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Introduction: Limited evidence exists on health system characteristics associated with initial and long-term prescribing of opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) following total hip and knee arthroplasty (THA/TKA), and if these characteristics differ among individuals based on preoperative NSAID exposure. We identified orthopedic surgeon opioid prescribing practices, hospital characteristics, and regional factors associated with initial and long-term prescribing of opioids and NSAIDs among older adults receiving THA/TKA. Materials and Methods: This observational study included opioid-naïve Medicare beneficiaries aged ≥65 years receiving elective THA/TKA between January 1, 2014 and July 4, 2017. We examined initial (days 1-30 following THA/TKA) and long-term (days 90-180) opioid or NSAID prescribing, stratified by preoperative NSAID exposure. Risk ratios (RRs) for the associations between 10 health system characteristics and case-mix adjusted outcomes were estimated using multivariable Poisson regression models. Results: The study population included 23,351 NSAID-naïve and 10,127 NSAID-prevalent individuals. Increases in standardized measures of orthopedic surgeon opioid prescribing generally decreased the risk of initial NSAID prescribing but increased the risk of long-term opioid prescribing. For example, among NSAID-naïve individuals, the RRs (95% confidence intervals [CIs]) for initial NSAID prescribing were 0.95 (0.93-0.97) for 1-2 orthopedic surgeon opioid prescriptions per THA/TKA procedure, 0.94 (0.92-0.97) for 3-4 prescriptions per procedure, and 0.91 (0.89-0.93) for 5+ opioid prescriptions per procedure (reference: <1 opioid prescription per procedure), while the RRs (95% CIs) for long-term opioid prescribing were 1.06 (1.04-1.08), 1.08 (1.06-1.11), and 1.13 (1.11-1.16), respectively. Variation in postoperative analgesic prescribing was observed across U.S. regions. For example, among NSAID-naïve individuals, the RR (95% CIs) for initial opioid prescribing were 0.98 (0.96-1.00) for Region 2 (New York), 1.09 (1.07-1.11) for Region 3 (Philadelphia), 1.07 (1.05-1.10) for Region 4 (Atlanta), 1.03 (1.01-1.05) for Region 5 (Chicago), 1.16 (1.13-1.18) for Region 6 (Dallas), 1.10 (1.08-1.12) for Region 7 (Kansas City), 1.09 (1.06-1.12) for Region 8 (Denver), 1.09 (1.07-1.12) for Region 9 (San Francisco), and 1.11 (1.08-1.13) for Region 10 (Seattle) (reference: Region 1 [Boston]). Hospital characteristics were not meaningfully associated with postoperative analgesic prescribing. The relationships between health system characteristics and postoperative analgesic prescribing were similar for NSAID-naïve and NSAID-prevalent participants. Discussion: Future efforts aiming to improve the use of multimodal analgesia through increased NSAID prescribing and reduced long-term opioid prescribing following THA/TKA could consider targeting orthopedic surgeons with higher standardized opioid prescribing measures. Conclusions: Orthopedic surgeon opioid prescribing measures and U.S. region were the greatest health system level predictors of initial, and long-term, prescribing of opioids and prescription NSAIDs among older Medicare beneficiaries following THA/TKA. These results can inform future studies that examine why variation in analgesic prescribing exists across geographic regions and levels of orthopedic surgeon opioid prescribing. [ABSTRACT FROM AUTHOR]

Background/Aims: When the randomized clusters in a cluster randomized trial are selected based on characteristics that influence treatment effectiveness, results from the trial may not be directly applicable to the target population. We used data from two large nursing home–based pragmatic cluster randomized trials to compare nursing home and resident characteristics in randomized facilities to eligible non-randomized and ineligible facilities. Methods: We linked data from the high-dose influenza vaccine trial and the Music & Memory Pragmatic TRIal for Nursing Home Residents with ALzheimer's Disease (METRICaL) to nursing home assessments and Medicare fee-for-service claims. The target population for the high-dose trial comprised Medicare-certified nursing homes; the target population for the METRICaL trial comprised nursing homes in one of four US-based nursing home chains. We used standardized mean differences to compare facility and individual characteristics across the three groups and logistic regression to model the probability of nursing home trial participation. Results: In the high-dose trial, 4476 (29%) of the 15,502 nursing homes in the target population were eligible for the trial, of which 818 (18%) were randomized. Of the 1,361,122 residents, 91,179 (6.7%) were residents of randomized facilities, 463,703 (34.0%) of eligible non-randomized facilities, and 806,205 (59.3%) of ineligible facilities. In the METRICaL trial, 160 (59%) of the 270 nursing homes in the target population were eligible for the trial, of which 80 (50%) were randomized. Of the 20,262 residents, 973 (34.4%) were residents of randomized facilities, 7431 (36.7%) of eligible non-randomized facilities, and 5858 (28.9%) of ineligible facilities. In the high-dose trial, randomized facilities differed from eligible non-randomized and ineligible facilities by the number of beds (132.5 vs 145.9 and 91.9, respectively), for-profit status (91.8% vs 66.8% and 68.8%), belonging to a nursing home chain (85.8% vs 49.9% and 54.7%), and presence of a special care unit (19.8% vs 25.9% and 14.4%). In the METRICaL trial randomized facilities differed from eligible non-randomized and ineligible facilities by the number of beds (103.7 vs 110.5 and 67.0), resource-poor status (4.6% vs 10.0% and 18.8%), and presence of a special care unit (26.3% vs 33.8% and 10.9%). In both trials, the characteristics of residents in randomized facilities were similar across the three groups. Conclusion: In both trials, facility-level characteristics of randomized nursing homes differed considerably from those of eligible non-randomized and ineligible facilities, while there was little difference in resident-level characteristics across the three groups. Investigators should assess the characteristics of clusters that participate in cluster randomized trials, not just the individuals within the clusters, when examining the applicability of trial results beyond participating clusters. [ABSTRACT FROM AUTHOR]

Background: Hospitalization with heart failure (HF) may signal an increased risk of Alzheimer's disease and related dementias (ADRD). Nursing homes routinely assess cognition but the association of these results with new ADRD diagnosis in a population at high risk of ADRD is not known. Objective: To determine the association between nursing home cognitive assessment results and new diagnosis of dementia after heart failure hospitalization. Methods: This retrospective cohort study included Veterans hospitalized for HF and discharged to nursing homes, from 2010 to 2015, without a prior diagnosis of ADRD. We determined mild, moderate, or severe cognitive impairment using multiple items of the nursing home admission assessment. We used Cox regression to determine the association of cognitive impairment with new ADRD diagnosis during 365 days of follow-up. Results: The cohort included 7,472 residents, new diagnosis of ADRD occurred in 4,182 (56%). The adjusted hazard ratio of ADRD diagnosis was 4.5 (95% CI 4.2, 4.8) for the mild impairment group, 5.4 (95% CI 4.8, 5.9) for moderate impairment, and 4.0 (95% CI 3.2, 5.0) for severe impairment compared to the cognitively intact group. Conclusion: New ADRD diagnoses occurred in more than half of Veterans with HF admitted to nursing homes for post-acute care. [ABSTRACT FROM AUTHOR]

