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The aim of the study was to determine the association of sex and race/ethnicity with acute hospital readmissions ("within-stay readmissions") during inpatient rehabilitation facility care versus patients discharged home without a within-stay readmission among traumatic brain injury patients.The study used a secondary analysis ( N = 210,440) of Uniform Data System for Medical Rehabilitation data using multiple logistic regression.Within-stay readmissions occurred for 11.79% of female and 11.77% of male traumatic brain injury patients. Sex-specific models identified insurance, comorbidities, and complications factored differently in likelihood of within-stay readmissions among female than male patients but association of all other factors were similar per group. Within-stay readmissions differences were more pronounced by race/ethnicity: White, 11.63%; Black, 11.32%; Hispanic/Latino, 9.78%; and other, 10.61%. Descriptive bivariate analysis identified racial/ethnic patients with within-stay readmissions had greater days from traumatic brain injury to inpatient rehabilitation facility admission (White, 17.66; Black, 21.70; Hispanic/Latino, 23.81; other, 20.66) and lower admission cognitive and motor function. Factors differed across models predicting within-stay readmissions for race/ethnic groups; age, admission motor and cognitive function, complications, and length of stay were consistent across groups.This study demonstrates disparities by race/ethnicity for inpatient rehabilitation facility within-stay readmissions among traumatic brain injury patients and factors predictive of this potentially preventable outcome by sex and race/ethnicity. Findings could inform care planning and quality improvement efforts for TBI patients.

Traumatic brain injury (TBI) among older adults is increasing and can affect cognition. To effectively meet the rehabilitation needs of older adults, a clearer picture is needed of patient-, clinical-, and facility-level characteristics that affect cognitive recovery during inpatient rehabilitation facility (IRF) stays.To identify patient, clinical, and facility factors associated with cognitive recovery among older adults with TBI who received IRF care.Secondary data analysis.Uniform Data System for Medical Rehabilitation-participating IRFs in the United States.Patients were 65 to 99 years of age at IRF admission for TBI. Participants received IRF care between 2002 and 2018 (N = 137,583); 56.3% were male; 84.2% were white; mean age was 78.7 years.Change in Functional Independence Measure Cognitive Score (FIM-Cognitive) from IRF admission to discharge, categorized as favorable (FIM-cognitive score gains ≥3 points) or poor (FIM-cognitive score gains3 points) cognitive outcomes.Not applicable.Patients had greater odds of favorable cognitive recovery if they were female (adjusted odds ratio [aOR] 1.05, 95% confidence interval [CI] 1.05-1.08), had higher motor functioning at IRF admission (aOR 1.03, 95% CI 1.03-1.04), longer length of stay (aOR 1.07, 95% CI 1.06-1.07), or received care at a freestanding IRF (vs. hospital rehab unit) (aOR 1.57, 95% CI 1.52-1.61). Patients who were older (aOR 0.99, 95% CI 0.98-0.99), Black (aOR 0.79, 95% CI 0.75-0.83), Hispanic or Latino (aOR 0.97, 95% CI 0.91-1.02), or were part of another racial or ethnic group (aOR 0.85, 95% CI 0.81-0.90) (vs. White), had high-cost comorbid conditions (aOR 0.71, 95% CI 0.65-0.76), or who had higher cognitive functioning at IRF admission (aOR 0.90, 95% CI 0.90-0.91) had lower odds of favorable cognitive recovery.Patient (age, sex, race, ethnicity), clinical (level of functioning at IRF admission, length of stay) and facility (e.g., freestanding IRF) factors contributed to the cognitive recoveries of older adults during IRF stays.

Coronary artery disease (CAD) is the leading cause of cardiovascular morbidity, mortality, and healthcare costs in the United States. There are few reports on how public health and payment reforms might have influenced inpatient hospital use among patients with CAD.This study describes trends in hospital discharges, hospital charges, and discharge destinations in a national sample of patients with CAD between 1997 and 2014.This was a longitudinal study with descriptive analysis of the Healthcare Cost and Utilization Project of National Inpatient Sample data.During this study period, the total number of discharges was 1 333 996. Patients with CAD between 65 and 84 years old were among the highest users of inpatient hospital services, followed by those in the 45- to 64-year age group. The death rate increased from 5961 to 7217 per 10 000 patients during this time. The mean charge increased more than 5 times, from $9100 to $49 643. There was a large difference in mean hospital charges in urban ($51 666) and rural ($25 548) locations in 2014. Coronary artery disease patients with private insurance paid more than those with Medicaid and Medicare plans. The discharge to home and healthcare costs increased by 4.1% and 4.8%, respectively.Future researchers should use data sets, such as Medicare claims/Medical Expenditure Panel Study, that can provide comprehensive insights into patient-level factors influencing the use of inpatient care services among patients with CAD. Healthcare providers in posthospital settings should be well skilled in providing advanced cardiac rehabilitation and education to patients with CAD.

