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Mortality and Functional Outcomes After Minor Urological Surgery in Nursing Home Residents: A National Study.

ABSTRACT: OBJECTIVES:To determine outcomes of minor urological surgery in frail older adults. DESIGN:Retrospective cohort study. SETTING:U.S. nursing homes (NHs). PARTICIPANTS:NH residents aged 65 and older undergoing minor inpatient urological surgery (cystoscopy, bladder biopsy, transurethral resection of bladder tumor, prostate biopsy, transurethral resection of prostate, removal of ureteral obstruction, suprapubic tube placement) in the United States between 2004 and 2012 (N=34,605). MEASUREMENTS:One-year mortality and changes in functional status before and after surgery using the Minimum Data Set Activity of Daily Living (MDS-ADL) summary scale. RESULTS:Overall 1-year mortality was 50%, and on average, residents had a 1.9-point worsening in their MDS-ADL score at 1 year, whereas the most highly functional residents (baseline quartile of MDS-ADL scores (0-12)) had a 4.7-point worsening in their MDS-ADL scores at 1 year. Functional decline in residents 1 year after surgery was associated with decline in function in the 6 months before surgery (adjusted hazard ratio (aH)=2.39, 95% confidence interval (CI)=2.29-2.49), emergency procedures (aHR=1.37, 95% CI=1.31-1.43), older age (?85 vs 65-74, aHR=1.17, 95% CI=1.11-1.23), and baseline cognitive impairment (aHR=1.15, 95% CI=1.11-1.20). CONCLUSION:Despite the low complexity of minor urological procedures, NH residents experience high mortality and many demonstrate sustained functional decline up to 1-year postoperatively.

SUBMITTER: Suskind AM

PROVIDER: S-EPMC6009834 | biostudies-literature | 2018 May

REPOSITORIES: biostudies-literature

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Mortality and Functional Outcomes After Minor Urological Surgery in Nursing Home Residents: A National Study.

Suskind Anne M AM Zhao Shoujun S Walter Louise C LC Boscardin W John WJ Finlayson Emily E

Journal of the American Geriatrics Society 20180323 5

<h4>Objectives</h4>To determine outcomes of minor urological surgery in frail older adults.<h4>Design</h4>Retrospective cohort study.<h4>Setting</h4>U.S. nursing homes (NHs).<h4>Participants</h4>NH residents aged 65 and older undergoing minor inpatient urological surgery (cystoscopy, bladder biopsy, transurethral resection of bladder tumor, prostate biopsy, transurethral resection of prostate, removal of ureteral obstruction, suprapubic tube placement) in the United States between 2004 and 2012 ...[more]

PMID: 29572851

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Project description:Little is known regarding outcomes after hip fracture among long-term nursing home residents.To describe patterns and predictors of mortality and functional decline in activities of daily living (ADLs) among nursing home residents after hip fracture.Retrospective cohort study of 60,111 Medicare beneficiaries residing in nursing homes who were hospitalized with hip fractures between July 1, 2005, and June 30, 2009.Data sources included Medicare claims and the Nursing Home Minimum Data Set. Main outcomes included death from any cause at 180 days after fracture and a composite outcome of death or new total dependence in locomotion at the latest available assessment within 180 days. Additional analyses described within-residents changes in function in 7 ADLs before and after fracture.Of 60,111 patients, 21,766 (36.2%) died by 180 days after fracture; among patients not totally dependent in locomotion at baseline, 53.5% died or developed new total dependence within 180 days. Within individual patients, function declined substantially after fracture across all ADL domains assessed. In adjusted analyses, the greatest decreases in survival after fracture occurred with age older than 90 years (vs ?75 years: hazard ratio [HR], 2.17; 95% CI, 2.09-2.26 [P?<?.001]), nonoperative fracture management (vs internal fixation: HR for death, 2.08; 95% CI, 2.01-2.15 [P?<?.001]), and advanced comorbidity (Charlson score of ?5 vs 0: HR, 1.66; 95% CI, 1.58-1.73 [P?<?.001]). The combined risk of death or new total dependence in locomotion within 180 days was greatest among patients with very severe cognitive impairment (vs intact cognition: relative risk [RR], 1.66; 95% CI, 1.56-1.77 [P?<?.001]), patients receiving nonoperative management (vs internal fixation: RR, 1.48; 95% CI, 1.45-1.51 [P?<?.001]), and patients older than 90 years (vs ?75 years: RR, 1.42; 95% CI, 1.37-1.46 [P?<?.001]).Survival and functional outcomes are poor after hip fracture among nursing home residents, particularly for patients receiving nonoperative management, the oldest old, and patients with multiple comorbidities and advanced cognitive impairment. Care planning should incorporate appropriate prognostic information related to outcomes in this population.