Background Trauma patients older than 80 years of age have higher mortality rates compared to younger peers. No studies have investigated the effectiveness of geriatrics comanagement on mortality in general trauma. Methods A retrospective cohort study from 2015 to 2016 comparing overall and inpatient mortality in a geriatrics trauma comanagement (GTC) program versus usual care (UC). Demographic and outcome measures were obtained from the trauma registry at an 11-bed trauma critical care unit within a 719-bed Level 1 Trauma Center. One thousand five hundred and seventy two patients, 80 years and older, with an admitting trauma diagnosis were evaluated. Primary outcome was in-hospital mortality and overall mortality (defined as inpatient death or discharge to hospice). Secondary outcomes included hospital length of stay (LOS), Intensive Care Unit (ICU) LOS, discharge location, and medical complications. Results Three hundred and forty six patients (22%) were placed in the GTC program. Overall mortality was lower in the GTC (4.9%) when compared with UC (11.9%), representing a 57% reduction (95% odds ratio [OR] confidence interval [CI] 0.24–0.75, p value = .0028). There was a 7.42% hospital mortality rate in the UC group compared to 2.6% in the GTC group (95% CI 0.21–0.92, p value = .0285), representing a 56% decrease in in-hospital mortality. GTC patients had a longer mean LOS (6.4 days vs 5.3 days, p value <.0001). More GTC patients were sent to inpatient rehabilitation facilities or skilled nursing facilities (80% vs 60%, p value <.0001). Conclusion Geriatrics trauma comanagement of trauma patients above the age of 80 may reduce mortality and deserves formal study. [ABSTRACT FROM AUTHOR]

Background: Alzheimer's disease and related dementias (ADRD) impact the diagnosis and infection control of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS‐CoV‐2) in nursing homes (NH) by influencing the behavior of residents and their caregivers. Health system data show an association between ADRD and SARS‐CoV‐2. Whether this association is present in NH populations remains unknown. How increased SARS‐CoV‐2 risk among residents with ADRD impacts the greater NH population also remains unknown. Methods: This retrospective cohort study used electronic health record data on Veterans residing in 133 Veterans Affairs Community Living Centers (CLC) and 15 spinal cord injury units from March 1, 2020 to December 13, 2020. We measured ADRD using diagnostic codes 12 months before an index SARS‐CoV‐2 test date for each resident. We used Poisson regression to determine the relative risk of SARS‐CoV‐2 for the highest quartile of facility ADRD prevalence versus the lowest, stratifying by individual ADRD status, and adjusting for covariates, with and without a random intercept to account for facility clustering. Results: Across the study period, 15,043 residents resided in CLCs, 1952 (13.0%) had SARS‐CoV‐2, and 8067 (53.6%) had ADRD. There was an estimated 60% increased risk of SARS‐CoV‐2 in facilities with highest dementia prevalence versus lowest (relative risk, 1.6 [95% confidence interval 0.95, 2.7]). Conclusions: CLC residents had a greater likelihood of SARS‐CoV‐2 infection in facilities with greater ADRD prevalence. Facility characteristics other than ADRD prevalence may account for this association. [ABSTRACT FROM AUTHOR]

Background: Since PCV13 was recommended in 2014, the characteristics of nursing home (NH) residents (and their facilities) recorded by facilities as not up‐to‐date with pneumococcal vaccination upon admission were unknown, and it is unknown if they received PCV13 in the NH. Methods: We conducted a retrospective cohort of NH residents of Centers for Medicare and Medicaid (CMS)‐certified skilled nursing facilities from October 1, 2014, through September 22, 2018. CMS' Minimum Data Set (MDS) was linked to Medicare Part B Carrier claims to corroborate pneumococcal vaccination up‐to‐date status in the MDS with pneumococcal vaccination claims. The primary outcome of interest was vaccination with PCV13 versus nonreceipt among those identified as "not up to date" according to facility MDS records. We estimated generalized estimating equation (GEE) models. Results: Of the 1,459,814 residents recorded not up‐to‐date, (78.2%) had no Part B claims for PCV13 before or in the NH, the majority of whom (71.5%) were reported to have refused the vaccine when offered. Only 1.3% subsequently received PCV13 within 99 days after NH admission. In adjusted analyses, residents less likely to receive PCV13 in the NH than those who did included: residence in a for‐profit facility (OR: 0.94 [95% CI: 0.89, 0.99]); male (OR: 0.92 [95% CI:0.89, 0.95]); black race (OR: 0.71 (95%CI: 0.66, 0.77); Hispanic ethnicity (OR: 0.69 [95%CI: 0.59, 0.75]); severely cognitively impaired compared with any lesser degree of impairment; had diabetes (OR: 0.93 [95%CI: 0.89, 0.97]); long‐stay (≥100 days) compared with short‐stay residents (OR: 0.17 (95%CI: 0.15, 0.20); and did not receive the influenza vaccine (OR: 0.74 (95%CI: 0.71, 0.77). Conclusions: Due to refusals, few NH residents recorded not up‐to‐date on pneumococcal vaccinations from 2014 to 2018 received PCV13 within three months of admission. Strategies to promote newly recommended PCV15 or PCV20 vaccination upon NH admission may be needed. [ABSTRACT FROM AUTHOR]

Background: At the height of the COVID‐19 pandemic, a large nursing home chain implemented a policy to temporarily hold potentially unnecessary medications. We describe rates of held and discontinued medications after a temporary hold policy of potentially unnecessary or nonessential medications. Methods: This retrospective cohort study uses electronic health record (EHR) data on 3247 residents of 64 nursing homes operated by a multistate long‐term care provider. Medications were documented in the electronic medication administration record. Overall medication held and discontinued incidences are reported. Hierarchical Bayesian modeling is used to determine individual probabilities for medication discontinuation within each facility. Results: In total, 3247 residents had 5297 nonessential medications held. Multivitamins were most likely to be held, followed by histamine‐2 receptor antagonists, antihistamines, and statins. At the end of the hold policy, 2897 of 5297 (54%) were permanently discontinued, including probiotics (73%), histamine‐2 receptor antagonists (66%), antihistamines (64%), and statins (45%). Demographics, cognitive and functional impairment were similar between residents with medications who were discontinued versus continued. For most medications, more than 50% of the variance in whether medications were discontinued was explained by facility rather than resident‐level factors. Conclusion: A temporary medication hold policy implemented during the CoVID‐19 pandemic led to the deprescribing of a plurality of 'nonessential' medications. This type of organization‐wide initiative may be an effective mechanism for altering future prescribing behaviors to reduce the use of unnecessary medications. [ABSTRACT FROM AUTHOR]

Background: Pneumonia and sepsis are among the most common causes of hospitalization in the United States and often result in discharges to a skilled nursing facility (SNF) for rehabilitation. We described the timing and most common causes of 30-day unplanned hospital readmission following an index hospitalization for pneumonia or sepsis. Methods and findings: This national retrospective cohort study included adults ≥65 years who were hospitalized for pneumonia or sepsis and were discharged to a SNF between July 1, 2012 and July 4, 2015. We quantified the ten most common 30-day unplanned readmission diagnoses and estimated the daily risk of first unplanned rehospitalization for four causes of readmission (circulatory, infectious, respiratory, and genitourinary). The index hospitalization was pneumonia for 92,153 SNF stays and sepsis for 452,254 SNF stays. Of these SNF stays, 20.9% and 25.9%, respectively, resulted in a 30-day unplanned readmission. Overall, septicemia was the single most common readmission diagnosis for residents with an index hospitalization for pneumonia (16.7% of 30-day readmissions) and sepsis (22.4% of 30-day readmissions). The mean time to unplanned readmission was approximately 14 days overall. Respiratory causes displayed the highest daily risk of rehospitalization following index hospitalizations for pneumonia, while circulatory and infectious causes had the highest daily risk of rehospitalization following index hospitalizations for sepsis. The day of highest risk for readmission occurred within two weeks of the index hospitalization discharge, but the readmission risk persisted across the 30-day follow-up. Conclusion: Among older adults discharged to SNFs following a hospitalization for pneumonia or sepsis, hospital readmissions for infectious, circulatory, respiratory, and genitourinary causes occurred frequently throughout the 30-day post-discharge period. Our data suggests further study is needed, perhaps on the value of closer monitoring in SNFs post-hospital discharge and improved communication between hospitals and SNFs, to reduce the risk of potentially preventable hospital readmissions. [ABSTRACT FROM AUTHOR]