The United States is facing an opioid epidemic that has only worsened with the COVID-19 pandemic. There is little evidence regarding patterns of opioid use among patients with total hip replacement (THR). Although the Centers for Disease Control and Prevention has put forward guidelines for prescribing opioids, it does not include guidance specifically for THR patients suffering from presurgical and postsurgical pain. The purpose of this study was to (1) compare presurgical and postsurgical opioid rates, (2) compare presurgical and postsurgical morphine milligram equivalents (MME), and (3) determine whether having a presurgical opioid prescription predicts the receipt of postsurgical opioid prescriptions among patients undergoing THR surgery. Retrospective cohort analysis of 4,405 patients undergoing THR at a major academic medical center in the United States from April 30, 2015, to April 30, 2018, was done. Patient characteristics, opioid rates, and average MME/day/person were described. Logistic regression was used to determine whether presurgical opioid prescription and opioid risk level predicted postsurgical opioid prescribing. Median age was 64 years (range = 18-85 years); patients were primarily Caucasian/White (78.8%) and female (54.7%). Opioid prescription rates in this sample for the 12-month presurgical and postsurgical periods were 66.1% and 95.6%, respectively. Oxycodone was the most common opioid prescribed in both periods. Among those prescribed an opioid, moderate/high risk for overdose and/or death was 6.3% presurgery and 19.8% postsurgery. Patients with a comorbidity were two times more likely to receive an opioid prescription in the postsurgical period. The median average MME/day/person was 26.5 (range = 0.3-180.0) for patients with an opioid prescribed during the presurgery period and 40.4 (range = 1.5-270.0) during the postsurgery period. Opioid use, regardless of strength, in the presurgical period as well as having one or more comorbidities predicted opioid use in the postsurgical period.

OBJECTIVE: To determine age- and sex-specific predictors of discharge destination among patients with traumatic brain injury (TBI) receiving inpatient rehabilitation facility (IRF) care. DESIGN: Secondary analysis of Uniform Data System for Medical Rehabilitation data. METHODS: Logistic regression of patients (N=221,961) age ≥18, TBI diagnosis, admitted to IRF between 2002-2018. OUTCOME: Discharge destination (subacute vs. home/community settings) RESULTS: Approximately 16% were discharged to subacute vs. 84% home. Younger versus older adults had lower odds of subacute discharge [OR=0.72; 95% CI: 0.69, 0.76]. Age and sex stratification of discharge destination was significant. Younger females had lower odds of subacute discharge (vs. home) than older females [OR=0.68; 95% CI: 0.63, 0.74]; younger males had lower odds of subacute discharge (vs. home) than older males [OR=0.74; 95% CI: 0.70, 0.78]. Younger females versus younger males had lower odds of subacute discharge (vs. home) [OR=0.83; 95% CI: 0.79, 0.87]. Older females versus older males had lower odds of subacute discharge (vs. home) [OR=0.93; 95% CI: 0.90, 0.97]. Predictors of discharge destination for age- and sex-stratified groups varied. CONCLUSIONS: Younger (vs. older) and female (vs. male) patients had lower odds of subacute discharge vs. home. Findings can inform IRF and transitional care planning and resource allocation.

The authors describe a family’s adaptive challenges and adaptive work during a family member’s treatment for Chronic Hepatitis C. We audiorecorded index and final clinical visits and interviewed participants (patients and providers) following the visits. We interviewed by telephone and reviewed medical records over the course of treatment. Transcripts were analyzed using directed content analysis. Three themes were identified: family adaptive challenges, patient-described aspects of family members’ adaptive challenges, and family adaptive work. There were four subthemes related to family adaptive work. The adaptive leadership framework for chronic illness provided direction for future family intervention.

