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Hospitalization and skilled nursing care are predictors of influenza vaccination among patients on hemodialysis: evidence of confounding by frailty.

ABSTRACT: Observational studies of preventive medications, such as vaccinations, can suffer from the healthy-user bias because vaccinated patients may be healthier than unvaccinated patients. Indicators of health status and frailty suitable for attenuating this bias could be identified in administrative data.To examine the association of baseline variables and time-dependent hospitalization and skilled nursing care with the receipt of influenza vaccination in patients with end-stage renal disease.Observational cohort study using United States Renal Data System files each year from 1999 to 2005.Population-based cohorts that included >115,000 adult, hemodialysis patients each year.We estimated hazard ratios for the association of baseline variables and time-dependent hospitalization days and skilled nursing days with influenza vaccination, controlling for demographic and baseline health status variables.Vaccination coverage increased from 47% in 1999 to 60% in 2005. Patients with any length of hospitalization were less likely to be vaccinated, however, the association was stronger in patients with longer stays [15-25 d: hazard ratio=0.64 (95% confidence interval, 0.62-0.65); 26-30 d: 0.40 (0.38-0.42)]. Patients with any length of skilled nursing care of >1 day had similar estimates; these patients were also less likely to be vaccinated [26-30 d: 0.66 (0.64-0.69)].Patients with long hospitalizations or skilled nursing stays were less likely to be vaccinated suggesting evidence of the healthy-user effect. These variables could be used to account for bias in studies of preventive services in patients on dialysis.

SUBMITTER: McGrath LJ

PROVIDER: S-EPMC5495477 | biostudies-literature | 2013 Dec

REPOSITORIES: biostudies-literature

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Hospitalization and skilled nursing care are predictors of influenza vaccination among patients on hemodialysis: evidence of confounding by frailty.

McGrath Leah J LJ Cole Stephen R SR Kshirsagar Abhijit V AV Weber David J DJ Stürmer Til T Brookhart M Alan MA

Medical care 20131201 12

<h4>Background</h4>Observational studies of preventive medications, such as vaccinations, can suffer from the healthy-user bias because vaccinated patients may be healthier than unvaccinated patients. Indicators of health status and frailty suitable for attenuating this bias could be identified in administrative data.<h4>Objective</h4>To examine the association of baseline variables and time-dependent hospitalization and skilled nursing care with the receipt of influenza vaccination in patients ...[more]

PMID: 23969584

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Project description:Background: As hospitals in the US face pressures to reduce lengths of stay, healthcare systems are increasingly utilizing skilled nursing facilities (SNFs) to continue treating patients stable enough to leave the hospital, but not to return home. Substance use disorder (SUD) can complicate care of patients transferred to SNFs. The objective of this paper is to understand SNF experiences for this population of patients with comorbid SUD transferred to SNFs and examine care experiences in these facilities. Methods: This secondary mixed-methods analysis focuses on SNF experiences from a clinical trial of patient navigation services for medically-hospitalized adults with comorbid opioid, cocaine, and/or alcohol use disorder. This study compared baseline assessments and medical record review for participants (N = 400) with vs. without SNF transfer, and analyzed semi-structured qualitative interviews with a subsample of 15 participants purposively selected based on their transfer to a SNF. Results: Over 1 in 4 participants had a planned discharged to a SNF (26.8% sub-acute, 3.3% acute). Compared to participants with other types of discharge, participants discharged to a SNF had longer initial hospitalizations (4.9 vs. 11.8 days, p < 0.001), and were more likely to be White (38.6 vs. 50.8%; p = 0.02), female (38.9 vs. 52.5%; p = 0.01), have opioid use disorder (75.7 vs. 85.0%, p = 0.03), and be hospitalized for infection (43.6 vs. 58.3%; p = 0.007), and less likely to have worked prior to hospitalization (24.3 vs. 12.5%; p = 0.006). Qualitative narratives identified several themes from the SNF experience, including opioid analgesic dosing issues, challenges to the use of opioid agonist treatment of OUD, illicit opioid dealing/use, and limited access to addiction recovery support services during and following the SNF stay. Conclusions: SNFs are a common disposition for patients in need of subacute services following hospitalization but may be ill-equipped to properly manage patients in need of new or continuing SUD treatment.

Project description:IntroductionPost-dialysis recovery time (DRT) has an important relationship to quality of life and survival, as identified in studies of ESRD patients on conventional dialysis. ESRD patients are often discharged from hospitals to skilled nursing facilities (SNFs) where on-site treatment using home hemodialysis technology is increasingly offered, but nothing is known about DRT in this patient population.MethodsFrom November 4, 2019 to June 11, 2021, within a dialysis organization providing service across 12 states and 154 SNFs, patients receiving in-SNF, more frequent dialysis (MFD) (modeled to deliver 14 treatment hours minimum per week and stdKt/V ≥2.0) were asked to describe their post-dialysis recovery time following their previous treatment, within predefined categoric choices: 0-½, ½-1, 1-2, 2-4, 4-8, 8-12 h, by next morning, or not even by next morning. Patients reporting DRT following at least one full-week treatment opportunity were included in a mixed model logistic regression of rapid recovery (DRT ≤2 h).FindingsTwo thousand three hundred and nine patients met the statistical modeling inclusion criteria, providing DRT on 108,876 dialysis sessions, while receiving mean (SD) 4.3 (0.96) weekly dialysis treatments. 2118 (92%) reported DRT ≤2 h. Results appeared biologically plausible, as lower odds of rapid DRT were observed for patients who were older, missed their previous treatment, or experienced intradialytic hypotension. Greater odds of rapid DRT were observed in patients receiving five dialyses in the previous week or having 160-179 mmHg pre-hemodialysis systolic blood pressure. Rapid recovery was associated with reduced mortality or hospitalization.DiscussionSNF dialysis patients receiving 5x per week MFD report rapid recovery time ≤2 h in 92% of dialyses despite advanced age, frailty, and comorbidities. Future studies will assess the practical ramifications of rapid DRT perception/experience on nursing home rehabilitation programs, which could impact patient health beyond the nursing home stay.