Background Influenza outbreaks in nursing homes pose a threat to frail residents and occur even in vaccinated populations. We conducted a pragmatic cluster-randomized trial comparing adjuvanted trivalent influenza vaccine (aTIV) versus trivalent influenza vaccine (TIV). We report an exploratory analysis to compare the effect of aTIV versus TIV on facility-reported influenza outbreaks. Methods We evaluated the impact of the intent-to-treat vaccine assignment on outbreaks reported from November 2016 to March 2017. We collected data according to standard CDC definitions for both suspected outbreaks and those with a laboratory-confirmed case and adjusted for facility-level vaccination rates and resident characteristics in nursing homes. Results Of 823 randomized nursing homes, 777 (aTIV, n = 387; TIV, n = 390) reported information on influenza outbreaks. Treatment groups had similar characteristics at baseline except for race/ethnicity: homes assigned to TIV had a higher percentage of African-American residents (18.0% vs 13.7%). There were 133 versus 162 facility-reported suspected influenza outbreaks in aTIV versus TIV facilities, respectively; of these, 115 versus 140 were laboratory confirmed. The aTIV group experienced a 17% reduction in suspected (rate ratio,.83; 95% confidence interval,.65–1.05) and laboratory-confirmed (.83;.63–1.06) influenza outbreaks. Covariate adjustment increased the estimated reduction for suspected outbreaks to 21% (.79;.61–.99) and 22% for laboratory-confirmed outbreaks (.78;.60–1.02). Conclusions In an exploratory analysis of a cluster-randomized trial we observed 17–21% fewer outbreaks with aTIV than TIV. Clinical Trials Registration. (NCT02882100). [ABSTRACT FROM AUTHOR]

Background Influenza leads in preventable infection-related hospitalization in nursing home (NH) residents. The adjuvanted trivalent influenza vaccine (aTIV) is more immunogenic than similarly dosed nonadjuvanted trivalent influenza vaccine (TIV), and observational studies suggest aTIV better prevents hospitalizations in older adults. We prospectively tested this in an NH setting. Methods NHs with ≥50 long-stay residents aged ≥65 years were randomized to offer aTIV or TIV for residents for the 2016–2017 influenza season. Using intent-to-treat resident-level analysis with Cox proportional hazards regression models adjusted for clustering by facility and a priori baseline covariates (eg, age, heart failure, and facility-level characteristics), we assessed relative aTIV:TIV effectiveness for hospitalization (ie, all-cause, respiratory, and pneumonia and influenza [P&I]). Results We randomized 823 NHs, housing 50 012 eligible residents, to aTIV or TIV. Residents were similar between groups by age (mean, ~79 years), heart failure, lung disease, and influenza and pneumococcal vaccine uptake, except aTIV homes housed fewer Black residents (14.5 vs 18.9%). Staff vaccine uptake was similar (~55%). P&I and all-cause resident hospitalization rates were lower (adjusted HR [aHR],.80 [95% CI,.66–.98; P =.03] and.94 [.89–.99; P =.02], respectively) for aTIV versus TIV, while the respiratory hospitalization rate was similar, in a season where vaccine effectiveness was considered poor. Conclusions aTIV was more effective than TIV in preventing all-cause and P&I hospitalization from NHs during an A/H3N2-predominant season when TIV was relatively ineffective. Clinical Trials Registration NCT02882100. [ABSTRACT FROM AUTHOR]

To compare rates of adverse events following Coronavirus Disease 2019 (COVID-19) vaccination among nursing home residents with and without previous severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Prospective cohort. A total of 20,918 nursing home residents who received the first dose of messenger RNA COVID-19 vaccine from December 18, 2020, through February 14, 2021, in 284 facilities within Genesis Healthcare, a large nursing home provider spanning 24 US states. We screened the electronic health record for adverse events, classified by the Brighton Collaboration, occurring within 15 days of a resident's first COVID-19 vaccine dose. All events were confirmed by physician chart review. To obtain risk ratios, multilevel logistic regression model that accounted for clustering (variability) across nursing homes was implemented. To balance the probability of prior SARS-CoV-2 infection (previous positive test or diagnosis by the International Classification of Diseases, 10th Revision, Clinical Modification) more than 20 days before vaccination, we used inverse probability weighting. To adjust for multiplicity of adverse events tested, we used a false discovery rate procedure. Statistically significant differences existed between those without (n = 13,163) and with previous SARS-CoV-2 infection [symptomatic (n = 5617) and asymptomatic (n = 2138)] for all baseline characteristics assessed. Only 1 adverse event was reported among those with previous SARS-CoV-2 infection (asymptomatic), venous thromboembolism [46.8 per 100,000 residents 95% confidence interval (CI) 8.3–264.5], which was not significantly different from the rate reported for those without previous infection (30.4 per 100,000 95% CI 11.8–78.1). Several other adverse events were observed for those with no previous infection, but were not statistically significantly higher than those reported with previous infection after adjustments for multiple comparisons. Although reactogenicity increases with preexisting immunity, we did not find that vaccination among those with previous SARS-CoV-2 infection resulted in higher rates of adverse events than those without previous infection. This study stresses the importance of monitoring novel vaccines for adverse events in this vulnerable population. [ABSTRACT FROM AUTHOR]

Objective: To compare rates of incident SARS‐CoV‐2 infection and 30‐day hospitalization or death among residents with confirmed infection in nursing homes with earlier versus later SARS‐CoV‐2 vaccine clinics. Design: Matched pairs analysis of nursing homes that had their initial vaccine clinics between December 18, 2020, and January 2, 2021, versus between January 3, 2021, and January 18, 2021. Matched facilities had their initial vaccine clinics between 12 and 16 days apart. Setting and Participants: Two hundred and eighty nursing homes in 21 states owned and operated by the largest long‐term care provider in the United States. Measurements: Incident SARS‐CoV‐2 infections per 100 at‐risk residents per week; hospital transfers and/or deaths per 100 residents with confirmed SARS‐CoV‐2 infection per day, averaged over a week. Results: The early vaccinated group included 136 facilities with 12,157 residents; the late vaccinated group included 144 facilities with 13,221 residents. After 1 week, early vaccinated facilities had a predicted 2.5 fewer incident SARS‐CoV‐2 infections per 100 at‐risk residents per week (95% CI: 1.2–4.0) compared with what would have been expected based on the experience of the late vaccinated facilities. The rates remained significantly lower for several weeks. Cumulatively over 5 weeks, the predicted reduction in new infections was 5.2 cases per 100 at‐risk residents (95% CI: 3.2–7.3). By 5 to 8 weeks post‐vaccine clinic, early vaccinated facilities had a predicted 1.1 to 3.8 fewer hospitalizations and/or deaths per 100 infected residents per day, averaged by week than expected based on late vaccinated facilities' experience for a cumulative on average difference of 5 events per 100 infected residents per day. Conclusions: The SARS‐CoV‐2 vaccines seem to have accelerated the rate of decline of incident infections, morbidity, and mortality in this large multi‐state nursing home population. See related editorial by Ouslander et al and related articles by Moore et al, Rudolph et al, and Domi et al. in this issue. [ABSTRACT FROM AUTHOR]

The devastating impact of the SARS-CoV-2 pandemic prompted the development and emergency use authorization of two mRNA vaccines in early 2020. Vaccine trials excluded nursing home (NH) residents, limiting adverse event data that directly apply to this population. To prospectively monitor for potential adverse events associated with vaccination, we used Electronic Health Record (EHR) data from Genesis HealthCare, the largest NH provider in the United States. EHR data on vaccinations and pre-specified adverse events were updated daily and monitored for signal detection among residents of 147 facilities who received the first dose of vaccine between December 18, 2020 and January 3, 2021. For comparison, unvaccinated residents during the same time period were included from 137 facilities that started vaccinating at least 15 days after the vaccinating-facilities. As of January 3, 2021, 8553 NH residents had received one dose of SARS-CoV-2 vaccine and by February 20, 2021, 8371 residents had received their second dose of vaccine; 11,072 were included in the unvaccinated comparator group. No significant associations were noted for neurologic outcomes, anaphylaxis, or cardiac events. No major safety problems were detected following the first or second dose of the vaccine to prevent COVID-19 in the study cohort from December 18, 2020 through March 7, 2021. [ABSTRACT FROM AUTHOR]

