR, 1.66; 95% CI, 1.45-1.90). The association between nonbenzodiazepine hypnotic drug use and hip fracture was somes greater in new users (OR, 2.20; 95% CI, 1.76-2.74) and in residents with mild vs moderate to severe impairment in cognition (OR, 1.86 vs 1.43; P = .06), with moderate vs total or severe functional impairment (OR, 1.71 vs 1.16; P = .11), with limited vs full assistance required with transfers (OR, 2.02 vs 1.43; P = .02), or in a facility with fewer Medicaid beds (OR, 1.90 vs 1.46; P = .05). CONCLUSIONS AND RELEVANCE The risk for hip fracture is elevated among nursing home residents using a nonbenzodiazepine hypnotic drug. New users and residents having mild to moderate cognitive impairment or requiring limited assistance with transfers may be most vulnerable to the use of these drugs. Caution should be exercised when prescribing sleep medications to nursing home residents.
Objectives: We examined the extent to which home and community-based services (HCBS) spending affected the likelihood of nursing home (NH) placement among black and white HCBS users with Alzheimer’s ...disease and related dementias (ADRD). Methods: The study population included new HCBS users with ADRD between 2010 and 2013 (N = 1,046,200). Results: We found that a one hundred dollar increase in monthly HCBS spending was associated with a 0.3 percentage points decrease in the NH placement rate among Whites, but a 0.3 percentage points increase in the NH placement rate among Blacks. The overall NH placement rate was 68.2% and 56.7% for Whites and Blacks, respectively. Discussion: A higher HCBS spending was associated with a decreased likelihood of NH placements for Whites but not for Blacks. It is important to understand how states’ HCBS expansion efforts influence Blacks and Whites with ADRD so that resources can be tailored to communities with different race-mix.
The National Partnership to Improve Dementia Care in Nursing Homes (i.e., the National Partnership) was launched in March 2012. Using national Medicare, Minimum Data Set, and Nursing Home Compare ...data in CY 2010–2014, we examined changes in hospital readmissions for older post-acute skilled nursing facility (SNF) residents with Alzheimer’s disease or related dementias (ADRD) following the National Partnership. Using residents without ADRD as reference group to control for concurrent policy and SNF quality changes, we estimated linear probability models to examine the relationship between readmissions and the National Partnership for residents with ADRD, and also stratified the analysis by quality of SNFs. We found a decreasing trend in hospital readmissions over time. The risk of readmissions in residents with ADRD decreased additional 0.3 percentage-point
s
(p < .01) after the launch of the National Partnership. This relationship varied across SNFs with different quality, as it was stronger in high-quality compared to low-quality SNFs.
BACKGROUND:Hospitalization is a difficult experience, especially for patients with dementia. Understanding whether better continuity of care (COC) reduces hospitalizations can indicate interventions ...that might help curb hospitalizations.
OBJECTIVE:To estimate the causal impact of COC on hospitalizations and different reasons for hospitalization among community-dwelling older veterans with dementia.
RESEARCH DESIGN:Population-based observational study using nationwide Veterans Health Administration data linked to Medicare claims in Fiscal Years (FYs) 2014–2015. To account for unobserved confounders we used an instrumental variable for COC—whether veteran changed residence by more than 10 miles.
SUBJECTS:Community-dwelling veterans with dementia aged 66 and older, enrolled in Traditional Medicare (n=105,528).
MEASURES:Bice-Boxerman Continuity of Care (BBC) index (0—worst to 1—best COC); binary indicators of any hospitalization for all causes, for ambulatory care sensitive conditions (ACSCs) and for reasons grouped by major diagnostic category.
RESULTS:The mean BBC in FY 2014 was 0.32 (SD, 0.23). In FY 2015 43.3% of the cohort veterans were hospitalized. A 0.1 higher BBC resulted in 2.4% (95% confidence interval, 0.5%–4.4%) lower probability of hospitalization for all causes. BBC was not associated with hospitalization for ACSCs. Grouped by major diagnostic category, a 0.1 higher BBC resulted in 3.8% (95% confidence interval, 2.1%–5.4%) lower probability of hospitalization for neuropsychiatric diseases/disorders, with no impact on hospitalizations for circulatory, respiratory, infectious, kidney and urinary, digestive, musculoskeletal, and endocrine-metabolic diseases/disorders.
CONCLUSIONS:Among community-dwelling older veterans with dementia, better COC resulted in less hospitalizations, and this effect was primarily due to less hospitalization for neuropsychiatric diseases/disorders but not hospitalization for ACSCs, or other hospitalization reasons.
Recently, the Chinese government has implemented stringent water requirements based on the concept of ‘Basing four aspects on water resources’. However, existing research has inadequately addressed ...the constraints of water resources on population, city boundaries, land, and production, failing to adequately analyze the interplay between water resource limitations and urban development. Recognizing the interconnectedness between urban water use and economic development, a multi-objective model becomes crucial for optimizing urban water resources. This study establishes a nonlinear multi-objective water resources joint optimization model, aligning with the “Basing four aspects on water resources” requirement to maximize urban GDP and minimize total water use. A genetic algorithm (NSGA-II Algorithm) is applied to solve this complex nonlinear multi-objective model and obtain the Pareto solution set, addressing information loss inherent in the traditional water quota method. The model was tested in Wujiang District, an area located in China’s Jiangsu Province that has been rapidly urbanizing over the past few decades, and yielded 50 non-inferior water resource optimization schemes. The results reveal that the Pareto solution set visually illustrates the competition among objectives and comprehensively displays the interplay between water and urban development. The model takes a holistic approach to consider the relationships between water resources and urban population, land use, and industries, clearly presenting their intricate interdependencies. This study serves as a valuable reference for the rational optimization of water resources in urban development.