Project description:ImportanceBreast cancer surgery, the most common cancer operation performed in nursing home residents, is viewed as a low-risk surgical intervention. However, outcomes in patients with high functional dependence and limited life expectancy are poorly understood.ObjectiveTo assess the overall survival and functional status changes after breast cancer surgery in female nursing home residents stratified by surgery type.Design, setting, and participantsThis study used Medicare claims from 2003 to 2013 to identify 5969 US nursing home residents who underwent inpatient breast cancer surgery. Using the Minimum Data Set Activities of Daily Living (MDS-ADL) summary score, this study examined preoperative and postoperative function and identified patient characteristics associated with 30-day and 1-year mortality and 1-year functional decline after surgery. Cox proportional hazards regression was used to estimate unadjusted and adjusted hazard ratios (HRs) of mortality. Fine-Gray competing risks regression was used to estimate unadjusted and adjusted subhazard ratios (sHRs) of functional decline. Statistical analysis was performed from January 2016 to January 2018.Main outcomes and measuresFunctional status and death.ResultsFrom 2003 to 2013, a total of 5969 female nursing home residents (mean [SD] age, 82 [7] years; 4960 [83.1%] white) underwent breast cancer surgery: 666 (11.2%) underwent lumpectomy, 1642 (27.5%) underwent mastectomy, and 3661 (61.3%) underwent lumpectomy or mastectomy with axillary lymph node dissection (ALND). The 30-day mortality rates were 8% after lumpectomy, 4% after mastectomy, and 2% after ALND. The 1-year mortality rates were 41% after lumpectomy, 30% after mastectomy, and 29% after ALND. Among 1-year survivors, the functional decline rate was 56% to 60%. The mean MDS-ADL score increased (signifying greater dependency) by 3 points for lumpectomy, 4 points for mastectomy, and 5 points for ALND. In multivariate analysis, poor baseline MDS-ADL score (range, 20-28) was associated with a higher 1-year mortality risk (lumpectomy: HR, 1.92 [95% CI, 1.23-3.00], P = .004; mastectomy: HR, 1.80 [95% CI, 1.35-2.39], P < .001; and ALND: HR, 1.77 [95% CI, 1.46-2.15], P < .001). After multivariate adjustment, preoperative decline in MDS-ADL score (lumpectomy: sHR, 1.59 [95% CI, 1.25-2.03], P < .001; mastectomy: sHR, 1.79; [95% CI, 1.52-2.09], P < .001; and ALND: sHR, 1.72 [95% CI, 1.56-1.91], P < .001) and cognitive impairment (lumpectomy: sHR, 1.27 [95% CI, 1.03-1.56], P = .02; mastectomy: sHR, 1.26 [95% CI, 1.09-1.45], P = .002; and ALND: sHR, 1.14 [95% CI, 1.04-1.24], P = .003) were significantly associated with 1-year functional decline across all breast cancer surgery groups.Conclusions and relevanceFor female nursing home residents who underwent breast cancer surgery, 30-day mortality and survival as well as 1-year mortality and functional decline were high. The 1-year survivors had significant functional decline. This study's findings suggest that this information should be incorporated into collaborative surgical decision-making processes.

Project description:ObjectivesEstimates of influenza vaccine use are not available at the county level for U.S. nursing home (NH) residents but are critically necessary to guide the implementation of quality improvement programs aimed at increasing vaccination. Furthermore, estimates that account for differences in resident characteristics between counties are unavailable. We estimated risk-standardized vaccination rates (RSVRs) among short- and long-stay NH residents by U.S. county and identified drivers of geographic variation.MethodsWe conducted a retrospective cohort study utilizing 100% of 2013-2015 fee-for-service Medicare claims, Minimum Data Set assessments, Certification and Survey Provider Enhanced Reports, and Long-Term Care: Facts on Care in the U.S. We separately evaluated short-stay (<100 days) and long-stay (≥100 days) residents aged 65 and older across the 2013-2014 and 2014-2015 influenza seasons. We estimated RSVRs via hierarchical logistic regression adjusting for 32 resident-level covariates. We then used multivariable linear regression models to assess associations between county-level NHs predictors and RSVRs.ResultsThe study cohort consisted of 2,817,217 residents in 14,658 NHs across 2798 counties. Short-stay residents had lower RSVRs than long-stay residents (2013-2014: median [interquartile range], 69.6% [62.8-74.5] vs 84.0% [80.8-86.4]), and there was wide variation within each population (range, 11.4-89.8 vs 49.1-92.6). Several modifiable facility-level characteristics were associated with increased RSVRs, including higher registered nurse to total nurse ratio and higher total staffing for licensed practical nurses, speech-language pathologists, and social workers. Characteristics associated with lower RSVRs included higher percentage of residents restrained, with a pressure ulcer, and NH-level hospitalizations per resident-year.ConclusionsSubstantial county-level variation in influenza vaccine use exists among short- and long-stay NH residents. Quality improvement interventions to improve vaccination rates can leverage these results to target NHs located in counties with lower risk-standardized vaccine use.