BACKGROUND/OBJECTIVES: Infection screening tools classically define fever as 38.0°C (100.4°F). Frail older adults may not mount the same febrile response to systemic infection as younger or healthier individuals. We evaluate temperature trends among nursing home (NH) residents undergoing diagnostic SARS‐CoV‐2 testing and describe the diagnostic accuracy of temperature measurements for predicting test‐confirmed SARS‐CoV‐2 infection. DESIGN: Retrospective cohort study evaluating diagnostic accuracy of pre–SARS‐CoV‐2 testing temperature changes. SETTING: Two separate NH cohorts tested diagnostically (e.g., for symptoms) for SARS‐CoV‐2. PARTICIPANTS Veterans residing in Veterans Affairs (VA) managed NHs and residents in a private national chain of community NHs. MEASUREMENTS: For both cohorts, we determined the sensitivity, specificity, and Youden's index with different temperature cutoffs for SARS‐CoV‐2 polymerase chain reaction results. RESULTS: The VA cohort consisted of 1,301 residents in 134 facilities from March 1, 2020, to May 14, 2020, with 25% confirmed for SARS‐CoV‐2. The community cohort included 3,368 residents spread across 282 facilities from February 18, 2020, to June 9, 2020, and 42% were confirmed for SARS‐CoV‐2. The VA cohort was younger, less White, and mostly male. A temperature testing threshold of 37.2°C has better sensitivity for SARS‐CoV‐2, 76% and 34% in the VA and community NH, respectively, versus 38.0°C with 43% and 12% sensitivity, respectively. CONCLUSION: A definition of 38.0°C for fever in NH screening tools should be lowered to improve predictive accuracy for SARS‐CoV‐2 infection. Stakeholders should carefully consider the impact of adopting lower testing thresholds on testing availability, cost, and burden on staff and residents. Temperatures alone have relatively low sensitivity/specificity, and we advocate any threshold be used as part of a screening tool, along with other signs and symptoms of infection. [ABSTRACT FROM AUTHOR]

There is large county-level geographic variation in pneumonia and influenza hospitalizations among short-stay and long-stay long-term care facility residents in the United States. Long-term care facilities in counties in the Southern and Midwestern regions had the highest rates of pneumonia and influenza from 2013 to 2015. Future research should identify reasons for these geographic differences. [ABSTRACT FROM AUTHOR]

OBJECTIVE To identify county and facility factors associated with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) outbreaks in skilled nursing facilities (SNFs). DESIGN Cross‐sectional study linking county SARS‐CoV‐2 prevalence data, administrative data, state reports of SNF outbreaks, and data from Genesis HealthCare, a large multistate provider of post‐acute and long‐term care. State data are reported as of April 21, 2020; Genesis data are reported as of May 4, 2020. SETTING AND PARTICIPANTS The Genesis sample consisted of 341 SNFs in 25 states, including a subset of 64 SNFs that underwent universal testing of all residents. The non‐Genesis sample included all other SNFs (n = 3,016) in the 12 states where Genesis operates that released the names of SNFs with outbreaks. MEASUREMENTS For Genesis and non‐Genesis SNFs: any outbreak (one or more residents testing positive for SARS‐CoV‐2). For Genesis SNFs only: number of confirmed cases, SNF case fatality rate, and prevalence after universal testing. RESULTS: One hundred eighteen (34.6%) Genesis SNFs and 640 (21.2%) non‐Genesis SNFs had outbreaks. A difference in county prevalence of 1,000 cases per 100,000 (1%) was associated with a 33.6 percentage point (95% confidence interval (CI) = 9.6–57.7 percentage point; P =.008) difference in the probability of an outbreak for Genesis and non‐Genesis SNFs combined, and a difference of 12.5 cases per facility (95% CI = 4.4–20.8 cases; P =.003) for Genesis SNFs. A 10‐bed difference in facility size was associated with a 0.9 percentage point (95% CI = 0.6–1.2 percentage point; P <.001) difference in the probability of outbreak. We found no consistent relationship between Nursing Home Compare Five‐Star ratings or past infection control deficiency citations and probability or severity of outbreak. CONCLUSIONS: Larger SNFs and SNFs in areas of high SARS‐CoV‐2 prevalence are at high risk for outbreaks and must have access to universal testing to detect cases, implement mitigation strategies, and prevent further potentially avoidable cases and related complications. J Am Geriatr Soc 68:2167–2173, 2020. See related Special Article by Ouslander et al. in this issue. [ABSTRACT FROM AUTHOR]

Background: Influenza, the most important viral infection affecting older adults, produces a substantial burden in health care costs, morbidity, and mortality. Influenza vaccination remains the mainstay in prevention and is associated with reduced rates of hospitalization, stroke, heart attack, and death in non-institutional older adult populations. Influenza vaccination produces considerably lower antibody response in the elderly compared to young adults. Four-fold higher vaccine antigen (high-dose) than in the standard adult vaccine (standard-dose) elicits higher serum antibody levels and antibody response in ambulatory elderly. Purpose: To describe the design considerations of a large clinical trial of high-dose compared to standard-dose influenza vaccine in nursing homes and baseline characteristics of participating nursing homes and long-stay (more than 90 days) residents over 65 years of age. Methods: The high-dose influenza vaccine intervention trial is multifacility, cluster randomized controlled trial with a 2×2 factorial design that compares hospitalization rates, mortality, and functional decline among long-stay nursing home residents in facilities randomized to receive high-dose versus standard-dose influenza vaccine and also randomized with or without free staff vaccines provided by study organizers. Enrollment focused on nursing homes with a large long-stay resident population over 65 years of age. The primary outcome is the resident-level incidence of hospitalization with a primary diagnosis of pulmonary and influenza-like illness, based upon Medicare inpatient hospitalization claims. Secondary outcomes are all-cause mortality based upon the vital status indicator in the Medicare Vital Status file, all-cause hospitalization directly from the nursing home Minimum Data Set discharge records, and the probability of declining at least 4 points on the 28-point Activities of Daily Living Scale. Results: Between February and September 2013, the high-dose influenza vaccine trial recruited and randomized 823 nursing homes. The analysis sample includes 53,035 long-stay nursing home residents over 65 years of age, representing 57.7% of the participating facilities’ population. Residents are mainly women (72.2%), white (75.5%), with a mean age of 83 years. Common conditions include hypertension (79.2%), depression (55.1%), and diabetes mellitus (34.4%). The prevalence of circulatory and pulmonary disorders includes heart failure (20.5%), stroke (20.1%), and asthma/chronic obstructive pulmonary disease (20.2%). Conclusions: This high-dose influenza vaccine trial uniquely offers a paradigm for future studies of clinical and programmatic interventions within the framework of efforts designed to test the impact of changes in usual treatment practices adopted by health care systems. Trial registration: NCT01815268 [ABSTRACT FROM AUTHOR]

OBJECTIVES: To determine whether the racial inequity between African Americans and Caucasians in receipt of influenza vaccine is narrower in residents of nursing homes with facility-wide vaccination strategies than in residents of facilities without vaccination strategies. DESIGN: Secondary data analysis using the National Nursing Home Survey 2004, a nationally representative survey. SETTING: One thousand one hundred seventy-four participating nursing homes sampled systematically with probability proportional to bed size. PARTICIPANTS: Thirteen thousand five hundred seven randomly sampled residents of nursing homes between August and December 2004. MEASUREMENTS: Receipt of influenza vaccine within the last year. Logistic regression was used to examine the relationship between facility-level influenza immunization strategy and racial inequity in receipt of vaccination, adjusted for characteristics at the resident, facility, state, and regional levels. RESULTS: Overall in the Untied States, vaccination coverage was higher for Caucasian and African-American residents; the racial vaccination gaps were smaller (<6 percentage points) and nonsignificant in residents of homes with standing orders for influenza vaccinations ( P=.14), verbal consent allowed for vaccinations( P=.39), and routine review of facility-wide vaccination rates ( P=.61) than for residents of homes without these strategies. The racial vaccination gap in residents of homes without these strategies were two to three times as high ( P=.009, P=.002, and P=.002, respectively). CONCLUSION: The presence of several immunization strategies in nursing homes is associated with higher vaccination coverage for Caucasian and African-American residents, narrowing the national vaccination racial gap. [ABSTRACT FROM AUTHOR]

