Dataset Information

Association of Antidementia Therapies With Time to Skilled Nursing Facility Admission and Cardiovascular Events Among Elderly Adults With Alzheimer Disease.

ABSTRACT: Importance:To date, no study has compared time to skilled nursing facility (SNF) admission and cardiovascular events across medications available to treat Alzheimer disease. Objective:To compare time to SNF admission and cardiovascular events between acetylcholinesterase inhibitor (AChEI) monotherapy, memantine hydrochloride monotherapy, and combination therapy with an AChEI and memantine in treating elderly adults with Alzheimer disease. Design, Setting, and Participants:This retrospective cohort study uses January 1, 2006, to December 31, 2014, claims data from a 5% random sample of Medicare beneficiaries who had received a new diagnosis of Alzheimer disease between January 1, 2007, and December 31, 2013, and who initiated AChEI monotherapy, memantine monotherapy, or combination therapy with an AChEI and memantine (N?=?73?475). Patients were followed up until discontinuation of treatment, switch of treatment, death, or the end of the study period. Statistical analysis was conducted from February 15, 2018, to June 15, 2018. Exposures:Acetylcholinesterase inhibitor monotherapy (n?=?44?424), memantine monotherapy (n?=?11?809), and combination therapy with an AChEI and memantine (n?=?17?242). Main Outcomes and Measures:Primary outcomes were time to SNF admission and the composite of the following cardiovascular events: acute myocardial infarction, bradycardia, syncope, atrioventricular block, QT interval prolongation, and ventricular tachycardia. Cox proportional hazards regression models were constructed to compare outcomes between each pair of treatment groups, controlling for a comprehensive list of patient characteristics. Results:The study population included 73?475 participants (53?068 women and 20?407 men; mean [SD] age, 81.8 [8.3] years); 25.5% of the participants initiating AChEI monotherapy, 25.6% of participants initiating memantine monotherapy, and 29.7% of participants initiating combination therapy with an AChEI and memantine were admitted to an SNF. Similarly, 22.2% of the participants initiating AChEI monotherapy, 20.0% of those initiating memantine monotherapy, and 24.5% of those initiating combination therapy experienced at least 1 cardiovascular event. No difference in time to SNF admission was found across the 3 treatment groups. The risk of the composite measure of any cardiovascular event did not differ between the combination therapy and AChEI monotherapy groups (adjusted hazard ratio [aHR], 0.99; 95% CI, 0.96-1.03); however, it was higher for both AChEI monotherapy (aHR, 1.07; 95% CI, 1.02-1.12) and combination therapy (aHR, 1.07; 95% CI, 1.01-1.12), relative to memantine monotherapy. This result was mainly driven by the lower risk of bradycardia and syncope observed for the memantine monotherapy group relative to both AChEI monotherapy (bradycardia: aHR, 0.88; 95% CI, 0.82-0.95; and syncope: aHR, 0.92; 95% CI, 0.86-0.97) and combination therapy (bradycardia: aHR, 0.89; 95% CI, 0.82-0.97; and syncope: aHR, 0.87; 95% CI, 0.83-0.94). Conclusions and Relevance:Time to SNF admission did not differ across treatment groups, but memantine monotherapy was associated with a lower risk of cardiovascular events compared with both AChEI monotherapy and combination therapy with an AChEI and memantine.

SUBMITTER: San-Juan-Rodriguez A

PROVIDER: S-EPMC6484658 | biostudies-literature | 2019 Mar

REPOSITORIES: biostudies-literature

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Association of Antidementia Therapies With Time to Skilled Nursing Facility Admission and Cardiovascular Events Among Elderly Adults With Alzheimer Disease.

San-Juan-Rodriguez Alvaro A Zhang Yuting Y He Meiqi M Hernandez Inmaculada I

JAMA network open 20190301 3

<h4>Importance</h4>To date, no study has compared time to skilled nursing facility (SNF) admission and cardiovascular events across medications available to treat Alzheimer disease.<h4>Objective</h4>To compare time to SNF admission and cardiovascular events between acetylcholinesterase inhibitor (AChEI) monotherapy, memantine hydrochloride monotherapy, and combination therapy with an AChEI and memantine in treating elderly adults with Alzheimer disease.<h4>Design, setting, and participants</h4>T ...[more]

