Dataset Information

Long-term Care Facility Variation in the Incidence of Pneumonia and Influenza.

ABSTRACT: Background:Pneumonia and influenza (P&I) increase morbidity and mortality among older adults, especially those residing in long-term care facilities (LTCFs). Facility-level characteristics may affect the risk of P&I beyond resident-level risk factors. However, the relationship between facility characteristics and P&I is poorly understood. To address this, we identified potentially modifiable facility-level characteristics that influence the incidence of P&I across LTCFs. Methods:We conducted a retrospective cohort study using 2013-2015 Medicare claims linked to Minimum Data Set and LTCF-level data. Short-stay (<100 days) and long-stay (100+ days) LTCF residents were followed for the first occurrence of hospitalization, LTCF discharge, Medicare disenrollment, or death. We calculated LTCF risk-standardized incidence rates (RSIRs) per 100 person-years for P&I hospitalizations by adjusting for over 30 resident-level demographic and clinical covariates using hierarchical logistic regression. Results:We included 1 767 241 short-stay (13 683 LTCFs) and 922 863 long-stay residents (14 495 LTCFs). LTCFs with lower RSIRs had more licensed independent practitioners (nurse practitioners or physician assistants) among short-stay (44.9% vs 41.6%, P < .001) and long-stay residents (47.4% vs 37.9%, P < .001), higher registered nurse hours/resident/day among short-stay and long-stay residents (mean [SD], 0.5 [0.7] vs 0.4 [0.4], P < .001), and fewer residents for whom antipsychotics were prescribed among short-stay (21.4% [11.6%] vs 23.6% [13.2%], P < .001) and long-stay residents (22.2% [14.3%] vs 25.5% [15.0%], P < .001). Conclusions:LTCF characteristics may play an important role in preventing P&I hospitalizations. Hiring more registered nurses and licensed independent practitioners, increasing staffing hours, and higher-quality care practices may be modifiable means of reducing P&I in LTCFs.

SUBMITTER: Bosco E

PROVIDER: S-EPMC6565378 | biostudies-literature | 2019 Jun

REPOSITORIES: biostudies-literature

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Long-term Care Facility Variation in the Incidence of Pneumonia and Influenza.

Bosco Elliott E Zullo Andrew R AR McConeghy Kevin W KW Moyo Patience P van Aalst Robertus R Chit Ayman A Mor Vincent V Gravenstein Stefan S

Open forum infectious diseases 20190515 6

<h4>Background</h4>Pneumonia and influenza (P&I) increase morbidity and mortality among older adults, especially those residing in long-term care facilities (LTCFs). Facility-level characteristics may affect the risk of P&I beyond resident-level risk factors. However, the relationship between facility characteristics and P&I is poorly understood. To address this, we identified potentially modifiable facility-level characteristics that influence the incidence of P&I across LTCFs.<h4>Methods</h4>W ...[more]

PMID: 31214626

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Project description:BACKGROUND:Older adults who reside in long-term care facilities (LTCFs) are at particularly high risk for infection, morbidity and mortality from pneumonia and influenza (P&I) compared to individuals of younger age and those living outside institutional settings. The risk factors for P&I hospitalizations that are specific to LTCFs remain poorly understood. Our objective was to evaluate the incidence of P&I hospitalization and associated person- and facility-level factors among post-acute (short-stay) and long-term (long-stay) care residents residing in LTCFs from 2013 to 2015. METHODS:In this retrospective cohort study, we used Medicare administrative claims linked to Minimum Data Set and LTCF-level data to identify short-stay (<?100?days, index?=?admission date) and long-stay (100+ days, index?=?day 100) residents who were followed from the index date until the first of hospitalization, LTCF discharge, Medicare disenrollment, or death. We measured incidence rates (IRs) for P&I hospitalization per 100,000 person-days, and estimated associations with baseline demographics, geriatric syndromes, clinical characteristics, and medication use using Cox regression models. RESULTS:We analyzed data from 1,118,054 short-stay and 593,443 long-stay residents. The crude 30-day IRs (95% CI) of hospitalizations with P&I in the principal position were 26.0 (25.4, 26.6) and 34.5 (33.6, 35.4) among short- and long-stay residents, respectively. The variables associated with P&I varied between short and long-stay residents, and common risk factors included: advanced age (85+ years), admission from an acute hospital, select cardiovascular and respiratory conditions, impaired functional status, and receipt of antibiotics or Beers criteria medications. Facility staffing and care quality measures were important risk factors among long-stay residents but not in short-stay residents. CONCLUSIONS:Short-stay residents had lower crude 30- and 90-day incidence rates of P&I hospitalizations than long-stay LTCF residents. Differences in risk factors for P&I between short- and long-stay populations suggest the importance of considering distinct profiles of post-acute and long-term care residents in infection prevention and control strategies in LTCFs. These findings can help clinicians target interventions to subgroups of LTCF residents at highest P&I risk.