Setting Targets—Achieving Results (STAR) is a Web-based tool that helps nursing home leadership select annual performance goals, or targets, for a subset of publicly reported quality measures. Previous results demonstrate that nursing homes whose staff implement STAR targets demonstrate greater improvement on the related outcomes. In this analysis, the authors hypothesized that nursing homes whose staff select the most ambitious targets (reflecting large improvement over their current performance) may be more successful in their related quality improvement efforts than homes with less-ambitious targets (reflecting lesser improvement). The authors analyzed data from 7,091 Medicare- or Medicaid-certified nursing homes that set STAR targets in 2005 or 2006 for two quality measures: the proportion of residents who were physically restrained daily and the proportion of high-risk residents with pressure ulcers. Targets were classified as ambitious or less ambitious based on the 75th and 50th rank-ordered percentiles, respectively. Improvement was calculated using four-quarter averages for baseline (the year ending when the target was set) and remeasurement (the subsequent year). The results indicate that nursing homes with ambitious targets demonstrate greater improvement than their peers selecting less-ambitious targets. With limited federal and local resources to assist providers with quality improvement, target values may be a used as a “flag” to help agencies allocate scarce resources to nursing homes committed to quality improvement efforts and with the organizational capacity to improve. [ABSTRACT FROM AUTHOR]

Residents of long-term care facilities (LTCFs) are at great risk for infection. Most residents are older and have multiple comorbidities that complicate recognition of infection; for example, typically defined fever is absent in more than one-half of LTCF residents with serious infection. Furthermore, LTCFs often do not have the on-site equipment or personnel to evaluate suspected infection in the fashion typically performed in acute care hospitals. In recognition of the differences between LTCFs and hospitals with regard to hosts and resources present, the Infectious Diseases Society of America first provided guidelines for evaluation of fever and infection in LTCF residents in 2000. The guideline presented here represents the second edition, updated by data generated over the intervening 8 years. It focuses on the typical elderly person institutionalized with multiple chronic comorbidities and functional disabilities (e.g., a nursing home resident). Specific topic reviews and recommendations are provided with regard to what resources are typically available to evaluate suspected infection, what symptoms and signs suggest infection in a resident of an LTCF, who should initially evaluate the resident with suspected infection, what clinical evaluation should be performed, how LTCF staff can effectively communicate about possible infection with clinicians, and what laboratory tests should be ordered. Finally, a general outline of how a suspected outbreak of a specific infectious disease should be investigated in an LTCF is provided. [ABSTRACT FROM AUTHOR]

Background: Despite vaccination, influenza commonly causes morbidity and mortality in institutional settings. Influenza control with rimantadine and amantadine is limited by emergence and transmission of drug-resistant influenza A variants, ineffectiveness against influenza B, and toxicity. This study evaluated the efficacy and tolerability of zanamivir versus rimantadine for influenza outbreak control in long-term care facilities. Methods: This double-blind, randomized, controlled study prospectively enrolled nursing home residents for 3 influenza seasons (1997 to 2000). Vaccine was offered to all subjects. Following influenza outbreak declaration, subjects were randomized to inhaled zanamivir 10 mg or standard of care (rimantadine 100 mg for influenza A or placebo for influenza B) once daily for 14 days. The proportion of randomized subjects developing symptomatic, laboratory-confirmed influenza during prophylaxis was the primary endpoint. Results: Of 482 randomizations (238 zanamivir, 231 rimantadine, 13 placebo), 96% of subjects were elderly or had high-risk conditions; over 90% were vaccinated. Symptomatic, laboratory-confirmed influenza occurred in 3% of zanamivir subjects and 8% of rimantadine subjects during chemoprophylaxis (P = .038; additional protective efficacy for zanamivir over rimantadine = 61%). Since only 25 subjects were randomized during 2 influenza B outbreaks and none developed influenza, the influenza B data were excluded from further analysis. Zanamivir was well tolerated and unassociated with emergence of resistant virus; rimantadine-resistant variants were common. Conclusions: This is the first prospective, controlled study demonstrating effectiveness of chemoprophylaxis for influenza outbreak control. Zanamivir prevents symptomatic, laboratory-confirmed influenza more effectively than rimantadine, is unassociated with resistant virus, and has a favorable safety profile. Zanamivir is an appropriate alternative for influenza outbreak control among institutionalized vaccinated elderly. [Copyright &y& Elsevier]

To prospectively detect amantadine-resistant influenza when amantadine was used for influenza A outbreak control.Prospective clinical surveillance and viral culture of all new respiratory illnesses during the course of amantadine prophylaxis.A 721-bed, 14-ward nursing home for veterans and spouses during an influenza A outbreak (1993–94).Residents of a veterans hospital and their spouses.Nasopharyngeal and throat viral culture. All residents with positive cultures who developed new respiratory symptoms while receiving or residing on a unit receiving amantadine prophylaxis had antiviral-resistance testing and polymerase chain reaction restriction analyses performed.Amantadine prophylaxis was administered sequentially on nine of 14 wards to all well residents for 14 to 31 days/ward to control influenza outbreaks between December 9, 1993, and January 28, 1994. Amantadine treatment was simultaneously provided to 29 ill residents. Between December 3, 1993, and January 22, 1994, 68 culture-positive cases of influenza A were detected. Twenty subjects were receiving or residing on units receiving amantadine prophylaxis. Amantadine sensitivity testing could be performed on 16 residents; 12 residents had amantadine resistant strains. Four of the 12 had not received any antiviral treatment. Illness onset ranged from 1 to 22 days after amantadine prophylaxis was begun on the individual's unit. Two ribonucleic acid (RNA) mutations in the gene coding the M2 protein transmembrane region were observed that were clustered in time and space. Isolates from two roommates, one receiving amantadine for 18 days and one on no antiviral, had identical RNA sequences.Antiviral resistance may be responsible for failure of prophylaxis in nursing home outbreaks. Strategies that use different classes of antivirals for prophylaxis and treatment may limit emergence and transmission of resistant virus. [ABSTRACT FROM AUTHOR]

BACKGROUND. Large outbreaks of influenza A and B may occur in nursing homes despite high resident vaccination rates, even when the vaccine strain is matched to the circulating strain. This study reports the occurrence of separate influenza A and B outbreaks in a nursing home where more than 85% of residents were vaccinated. METHODS. Prospective surveillance was used to identify symptomatic residents in a rural Wisconsin nursing home with 680 residents. Viral cultures were obtained from all consenting residents identified with new respiratory symptoms even in the absence of temperature elevation. A "case" refers to a resident with a respiratory illness and an influenza isolate. RESULTS. During the 1992-93 season, 86% of 670 total residents were vaccinated, 104 (15.5%) were cases with influenza B. During the 1993-94 season, 89% of 690 total residents were vaccinated, 68 (9.8%) were cases with influenza A. The antigenic matches between vaccine and epidemic strains were characterized as "identical or minimal difference" by the Centers for Disease Control and Prevention. CONCLUSIONS. There is still a need to protect residents from infectious secretions and for contingency plans to permit the rapid use of antiviral agents. Future efforts are needed to develop vaccines that provide greater protection and to improve staff vaccination rates. [ABSTRACT FROM AUTHOR]

Evaluates the duration of antiviral prophylaxis during outbreaks of influenza A at a nursing home. Documentation of influenza A virus activity during three seasons; Description of the methodology used in the evaluation; Circulation of influenza in the facility.

