Post-Acute Care Setting, Facility Characteristics, and Post-Stroke Outcomes: A Systematic Review

OBJECTIVE: To synthesize research comparing post-stroke health outcomes between patients rehabilitated in skilled nursing facilities (SNFs) and inpatient rehabilitation facilities (IRFs). Secondly, to evaluate relationships between facility characteristics and outcomes. DATA SOURCES: PubMed and CINAHL searches spanned January 1, 1998 to October 6, 2016 and encompassed MeSH and free-text keywords for stroke, IRF/SNF, and study outcomes. Human and English limits were used. STUDY SELECTION: Observational and experimental studies examining outcomes of adult stroke patients rehabilitated in an IRF or SNF were eligible. Studies had to provide site of care comparisons and/or analyses incorporating facility-level characteristics and had to report \u3e 1 primary outcome (discharge setting, functional status, readmission, quality of life, all-cause mortality). Unpublished, single-center, descriptive, and non-US studies were excluded. Articles were reviewed by one author and when uncertain, discussion with study coauthors achieved consensus. Fourteen (0.3%) titles were included. DATA EXTRACTION: The types of data, time period, size, design, and primary outcomes were extracted. We also extracted two secondary outcomes (length of IRF/SNF stay, cost) when reported by included studies. Effect measures, modeling approaches, methods for confounding adjustment, and potential confounders were extracted. Data were abstracted by one author and the accuracy verified by a second reviewer. DATA SYNTHESIS: Two studies evaluating community discharge, one study evaluating predicted readmission probability, and 3 studies evaluating all-cause mortality favored IRFs over SNFs. Functional status comparisons were inconsistent. No studies evaluated quality of life. Two studies confirmed increased costs in the IRF versus SNF setting. Although substantial facility variation was described, few studies characterized sources of variation. CONCLUSIONS: The few studies comparing post-stroke outcomes indicated better outcomes (with greater costs) for patients in IRFs versus SNFs. Contemporary research on the role of the post-acute care setting and its attributes in determining health outcomes should be prioritized to inform reimbursement system reform

Reduction in unplanned hospitalizations associated with a physician focused intervention to reduce potentially inappropriate medication use among older adults: a population-based cohort study

BACKGROUND: A multimodal general practitioner-focused intervention in the Local Health Authority (LHA) of Parma, Italy, substantially reduced the prevalence of potentially inappropriate medication (PIM) use among older adults. Our objective was to estimate changes in hospitalization rates associated with the Parma LHA quality improvement initiative that reduced PIM use. METHODS: This population-based longitudinal cohort study was conducted among older residents ( \u3e 65 years) using the Parma LHA administrative healthcare database. Crude and adjusted unplanned hospitalization rates were estimated in 3 periods (pre-intervention: 2005-2008, intervention: 2009-2010, post-intervention: 2011-2014). Multivariable negative binomial models estimated trends in quarterly hospitalization rates among individuals at risk during each period using a piecewise linear spline for time, adjusted for time-dependent and time-fixed covariates. RESULTS: The pre-intervention, intervention, and post-intervention periods included 117,061, 107,347, and 121,871 older adults and had crude hospitalization rates of 146.2 (95% CI: 142.2-150.3), 146.8 (95% CI: 143.6-150.0), and 140.8 (95% CI: 136.9-144.7) per 1000 persons per year, respectively. The adjusted pre-intervention hospitalization rate was declining by 0.7% per quarter (IRR = 0.993; 95% CI: 0.991-0.995). The hospitalization rate declined more than twice as fast during the intervention period (1.8% per quarter, IRR = 0.982; 95% CI: 0.979-0.985) and was nearly constant post-intervention (IRR: 0.999; 95% CI: 0.997-1.001). Contrasting model predictions for the intervention period (Q1 2009 to Q4 2010), the intervention was associated with 1481 avoided hospitalizations. CONCLUSION: In a large population of older adults, a multimodal general practitioner-focused intervention to decrease PIM use was associated with a decline in the unplanned hospitalization rate. Such interventions to reduce high risk medication use among older adults warrant consideration by health systems seeking to improve health outcomes and reduce high-cost acute care utilization

Did a physician-targeted intervention that reduced potentially inappropriate prescribing to elderly patients also reduce related hospitalizations?

Objectives: To determine whether a general practitioner focused intervention aimed at decreasing PIM prescribing in the elderly can decrease the risk of PIM-related hospitalizations. Poster presented at 2016 ISPOR conference in Washington DC.https://jdc.jefferson.edu/jcphposters/1005/thumbnail.jp

Adjuvant and salvage radiation therapy after prostatectomy : investigating beliefs and practices of radiation oncologists

Evidence regarding adjuvant radiation therapy (ART) and salvage radiation therapy (SRT) following radical prostatectomy (RP) for prostate cancer is inconsistent. The study objectives were to collect survey information on Italian radiation oncologists' (RO) beliefs regarding the use of ART and SRT following RP and to compare the results of Italian RO with those of American RO available from an analogous survey

Geographic Variation in the Initiation of Commonly Used Opioids and Dosage Strength in United States Nursing Homes

OBJECTIVES: To examine and quantify geographic variation in the initiation of commonly used opioids and prescribed dosage strength among older US nursing home residents. METHODS: We merged 2011 Minimum Data Set 3.0 to Medicare claims and facility characteristics data to conduct a cross-sectional study among long-stay nursing home residents who initiated short-acting opioids commonly used in nursing homes (oxycodone, hydrocodone, or tramadol). We examined geographic variation in specific opioids initiated and potentially inappropriate doses ( \u3e /=50 mg oral morphine equivalent/d) across hospital referral regions (HRR). Multilevel logistic models quantified the proportional change in between-HRR variation and associations between commonly initiated opioids and inappropriate doses after adjusting for resident characteristics, facility characteristics, and state. RESULTS: Oxycodone (9.4%) was initiated less frequently than hydrocodone (56.2%) or tramadol (34.5%) but varied dramatically between HRRs (range, 0%-74.5%). In total, resident/facility characteristics and state of residence, respectively explained 84.1%, 58.2%, 59.1%, and 46.6% of the between-HRR variation for initiating oxycodone, hydrocodone, tramadol, and inappropriate doses. In all cases, state explained the largest proportion of between-HRR variation. Relative to hydrocodone, residents initiating oxycodone were more likely (adjusted odds ratio, 5.00; 95% confidence interval, 4.57-5.47) and those initiating tramadol were less likely (adjusted odds ratio, 0.28; 95% confidence interval, 0.25-0.31) to be prescribed potentially inappropriately high doses. CONCLUSIONS: We documented extensive geographic variation in the opioid and dose initiated for nursing home residents, with state explaining the largest proportion of the observed variation. Further work is needed to understand potential drivers of opioid prescribing patterns at the state level