Project description:Importance:Although ?-blockers are a mainstay of treatment after acute myocardial infarction (AMI), these medications are commonly not prescribed for older nursing home residents after AMI, in part owing to concerns about potential functional harms and uncertainty of benefit. Objective:To study the association of ?-blockers after AMI with functional decline, mortality, and rehospitalization among long-stay nursing home residents 65 years or older. Design, Setting, and Participants:This cohort study of nursing home residents with AMI from May 1, 2007, to March 31, 2010, used national data from the Minimum Data Set, version 2.0, and Medicare Parts A and D. Individuals with ?-blocker use before AMI were excluded. Propensity score-based methods were used to compare outcomes in people who did vs did not initiate ?-blocker therapy after AMI hospitalization. Main Outcomes and Measures:Functional decline, death, and rehospitalization in the first 90 days after AMI. Functional status was measured using the Morris scale of independence in activities of daily living. Results:The initial cohort of 15?720 patients (11?140 women [70.9%] and 4580 men [29.1%]; mean [SD] age, 83 [8] years) included 8953 new ?-blocker users and 6767 nonusers. The propensity-matched cohort included 5496 new users of ?-blockers and an equal number of nonusers for a total cohort of 10?992 participants (7788 women [70.9%]; 3204 men [29.1%]; mean [SD] age, 84 [8] years). Users of ?-blockers were more likely than nonusers to experience functional decline (odds ratio [OR], 1.14; 95% CI, 1.02-1.28), with a number needed to harm of 52 (95% CI, 32-141). Conversely, ?-blocker users were less likely than nonusers to die (hazard ratio [HR], 0.74; 95% CI, 0.67-0.83) and had similar rates of rehospitalization (HR, 1.06; 95% CI, 0.98-1.14). Nursing home residents with moderate or severe cognitive impairment or severe functional dependency were particularly likely to experience functional decline from ?-blockers (OR, 1.34; 95% CI, 1.11-1.61 and OR, 1.32; 95% CI, 1.10-1.59, respectively). In contrast, little evidence of functional decline due to ?-blockers was found in participants with intact cognition or mild dementia (OR, 1.03; 95% CI, 0.89-1.20; P?=?.03 for effect modification) or in those in the best (OR, 0.99; 95% CI, 0.77-1.26) and intermediate (OR, 1.05; 95% CI, 0.86-1.27) tertiles of functional independence (P?=?.06 for effect modification). Mortality benefits of ?-blockers were similar across all subgroups. Conclusions and Relevance:Use of ?-blockers after AMI is associated with functional decline in older nursing home residents with substantial cognitive or functional impairment, but not in those with relatively preserved mental and functional abilities. Use of ?-blockers yielded a considerable mortality benefit in all groups.

Project description:ObjectivesImproving function is an important outcome of postacute care in skilled nursing facilities (SNFs), but cognitive impairment can limit a resident's ability to improve during a postacute care stay. Our objective was to examine the association between residents' cognitive status on admission and change in self-care and mobility during a Medicare-covered SNF stay.DesignRetrospective analysis of Medicare beneficiaries who had a new SNF stay between January and June 2017.SettingSNFs in the United States.ParticipantsNewly admitted residents with Medicare-covered SNF stays between January and June 2017 (n = 246 395).MeasurementsResidents' self-care and mobility at SNF admission and discharge were determined using items from Section GG (eating, oral hygiene, toileting hygiene, sit to lying, lying to sitting, sit to stand, chair/bed transfer, and toilet transfer) of the Minimum Data Set. Residents were classified as cognitively intact, mildly impaired, moderately impaired, or severely impaired, according to the Cognitive Function Scale. Multivariable regression models controlling for residents' demographic and clinical characteristics and SNF fixed effects were used to identify residents whose discharge scores for self-care and mobility were better or the same as expected according to their cognitive status on admission.ResultsResidents who were cognitively impaired on admission had lower functional status on admission and were less likely to improve in self-care and mobility compared with residents who were cognitively intact. Approximately 63% of residents who were cognitively intact had discharge scores for self-care and mobility that were better or the same as expected compared with 45% of residents with severe cognitive impairment.ConclusionsCognitive impairment is associated with poorer self-care and mobility function among SNF residents. These findings have important implications for clinicians, who may need additional support when caring for residents with cognitive impairment to make the same improvements in functional status as residents who are cognitively intact. J Am Geriatr Soc 67:553-557, 2019.

Dataset Information

Mortality and Functional Outcomes After Minor Urological Surgery in Nursing Home Residents: A National Study.

Publications

Mortality and Functional Outcomes After Minor Urological Surgery in Nursing Home Residents: A National Study.

Similar Datasets

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