The article presents an analysis on the 2009 H1N1 pandemic influenza affecting elderly patients in long-term care facilities in the U.S. It cites the case of an 84-year-old woman who developed respiratory symptoms characterized by cough and sneezing but without fever. According to the authors, because of the prevalence of the illness among younger adults, the vaccination for H1N1 influenza for older persons in nursing homes was less prioritized. It also emphasizes that because of the multiple morbidities experienced by nursing home residents, influenza symptoms may take the form of the aggravations of pre-existing conditions. Details related to the risk of influenza complications among nursing home residents and staffs and the difficulty in the diagnosis of the disease are also analyzed.

Examine physical function change and physical therapy (PT) use in short-stay and long-stay residents not infected by CoVID-19 within Veterans Affairs (VA) Community Living Centers (CLCs). Retrospective cohort study using Minimum Data Set (MDS) 3.0 assessments. 12,606 Veterans in 133 VA CLCs between September 2019 and September 2020. Difference in physical function [MDS Activities of Daily Living Score (MDS-ADL)] and PT use (minutes in past 7 days) from admission to last assessment in a period were compared between the pre-CoVID-19 (September 2019 to February 2020) and early CoVID-19 (April 2020 to September 2020) period using mixed effects regression with multivariable adjustment. Assessments after a positive CoVID-19 test were excluded. Differences were examined in the sample and repeated after stratifying into short- and long-stay stratums. Veterans admitted during early CoVID-19 had more comorbidities, worse MDS-ADL scores, and were more often long-stay residents compared with those admitted during pre-CoVID-19. In comparison to pre-CoVID-19, Veterans in VA CLCs during early CoVID-19 experienced greater improvements in their MDS-ADL (−0.49 points, 95% CI –0.27, −0.71) and received similar minutes of therapy (2.6 minutes, 95% CI –0.8, 6.0). Stratification revealed short-stay residents had relative improvements in their function (−0.69 points, 95% CI –0.44, −0.94) and higher minutes of PT (5.1 minutes, 95% CI 0.9, 9.2) during early CoVID-19 whereas long-stay residents did not see differences in functional change (0.08 points, 95% CI –0.36, 0.51) or PT use (−0.6 minutes, 95% CI –6.1, 4.9). During early CoVID-19, physical function improved while the amount of PT received was maintained compared with pre-CoVID-19 for Veterans in VA CLCs. Short-stay residents experienced greater improvements in physical function and increases in PT use. These findings may be partly due to selection bias relating to Veterans admitted to CLCs during early CoVID-19. [ABSTRACT FROM AUTHOR]

Older adults are at high risk of major acute cardiovascular events (MACE) linked to influenza illness and preventable by influenza vaccination. It is unknown whether high-dose vaccine might incrementally reduce the risk of MACE. We conducted a post-hoc analysis of data collected from a pragmatic cluster randomized study of 823 nursing homes (NH) randomized to standard-dose (SD) or high-dose (HD) influenza vaccine in the 2013–14 season. Adults age 65 year or older who are Medicare-enrolled long-stay residents were included in the analysis. There were no statistically significant differences in hospitalization for MACE, acute coronary syndromes (ACS), stroke or heart failure between the HD and SD arms. However, in the fee-for-service group, participants in the HD arm had significantly decreased risk of hospitalization for respiratory problems, which was not observed in the Medicare Advantage group. High-dose influenza vaccine was not shown to be incrementally protective against MACE relative to standard-dose vaccine. [ABSTRACT FROM AUTHOR]

Reverse transcription polymerase chain reaction (PCR) and antigen tests for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are sometimes discordant. We evaluated the discordance between antigen and PCR tests sampled in skilled nursing facilities (SNFs) to assess the relationship of symptom presence, timing between tests, and the presence of a facility outbreak. Observational study using electronic health record data. Residents of 306 SNFs in 23 states, operated by 1 company. We identified all rapid antigen and PCR tests conducted in study SNFs as of January 10, 2021, and classified whether symptoms were present and whether the facility was in outbreak at time of testing. We calculated the proportions of antigen tests with discordant follow-up PCR results conducted no more than 2 days after the antigen test. Of the 171,280 antigen tests in 34,437 SNF residents, 20,991 (12.3%) were followed by a PCR test within 2 days. A total of 1324 negative antigen tests were followed by a positive PCR result, representing 0.8% of all antigen tests and 6.3% of repeated antigen tests; while 337 positive antigen tests were followed by a negative PCR result, representing 0.2% of all antigen tests and 1.6% of repeated antigen tests. Discordance more often occurred when residents were symptomatic at time of antigen testing, during known facility outbreaks, and when the antigen test was compared with a PCR test done within 2 days vs 1 day. Overall, discordance between SARS-CoV-2 antigen and PCR tests was low. Discordance was more common when the individual was symptomatic at time of antigen testing and during facility outbreaks. This suggests that a testing strategy which couples widespread use of antigen tests with clinical thresholds to conduct follow-up confirmatory PCR testing appears to perform well in SNFs, where timely and accurate SARS-CoV-2 case identification are critical. [ABSTRACT FROM AUTHOR]

To evaluate a bundled electronic intervention to improve antibiotic prescribing practices in US nursing homes. Prospective mixed-methods quality improvement intervention. Nursing staff and residents in 13 nursing homes, and residents in 8 matched-control facilities (n = 21 facilities total, from 2 corporations). This study involved a 2-month design period (n = 5 facilities) focused on the acceptability and feasibility of a bundled electronic intervention consisting of 3 tools, followed by a 15-month implementation period (n = 8 facilities) during which we used rapid-cycle quality improvement methods to refine and add to the bundle. We used mixed-methods data from providers, intervention tools, and health records to assess feasibility and conduct a difference-in-difference analysis among the 8 intervention sites and 8 pair-matched controls. Nurses at 5 pilot sites reported that initial versions of the electronic tools were acceptable and feasible, but barriers emerged when 8 different facilities began implementing the tools, prompting iterative revisions to the training and bundle. The final bundle consisted of 3 electronic tools and training that standardized digital documentation to document and track a change in resident condition, infections, antibiotic prescribing, and antibiotic follow-up. By the end of the implementation phase, all 8 facilities were using at least 1 of the 3 tools. Early antibiotic discontinuation increased 10.5% among intervention sites, but decreased 10.8% among control sites. The 3 tools in our bundled electronic intervention capture clinical and prescribing data necessary to assess changes in antibiotic use and were feasible for nurses to adopt. Achieving this required modifying the tools and training before the intervention reached its final form. Comparisons of rates of antibiotic use at intervention and control facilities showed promising improvement in antibiotic discontinuation, demonstrating that the intervention could be evaluated using secondary electronic health record data. [ABSTRACT FROM AUTHOR]

Patients discharged from the hospital to a skilled nursing facility (SNF) are not typically part of a heart failure disease management program (HF-DMP). The objective of this study is to determine if an HF-DMP in SNF improves outcomes for patients with HF. Cluster-randomized controlled trial. The trial was conducted in 47 SNFs, and 671 patients were enrolled (329 HF-DMP; 342 to usual care). The HF-DMP included documentation of ejection fraction, symptoms, weights, diet, medication optimization, education, and 7-day visit post SNF discharge. The composite outcome was all-cause hospitalization, emergency department visits, or mortality at 60 days. Secondary outcomes included the composite endpoint at 30 days, change in the Kansas City Cardiomyopathy Questionnaire and the Self-care of HF Index at 60 days. Rehospitalization and mortality rates were calculated as an exploratory outcome. Mean age of the patients was 79 ± 10 years, 58% were women, and the mean ejection fraction was 51% ± 16%. At 30 and 60 days post SNF admission, the composite endpoint was not significant between DMP (29%) and usual care (32%) at 30 days and 60 days (43% vs 47%, respectively). The Kansas City Cardiomyopathy Questionnaire significantly improved in the HF-DMP vs usual care for the Physical Limitation (11.3 ± 2.9 vs 20.8 ± 3.6; P =.039) and Social Limitation subscales (6.0 ± 3.1 vs 17.9 ± 3.8; P =.016). Self-care of HF Index was not significant. The total number of events (composite endpoint) totaled 517 (231 in HF-DMP and 286 in usual care). Differences in the 60-day hospitalization rate [mean HF-DMP rate 0.43 (SE 0.03) vs usual care 0.54 (SE 0.05), P =.04] and mortality rate (HF-DMP 5.2% vs usual care 10.8%, P <.001) were significant. The composite endpoint was high for patients with HF in SNF regardless of group. Rehospitalization and mortality rates were reduced by the HF-DMP. HF-DMPs in SNFs may be beneficial to the outcomes of patients with HF. SNFs should consider structured HF-DMPs for their patients. [ABSTRACT FROM AUTHOR]