PMID: 30821828

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Project description:BackgroundClose to 1 in 5 patients admitted to a skilled nursing facility (SNF) are readmitted to the acute hospital within 30 days, and a substantial percentage are readmitted within 2 days of the SNF admission. These rapid returns to the hospital may provide insights for improving care transitions between the acute hospital and the SNF.ObjectivesTo describe the characteristics of SNF to hospital transfers that occur within 48 hours and 30 days of SNF admission based on root cause analyses (RCAs) performed by SNF staff, and identify potential areas of focus for improving transitions between hospitals and SNFs.DesignTrained staff from SNFs enrolled in a randomized, controlled clinical trial of the INTERACT (Interventions to Reduce Acute Care Transfers) quality improvement program performed retrospective RCAs on hospital transfers during a 12-month implementation period.SettingSNFs from across the United States.Participants64 of 88 SNFs randomized to the intervention group submitted RCAs.InterventionsSNFs were implementing the INTERACT quality improvement program.MeasuresData were abstracted from the INTERACT Quality Improvement (QI) tool, a structured, retrospective RCA on hospital transfers.ResultsAmong 4658 transfers for which data on the time between SNF admission and hospital transfer were available, 353 (8%) occurred within 48 hours of SNF admission, 524 (11%) 3 to 6 days after SNF admission, 1450 (31%) 7 to 29 days after SNF admission, and 2331 (50%) occurred 30 days or longer after admission. Comparisons between transfers that occurred within 48 hours and within 30 days of SNF admission to transfers that occurred 30 days or longer after SNF admission revealed several statistically significant differences between patient risk factors for transfer, symptoms and signs precipitating the transfers, and other characteristics of the transfers. Hospitalization in the last 30 days and year was significantly more common among those with rapid returns to the hospital. Shortness of breath was significantly more common among those transferred within 48 hours or 30 days, and falls, functional decline, suspected respiratory infection, and new urinary incontinence less common. SNF staff rated a higher proportion of transfers within 30 days versus 30 days or longer as potentially preventable (25.1% vs 21.5%, P = .005). Case descriptions derived from the QI tools of transfers back to the hospital within 48 hours of SNF admission illustrate several factors underlying these rapid returns to the hospital.ConclusionRCAs on transfers back to the hospital shortly after SNF admission provide insights into strategies that both hospitals and SNFs can consider in collaborative efforts to reduce potentially avoidable hospital readmissions.

Project description:ObjectiveTo describe the frequency and timing of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibody detection in a convenience sample of skilled nursing facility (SNF) residents with and without confirmed SARS-CoV-2 infection.DesignRetrospective analysis of SNF electronic health records.SettingQualitative SARS-CoV-2 antibody test results were available from 81 SNFs in 16 states.ParticipantsSix hundred and sixty nine SNF residents who underwent both polymerase chain reaction (PCR) and antibody testing for SARS-CoV-2.MeasurementsPresence of SARS-CoV-2 antibodies following the first positive PCR test for confirmed cases, or first PCR test for non-cases.ResultsAmong 397 residents with PCR-confirmed infection, antibodies were detected in 4 of 7 (57.1%) tested within 7-14 days of their first positive PCR test; in 44 of 47 (93.6%) tested within 15-30 days; in 182 of 219 (83.1%) tested within 31-60 days; and in 110 of 124 (88.7%) tested after 60 days. Among 272 PCR negative residents, antibodies were detected in 2 of 9 (22.2%) tested within 7-14 days of their first PCR test; in 41 of 81 (50.6%) tested within 15-30 days; in 65 of 148 (43.9%) tested within 31-60 days; and in 9 of 34 (26.5%) tested after 60 days. No significant differences in baseline resident characteristics or symptoms were observed between those with versus without antibodies.ConclusionsThese findings suggest that vulnerable older adults can mount an antibody response to SARS-CoV-2, and that antibodies are most likely to be detected within 15-30 days of diagnosis. That antibodies were detected in a large proportion of residents with no confirmed SARS-CoV-2 infection highlights the complexity of identifying who is infected in real time. Frequent surveillance and diagnostic testing based on low thresholds of clinical suspicion for symptoms and/or exposure will remain critical to inform strategies designed to mitigate outbreaks in SNFs while community SARS-CoV-2 prevalence remains high.

Project description:ImportanceThe new Medicare Skilled Nursing Facility Value-Based Purchasing program (SNF VBP) seeks to improve patient outcomes by awarding financial incentives or penalties based on 30-day hospital readmission rates. Skilled nursing facilities (SNFs) can avoid a penalty through low baseline readmission rates or improvement over time.ObjectiveTo assess the baseline performance and improvement over time of SNFs in the SNF VBP program.Design, setting, and participantsThis cross-sectional study examined readmission rates, financial penalties and incentives, and facility and patient characteristics associated with these outcomes at 14 959 US SNFs that received Medicare payments between January 1, 2015, and December 31, 2019.Main outcomes and measuresOutcomes were readmission rates and financial penalties by facility. The SNFs were classified as improvers in the analysis if they had better improvement scores than baseline scores under the program and achievers if they had higher baseline scores than improvement scores.ResultsOf 14 959 SNFs studied, 1849 (12.3%) were assigned their improvement score as their performance score in the first year of the program. Of these, 1167 (63.1%) received a financial penalty, whereas 374 (20.2%) received a bonus. Only 52 facilities that performed poorly at baseline (0.3% of all SNFs and 0.7% of below-median performers) were able to improve enough to avoid a financial penalty, despite large improvements in readmission rates. Improver SNFs treated larger racial minority populations (mean [SD], 74.57% [23.42%] White in the improver group vs 79.15% [22.18%] in the achiever group) and were located in counties with larger minority populations (mean [SD], 15.48% [14.05%] Black in the improver group vs 11.57% [12.72%] Black in the achiever group). The most important predictors of improvement were related to SNF finances, such as operating margin (mean [SD], -0.74 [13.87]) and occupancy rates (mean [SD], 79.93 [14.81]).Conclusions and relevanceThis cross-sectional study suggests that the SNF VBP program did not offer a viable path for nearly all low-performing SNFs to avoid financial penalties through improved readmission rates.

Dataset Information

Association of Antidementia Therapies With Time to Skilled Nursing Facility Admission and Cardiovascular Events Among Elderly Adults With Alzheimer Disease.

Publications

Association of Antidementia Therapies With Time to Skilled Nursing Facility Admission and Cardiovascular Events Among Elderly Adults With Alzheimer Disease.

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