Project description:IntroductionThe purpose of this study was to identify predictors of initial hospitalization and describe the outcomes of high-risk patients hospitalized with influenza.MethodsData were taken from the 5% national US Medicare database from 2012 to 2015. Patients (aged at least 13 years) were required to have at least one diagnosis for influenza and have continuous health plan enrollment for 6 months before (baseline) and 3 months (follow-up) after the date of influenza diagnosis. Patients who died during follow-up were included. Patients were categorized as initially hospitalized if hospitalized within 0-1 day of diagnosis. High-risk initially hospitalized patients were defined as patients aged at least 65 years or those that had a diagnostic code for chronic lung disease, cardiovascular or cerebrovascular disease, or weakened immune system during baseline period. Logistic regression models were developed to determine predictors of initial hospitalization.ResultsThe study population included 8127 high-risk patients who were initially hospitalized and 16,784 who were not hospitalized. Among high-risk patients, 89.3% were diagnosed in the emergency room, whereas 7.5% and 3.2% were diagnosed in a physician's office or other Medicare settings, respectively. Chronic obstructive pulmonary disorder, congestive heart failure, chronic kidney disease, older age, being male, other comorbidities, number of comorbidities, and baseline healthcare resource use were the predictors of hospitalization. Median length of stay for the hospitalization was 5.0 days, and the 30-day readmission rate was 14%. All-cause mortality rate was 5.1% during the inpatient stay and 9.2% within 30 days of diagnosis. Hospitalized patients with influenza incurred an increase of $16,568 per patient in total all-cause healthcare costs from pre-influenza to post-influenza diagnosis.ConclusionThe study characterized the burden of hospitalization for influenza and found that hospitalized high-risk patients experience greater comorbidity burden, higher likelihood of multiple inpatient admissions, and costly medical interventions compared to patients who were not hospitalized.

Project description:ImportanceA substantial number of patients discharged to skilled nursing facilities (SNFs) after heart failure (HF) hospitalization experience regression in function or do not improve. Delirium is one of few modifiable risk factors in this patient population. Therefore, understanding the role of delirium in functional recovery may be useful for improving outcomes.ObjectiveTo assess the association of delirium with 30-day functional improvement in patients discharged to SNFs after HF hospitalization.Design, setting, and participantsThis retrospective cohort study included patients hospitalized for HF in 129 US Department of Veterans Affairs hospitals who were discharged to SNFs from October 1, 2010, to September 30, 2015. Data were analyzed from June 14 to December 18, 2020.ExposuresDelirium, as determined by the Minimum Data Set (MDS) 3.0 Confusion Assessment Method, with dementia as a covariate, determined via International Classification of Diseases, Ninth Revision (ICD-9) coding.Main outcomes and measuresThe difference between admission and 30-day MDS 3.0 Activities of Daily Living (ADL) scores.ResultsA total of 20 495 patients (mean [SD] age, 78 [10.3] years; 78.9% White; and 97% male) were included in the analysis. Of the total sample, 882 patients (4.3%) had delirium on an SNF admission. The mean (SD) baseline ADL score on admission to SNF was significantly worse among patients with delirium than without (18.3 [4.7] vs 16.1 [5.2]; P < .001; d = 0.44.). On the 30-day repeated assessment, mean (SD) function (ADL scores) improved for both patients with delirium (0.6 [2.9]) and without delirium (1.8 [3.6]) (P < .001; d = -0.38). In the multivariate adjusted model, delirium was associated with statistically significant lower ADL improvement (difference in ADL score, -1.07; 95% CI, -1.31 to -0.83; P < .001).Conclusions and relevanceIn this retrospective cohort study, patients with HF discharged to SNFs with delirium were less likely to show improvement in function compared with patients without delirium. Findings suggest a potential need to reexamine how and when health care professionals assess delirium in HF patients throughout their hospitalization and SNF course. Identifying and treating delirium for HF patients earlier in their care trajectory may play an important role in improving care and long-term functional outcomes in this population. Future research is warranted to further investigate the association between delirium and functional recovery for HF and other patient populations.

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Hospitalization and skilled nursing care are predictors of influenza vaccination among patients on hemodialysis: evidence of confounding by frailty.

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Hospitalization and skilled nursing care are predictors of influenza vaccination among patients on hemodialysis: evidence of confounding by frailty.

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