More older adults enrolled in Medicare Advantage (MA) are entering nursing homes (NHs), and MA concentration could affect vaccination rates through shifts in resident characteristics and/or payer-related influences on preventive services use. We investigated whether rates of influenza vaccination and refusal differ across NHs with varying concentrations of MA-enrolled residents. We analyzed 2014–2015 Medicare enrollment data and Minimum Data Set clinical assessments linked to NH-level characteristics, star ratings, and county-level MA penetration rates. The independent variable was the percentage of residents enrolled in MA at admission and categorized into three equally-sized groups. We examined three NH-level outcomes including the percentages of residents assessed and appropriately considered for influenza vaccination, received influenza vaccination, and refused influenza vaccination. There were 936,513 long-stay residents in 12,384 NHs. Categories for the prevalence of MA enrollment in NHs were low (0% to 3.3%; n = 4131 NHs), moderate (3.4% to 18.6%; n = 4127 NHs) and high (>18.6%; n = 4126 NHs). Overall, 81.3% of long-stay residents received influenza vaccination and 14.3% refused the vaccine when offered. Adjusting for covariates, influenza vaccination rates among long-stay residents were higher in NHs with moderate (1.70 percentage points [pp], 95% confidence limits [CL]: 1.15 pp, 2.24 pp), or high (3.05 pp, 95% CL: 2.45 pp, 3.66 pp) MA versus the lowest prevalence of MA. Influenza vaccine refusal was lower in NHs with moderate (-3.10 pp, 95% CL: −3.53 pp, −2.68 pp), or high (-4.63 pp, 95% CL: −5.11 pp, −4.15 pp) MA compared with NHs with the lowest prevalence of MA. A higher concentration of long-stay NH residents enrolled in MA was associated with greater influenza vaccine receipt and lower vaccine refusal. As MA becomes a larger share of the Medicare program, and more MA beneficiaries enter NHs, decisionmakers need to consider how managed care can be leveraged to improve the delivery of preventive services like influenza vaccinations in NH settings. [ABSTRACT FROM AUTHOR]

To determine if implementation of Project Re-Engineered Discharge (RED), designed for hospitals but adapted for skilled nursing facilities (SNFs), reduces hospital readmissions after SNF discharge to the community in residents admitted to the SNF following an index hospitalization. A pragmatic trial. SNFs in southeastern Massachusetts, and residents discharged to the community. We compared SNFs that deployed an adapted RED intervention to a matched control group from the same region. The primary outcome was hospital readmission within 30 days after SNF discharge, among residents who had been admitted to the SNF following an index hospitalization and then discharged home. January 2016 through March 2017 was the baseline period; April 2017 through June 2018 was the follow-up period (after implementation of the intervention). We used a difference-in-differences analysis to compare the intervention SNFs to the control group, using generalized estimating equation regression and controlling for facility characteristics. After implementation of RED, readmission rates were lower across all 4 measures in the intervention group; control facilities' readmission rates remained stable or increased. The relative decrease was 0.9% for the primary outcome of hospital readmission within 30 days after SNF discharge and 1.7% for readmission within 30 days of the index hospitalization discharge date (P ≤.001 for both comparisons). We found that a systematic discharge process developed for the hospital can be adapted to the SNF environment and can reduce readmissions back to the hospital, perhaps through improved self-management skills and better engagement with community services. This work is particularly timely because of Medicare's new Value-Based Purchasing Program, in which nursing homes can receive incentive payments if their hospital readmission rates are low relative to their peers. To verify its scalability and broad potential, RED should be validated across a broader diversity of SNFs nationally. [ABSTRACT FROM AUTHOR]

To determine temporal associations of local measures of influenza morbidity and mortality by the Centers for Disease Control and Prevention (CDC) with influenza hospitalizations in nursing home residents. Retrospective, longitudinal panel study. Long-stay nursing home residents, aged 65 years or older in 823 nursing homes from 2011 to 2015. CDC-reported rates of influenza and pneumonia mortality and laboratory-confirmed influenza hospitalizations. We compared the CDC measures to nursing home resident hospitalizations due to (1) all-cause, (2) a primary diagnosis of respiratory or circulatory illness, and (3) a primary diagnosis of pneumonia or influenza based on Medicare Part A Claims data. Our final sample included 273,743 unique residents in 819 nursing homes in 108 cities. National laboratory-confirmed influenza-associated hospitalizations for the group aged 65 and older occurred 0 to 1 week prior to nursing home resident influenza-related hospitalizations (Spearman ρ = 0.54). CDC-reported influenza hospitalizations occurred 3 weeks prior to CDC-reported influenza deaths (ρ = 0.59). Nursing home resident influenza hospitalizations occurred 2 weeks before local CDC-reported pneumonia and influenza deaths occurred (ρ = 0.44). Publicly reported CDC measures correlate well with nursing home hospitalizations for pneumonia and influenza. Rates of laboratory-confirmed influenza hospitalizations (as reported by the CDC) may be a useful surrogate for nursing home influenza outbreaks but should be considered along with local indicators of disease outbreaks. Early community signals could be clinically leveraged as a trigger for increased infection control measures in nursing homes. [ABSTRACT FROM AUTHOR]

Quantify the relationship between increasing influenza and respiratory syncytial virus (RSV) community viral activity and cardiorespiratory rehospitalizations among older adults discharged to skilled nursing facilities (SNFs). Retrospective cohort. Adults aged ≥65 years who were hospitalized and then discharged to a US SNF between 2012 and 2015. We linked Medicare Provider Analysis and Review claims to Minimum Data Set version 3.0 assessments, PRISM Climate Group data, and the Centers for Disease Control and Prevention viral testing data. All data were aggregated to US Department of Health and Human Services regions. Negative binomial regression models quantified the relationship between increasing viral activity for RSV and 3 influenza strains (H1N1pdm09, H3N2, and B) and cardiorespiratory rehospitalizations from SNFs. Incidence rate ratios described the relationship between a 5% increase in circulating virus and the rates of rehospitalization for cardiorespiratory outcomes. Analyses were repeated using the same model, but influenza and RSV were considered "in season" or "out of season" based on a 10% positive testing threshold. Cardiorespiratory rehospitalization rates increased by approximately 1% for every 5% increase in circulating influenza A(H3N2), influenza B, and RSV, but decreased by 1% for every 5% increase in circulating influenza A(H1N1pdm09). When respiratory viruses were in season (vs out of season), cardiorespiratory rehospitalization rates increased by approximately 6% for influenza A(H3N2), 3% for influenza B, and 5% for RSV, but decreased by 6% for influenza A(H1N1pdm09). The respiratory season is a particularly important period to implement interventions that reduce cardiorespiratory hospitalizations among SNF residents. Decreasing viral transmission in SNFs through practices such as influenza vaccination for residents and staff, use of personal protective equipment, improved environmental cleaning measures, screening and testing of residents and staff, surveillance of viral activity, and quarantining infected individuals may be potential strategies to limit viral infections and associated cardiorespiratory rehospitalizations. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: Nationwide among nursing home residents, receipt of the influenza vaccine is 8 to 9 percentage points lower among blacks than among whites. The objective of this study was to determine if the national inequity in vaccination is because of the characteristics of facilities and/or residents. Design: Cross-sectional study with multilevel modeling. Setting and Participants: States in which 1% or more of nursing home residents were black and the difference in influenza vaccination coverage between white and black nursing home residents was 1 percentage point or higher (n = 39 states and the District of Columbia). Data on residents (n = 2,359,321) were obtained from the Centers for Medicare & Medicaid Service’s Minimum Data Set for October 1, 2008, through March 31, 2009. Measurements: Residents’ influenza vaccination status (vaccinated, refused vaccine, or not offered vaccination). Results: States with higher overall influenza vaccination coverage among nursing home residents had smaller racial inequities. In nursing homes with higher proportions of black residents, vaccination coverage was lower for both blacks and whites. The most dramatic inequities existed between whites in nursing homes with 0% blacks (L1) and blacks in nursing homes with 50% or more blacks (L5) in states with overall racial inequities of 10 percentage points or more. In these states, more black nursing home residents lived in nursing homes with 50% or more blacks (L5); in general, the same homes with low overall coverage. Conclusion: Inequities in influenza vaccination coverage among nursing home residents are largely because of low vaccination coverage in nursing homes with a high proportion of black residents. Findings indicate that implementation of culturally appropriate interventions to increase vaccination in facilities with larger proportions of black residents may reduce the racial gap in influenza vaccination as well as increase overall state-level vaccination. [Copyright &y& Elsevier]