The Minimum Data Set (MDS) for nursing home resident assessment has been required in all U.S. nursing homes since 1990 and has been universally computerized since 1998. Initially intended to ...structure clinical care planning, uses of the MDS expanded to include policy applications such as case-mix reimbursement, quality monitoring and research. The purpose of this paper is to summarize a series of analyses examining the internal consistency and predictive validity of the MDS data as used in the "real world" in all U.S. nursing homes between 1999 and 2007.
We used person level linked MDS and Medicare denominator and all institutional claim files including inpatient (hospital and skilled nursing facilities) for all Medicare fee-for-service beneficiaries entering U.S. nursing homes during the period 1999 to 2007. We calculated the sensitivity and positive predictive value (PPV) of diagnoses taken from Medicare hospital claims and from the MDS among all new admissions from hospitals to nursing homes and the internal consistency (alpha reliability) of pairs of items within the MDS that logically should be related. We also tested the internal consistency of commonly used MDS based multi-item scales and examined the predictive validity of an MDS based severity measure viz. one year survival. Finally, we examined the correspondence of the MDS discharge record to hospitalizations and deaths seen in Medicare claims, and the completeness of MDS assessments upon skilled nursing facility (SNF) admission.
Each year there were some 800,000 new admissions directly from hospital to US nursing homes and some 900,000 uninterrupted SNF stays. Comparing Medicare enrollment records and claims with MDS records revealed reasonably good correspondence that improved over time (by 2006 only 3% of deaths had no MDS discharge record, only 5% of SNF stays had no MDS, but over 20% of MDS discharges indicating hospitalization had no associated Medicare claim). The PPV and sensitivity levels of Medicare hospital diagnoses and MDS based diagnoses were between .6 and .7 for major diagnoses like CHF, hypertension, diabetes. Internal consistency, as measured by PPV, of the MDS ADL items with other MDS items measuring impairments and symptoms exceeded .9. The Activities of Daily Living (ADL) long form summary scale achieved an alpha inter-consistency level exceeding .85 and multi-item scale alpha levels of .65 were achieved for well being and mood, and .55 for behavior, levels that were sustained even after stratification by ADL and cognition. The Changes in Health, End-stage disease and Symptoms and Signs (CHESS) index, a summary measure of frailty was highly predictive of one year survival.
The MDS demonstrates a reasonable level of consistency both in terms of how well MDS diagnoses correspond to hospital discharge diagnoses and in terms of the internal consistency of functioning and behavioral items. The level of alpha reliability and validity demonstrated by the scales suggest that the data can be useful for research and policy analysis. However, while improving, the MDS discharge tracking record should still not be used to indicate Medicare hospitalizations or mortality. It will be important to monitor the performance of the MDS 3.0 with respect to consistency, reliability and validity now that it has replaced version 2.0, using these results as a baseline that should be exceeded.
The shortage of home health aides has been exacerbated in recent years partially because of low wages. Minimum wage (MW) policy changes may alleviate this workforce shortage. This study examined the ...effects of MW policies on wages and employment of home health aides. We performed a county-level longitudinal analysis using 2012 to 2018 national data. The study cohort included 2,496 counties and focused on all workers in the home health industry. Outcome variables included wages and the employment of home health aides. Key variables of interest included the consumer price index adjusted state MW and a set of variables that captured the effect of the Fair Labor Standards Act (FLSA) extension. This study found that home health aides’ hourly wages were $1.00 higher (p = .011) in states that increased their MWs from below $8 to above $10. The FLSA extension was associated with $1.15 higher wages in states with higher MWs (i.e., state MW above $10 in 2014). The FLSA extension was associated with higher employment of home health aides in less-competitive markets, rather than high- or average-competitive markets. This study suggests that state MW increases combined with the FLSA extension may help maintain the current home health workforce and improve their wages.
Background
Care transitions are frequent among patients with dementia. This study aimed to estimate the impact of continuity of care (COC) on successful community discharge after hospitalization.
...Methods
National Veterans Health Administration data linked to Medicare claims in fiscal years 2014–2015. Community-dwelling older veterans with dementia with an acute hospitalization were included (n = 31,648). COC was measured by the Bice-Boxerman Continuity of Care (BBC) index (0–1). Association of COC before hospitalization on successful community discharge was examined separately among veterans discharged to the community directly and through post-acute care facilities.
Results
Veterans with a 0.1 higher BBC were 4.6% (p = .06) more likely to have successful direct community discharge; but BBC had no demonstrable effect when discharge was through post-acute care facilities.
Conclusion
Better COC may have impact at improving successful direct community discharge, although the effect is small and the type I error rate (statistical significance) was 6%.
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