Project description:ImportanceOlder adults residing in long-term care facilities (LTCFs) are at a high risk of being infected with respiratory viruses, such as influenza and respiratory syncytial virus (RSV). Although these infections commonly have many cardiorespiratory sequelae, the national burden of influenza- and RSV-attributable cardiorespiratory events remains unknown for the multimorbid and vulnerable LTCF population.ObjectiveTo estimate the incidence of cardiorespiratory hospitalizations that were attributable to influenza and RSV among LTCF residents and to quantify the economic burden of these hospitalizations on the US health care system by estimating their associated cost and length of stay.Design, setting, and participantsThis retrospective cohort study used national Medicare Provider Analysis and Review inpatient claims and Minimum Data Set clinical assessments for 6 respiratory seasons (2011-2017). Long-stay residents of LTCFs were identified as those living in the facility for at least 100 days (index date), aged 65 years or older, and with 6 months of continuous enrollment in Medicare Part A were included. Follow-up occurred from the resident's index date until the first hospitalization, discharge from the LTCF, disenrollment from Medicare, death, or the end of the study. Residents could re-enter the sample; thus, long-stay episodes of care were identified. Data analysis was performed between January 1 and September 30, 2020.ExposuresSeasonal circulating pandemic 2009 influenza A(H1N1), human influenza A(H3N2), influenza B, and RSV.Main outcomes and measuresCardiorespiratory hospitalizations (eg, asthma exacerbation, heart failure) were identified using primary diagnosis codes. Influenza- and RSV-attributable cardiorespiratory events were estimated using a negative binomial regression model adjusted for weekly circulating influenza and RSV testing data. Length of stay and costs of influenza- and RSV-attributable events were then estimated.ResultsThe study population comprised 2 909 106 LTCF residents with 3 138 962 long-stay episodes and 5 079 872 person-years of follow-up. Overall, 10 939 (95% CI, 9413-12 464) influenza- and RSV-attributable cardiorespiratory events occurred, with an incidence of 215 (95% CI, 185-245) events per 100 000 person-years. The cost of influenza- and RSV-attributable cardiorespiratory events was $91 055 393 (95% CI, $77 885 316-$104 225 470), and the length of stay was 56 858 (95% CI, 48 757-64 968) days.Conclusions and relevanceThis study found that many cardiorespiratory hospitalizations among LTCF residents in the US were attributable to seasonal influenza and RSV. To minimize the burden these events place on the health care system and residents of LTCFs and to prevent virus transmission, additional preventive measures should be implemented.

Project description:Importance:Despite providing an overlapping level of care, it is unknown why hospitalized older adults are transferred to long-term acute care hospitals (LTACs) vs less costly skilled nursing facilities (SNFs) for postacute care. Objective:To examine factors associated with variation in LTAC vs SNF transfer among hospitalized older adults. Design, Setting, and Participants:We conducted this retrospective observational cohort study of hospitalized older adults (≥65 years) transferred to an LTAC vs SNF during fiscal year 2012 using national 5% Medicare data. Main Outcomes and Measures:Predictors of LTAC transfer were assessed using a multilevel mixed-effects model adjusting for patient-, hospital-, and region-level factors. We estimated variation partition coefficients and adjusted hospital- and region-specific LTAC transfer rates using sequential models. Results:Among 65 525 hospitalized older adults (42 461 [64.8%] women; 39 908 [60.9%] ≥85 years) transferred to an LTAC or SNF, 3093 (4.7%) were transferred to an LTAC. We identified 29 patient-, 3 hospital-, and 5 region-level independent predictors. The strongest predictors of LTAC transfer were receiving a tracheostomy (adjusted odds ration [aOR], 23.8; 95% CI, 15.8-35.9) and being hospitalized in close proximity to an LTAC (0-2 vs >42 miles; aOR, 8.4, 95% CI, 6.1-11.5). After adjusting for case-mix, differences between patients explained 52.1% (95% CI, 47.7%-56.5%) of the variation in LTAC use. The remainder was attributable to hospital (15.0%; 95% CI, 12.3%-17.6%), and regional differences (32.9%; 95% CI, 27.6%-38.3%). Case-mix adjusted LTAC use was very high in the South (17%-37%) compared with the Pacific Northwest, North, and Northeast (<2.2%). From the full multilevel model, the median adjusted hospital LTAC transfer rate was 2.1% (10th-90th percentile, 0.24%-10.8%). Even within a region, adjusted hospital LTAC transfer rates varied substantially (intraclass correlation coefficient [ICC], 0.26; 95% CI, 0.23-0.30). Conclusions and Relevance:Although many patient-level factors were associated with LTAC use, half of the variation in LTAC vs SNF transfer is independent of patients' illness severity or clinical complexity, and is explained by where the patient was hospitalized and in what region, with far greater use in the South. Even among hospitals in regions with similar LTAC access, there was considerable variation in LTAC use. Given the higher expense associated with LTACs vs SNFs, greater attention is needed to define the optimal role of LTACs in the postacute care of older adults.

Dataset Information

Long-term Care Facility Variation in the Incidence of Pneumonia and Influenza.

Publications

Long-term Care Facility Variation in the Incidence of Pneumonia and Influenza.

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