Objective: To evaluate relative improvement among nursing homes that set targets using the Nursing Home Setting Targets—Achieving Results (STAR) Site for 2 quality measures: (1) the proportion of long-stay residents who are physically restrained daily; and (2) the proportion of high-risk long-stay residents who have pressure ulcers. Setting and Participants: This analysis focuses on the 7091 Medicare- and/or Medicaid-certified nursing homes whose staff set STAR targets in 2005 for at least 1 of the 2 quality measures included in this analysis. Intervention: In 2005, the Centers for Medicare & Medicaid Services (CMS) launched STAR to help nursing homes select annual performance goals, or targets, for 4 outcomes that CMS publicly reports quarterly on Nursing Home Compare. Volunteer nursing homes used STAR to evaluate current clinical performance, identify targets, and then track their achievement of those targets. Measurements: To assess improvement, the project team calculated 4-quarter averages for baseline (ending the quarter when the target was set) and remeasurement (ending the quarter when the target expired) time periods. The team also estimated the number of lives impacted by improvements associated with setting STAR targets. Results: When compared to nursing homes that did not set physical restraint or pressure ulcer targets, nursing homes that set a target had significantly greater relative improvement for the associated quality measure. In particular, nursing homes that set physical restraint targets improved nearly twice as much on the physical restraint quality measure. These trends persisted regardless of nursing home characteristics (eg, facility size or membership in a multifacility corporation) or nursing homes'' intensive participation in work with their state''s Quality Improvement Organization (QIO). During the 1-year observation period, target setting was associated with 2576 fewer residents at risk for pressure ulcers developing a pressure ulcer and 4321 fewer residents being physically restrained. Conclusion: These analyses demonstrate consistently greater relative improvement among nursing homes that set STAR targets for the daily physical restraint or high-risk pressure ulcer quality measures than among nursing homes that did not set these targets. Although the absolute improvement is relatively small—less than 1% for each quality measure—the number of residents affected is substantial. If STAR targets were routinely incorporated into practice and this level of improvement realized by all nursing homes nationwide, an estimated 45,000 residents would experience better pressure ulcer and physical restraint outcomes at the end of 1 year. [Copyright &y& Elsevier]

Anemia is a frequent problem among older persons, the prevalence of which may be particularly high in skilled-nursing facilities but recent data in this regard is lacking. The purpose of this study was to define the prevalence of anemia and its association with hospitalization in skilled-nursing home residents. We retrospectively reviewed randomly selected charts among five skilled-nursing facilities within the National Geriatrics Research Consortium (NGRC). Among 900 chronically residing patients with completed chart information, the mean and median ages were 79 years and 82 years, respectively. Eighty-seven percent of patients were 65 years or greater. Applying the World Health Organization criteria for anemia (hemoglobin <12 g/dl for women and hemoglobin <13 g/dl for men), we found a 6-month point prevalence of 48%. The hospitalization rate was higher among those with more severe anemia. Few residents were treated with recombinant erythropoietin therapy or red blood cell transfusion. Anemia is very common in the nursing home, and despite being associated with increased morbidity; it is, for the most part, untreated in this setting. With an increased understanding of erythropoiesis and the availability of recombinant growth factors, future studies should evaluate the causes and potential benefits of treatment in terms of quality of life, reduced morbidity and health economics. [Copyright &y& Elsevier]

Quantify how observable characteristics contribute to influenza vaccination disparities among White, Black, and Hispanic nursing home (NH) residents. Retrospective cohort. Short- and long-stay U.S. NH residents aged ≥65 years. We linked Minimum Data Set (MDS) and Medicare data to LTCFocUS and other facility data. We included residents with 6-month continuous enrollment in Medicare and an MDS assessment between October 1, 2013, and March 31, 2014. Residents were classified as short-stay (<100 days in NH) or long-stay (≥100 days in NH). We fit multivariable logistic regression models to assess the relationships between 27 resident and NH-level characteristics and receipt of influenza vaccination. Using nonlinear Oaxaca-Blinder decomposition, we decomposed the disparity in influenza vaccination between White versus Black and White versus Hispanic NH residents. Analyses were repeated separately for short- and long-stay residents. Our study included 630,373 short-stay and 1,029,593 long-stay residents. Proportions vaccinated against influenza included 67.2% of White, 55.1% of Black, and 54.5% of Hispanic individuals among short-stay residents and 84.2%, 76.7%, and 80.8%, respectively among long-stay residents. Across 4 comparisons, the crude disparity in influenza vaccination ranged from 3.4 to 12.7 percentage points. By equalizing 27 prespecified characteristics, these disparities could be reduced 37.7% to 59.2%. Living in a predominantly White facility and proxies for NH quality were important contributors across all analyses. Characteristics unmeasured in our data (eg, NH staff attitudes and beliefs) may have also contributed significantly to the disparity. The racial/ethnic disparity in influenza vaccination was most dramatic among short-stay residents. Intervening on factors associated with NH quality would likely reduce these disparities; however, future qualitative research is essential to explore potential contributors that were unmeasured in our data and to understand the degree to which these factors contribute to the overall disparity in influenza vaccination. [ABSTRACT FROM AUTHOR]

Abstract: Background: Heart failure (HF) disease management can improve health outcomes for older community dwelling patients with heart failure. HF disease management has not been studied in skilled nursing facilities, a major site of transitional care for older adults. Methods and anticipated results: The objective of this trial is to investigate if a HF- disease management program (HF-DMP) in skilled nursing facilities (SNF)s will decrease all-cause rehospitalizations for the first 60 days post-SNF admission. The trial is a randomized cluster trial to be conducted in 12 for-profit SNF in the greater Cleveland area. The study population is inclusive of patients with HF regardless of ejection fraction but excludes those patients on dialysis and with a life expectancy of 6 months or less. The HF-DMP includes 7 elements considered standard of care for patients with HF documentation of left ventricular function, tracking of weight and symptoms, medication titration, discharge instructions, 7-day follow-up appointment post-SNF discharge, and patient education. The HF-DMP is conducted by a research nurse tasked with adhering to each element of the program and regularly audited to maintain fidelity of the program. Additional outcomes include health status, self-care management, and discharge destination. Conclusions: The SNF-Connect Trial is the first trial of its kind to assess if a HF-DMP will improve outcomes for patients in SNFs. This trial will provide evidence on the effectiveness of HF-DMP to improve outcomes for older frail HF patients undergoing postacute rehabilitation. [Copyright &y& Elsevier]