Objectives To evaluate a machine learning model designed to predict mortality for Medicare beneficiaries aged >65 years treated for hip fracture in Inpatient Rehabilitation Facilities (IRFs). Design Retrospective design/cohort analysis of Centers for Medicare & Medicaid Services Inpatient Rehabilitation Facility–Patient Assessment Instrument data. Setting and Participants A total of 17,140 persons admitted to Medicare-certified IRFs in 2015 following hospitalization for hip fracture. Measures Patient characteristics include sociodemographic (age, gender, race, and social support) and clinical factors (functional status at admission, chronic conditions) and IRF length of stay. Outcomes were 30-day and 1-year all-cause mortality. We trained and evaluated 2 classification models, logistic regression and a multilayer perceptron (MLP), to predict the probability of 30-day and 1-year mortality and evaluated the calibration, discrimination, and precision of the models. Results For 30-day mortality, MLP performed well [acc = 0.74, area under the receiver operating characteristic curve (AUROC) = 0.76, avg prec = 0.10, slope = 1.14] as did logistic regression (acc = 0.78, AUROC = 0.76, avg prec = 0.09, slope = 1.20). For 1-year mortality, the performances were similar for both MLP (acc = 0.68, AUROC = 0.75, avg prec = 0.32, slope = 0.96) and logistic regression (acc = 0.68, AUROC = 0.75, avg prec = 0.32, slope = 0.95). Conclusion and Implications A scoring system based on logistic regression may be more feasible to run in current electronic medical records. But MLP models may reduce cognitive burden and increase ability to calibrate to local data, yielding clinical specificity in mortality prediction so that palliative care resources may be allocated more effectively.

Purpose Patient priorities for quality of life change with age. We conducted a qualitative study to identify quality of life themes of importance to older adults receiving dialysis and the extent to which these are represented in existing quality of life instruments. Methods We conducted semi-structured interviews with 12 adults aged ≥ 75 years receiving hemodialysis to elicit participant perspectives on what matters most to them in life. We used framework analysis methodology to process interview transcripts (coding, charting, and mapping), identify major themes, and compare these themes by participant frailty status. We examined for representation of our study’s subthemes in the Kidney Disease Quality of Life (KDQOL-36) and the World Health Organization Quality of Life for Older Adults (WHOQOL-OLD) instruments. Results Among the 12 participants, average age was 81 (4.2) years, 7 African-American, 6 women, and 6 met frailty criteria. We identified two major quality of life themes: (1) having physical well-being (subthemes: being able to do things independently, having symptom control, maintaining physical health, and being alive) and (2) having social support (subthemes: having practical social support, emotional social support, and socialization). Perspectives on the subthemes often varied by frailty status. For example, being alive meant surviving from day-to-day for frail participants, but included a desire for new life experiences for non-frail participants. The majority of the subthemes did not correspond with domains in the KDQOL-36 and WHOQOL-OLD instruments. Conclusion Novel instruments are likely needed to elicit the dominant themes of having physical well-being and having social support identified by older adults receiving dialysis.

The United States is facing an opioid epidemic that has only worsened with the COVID-19 pandemic. There is little evidence regarding patterns of opioid use among patients with total hip replacement (THR). Although the Centers for Disease Control and Prevention has put forward guidelines for prescribing opioids, it does not include guidance specifically for THR patients suffering from presurgical and postsurgical pain. The purpose of this study was to (1) compare presurgical and postsurgical opioid rates, (2) compare presurgical and postsurgical morphine milligram equivalents (MME), and (3) determine whether having a presurgical opioid prescription predicts the receipt of postsurgical opioid prescriptions among patients undergoing THR surgery. Retrospective cohort analysis of 4,405 patients undergoing THR at a major academic medical center in the United States from April 30, 2015, to April 30, 2018, was done. Patient characteristics, opioid rates, and average MME/day/person were described. Logistic regression was used to determine whether presurgical opioid prescription and opioid risk level predicted postsurgical opioid prescribing. Median age was 64 years (range = 18-85 years); patients were primarily Caucasian/White (78.8%) and female (54.7%). Opioid prescription rates in this sample for the 12-month presurgical and postsurgical periods were 66.1% and 95.6%, respectively. Oxycodone was the most common opioid prescribed in both periods. Among those prescribed an opioid, moderate/high risk for overdose and/or death was 6.3% presurgery and 19.8% postsurgery. Patients with a comorbidity were two times more likely to receive an opioid prescription in the postsurgical period. The median average MME/day/person was 26.5 (range = 0.3-180.0) for patients with an opioid prescribed during the presurgery period and 40.4 (range = 1.5-270.0) during the postsurgery period. Opioid use, regardless of strength, in the presurgical period as well as having one or more comorbidities predicted opioid use in the postsurgical period.

Roughly 88 million adults have prediabetes and over 84% are unaware that they even have prediabetes. African-Americans have an increased risk of being diagnosed with prediabetes. Faith-based organizations have a history of serving as a primary source of social support for African-Americans. Parishioners with prediabetes from four African-American churches participated in free, evidence-based group coaching to learn how to manage and control risk factors associated with type 2 diabetes. The weekly group coaching sessions took place at a local church and they were co-facilitated by two trained professionals: a lifestyle coach and a nurse practitioner. At the conclusion of the 16-week group coaching sessions, participants had a decrease in hemoglobin A1C levels, an increase in minutes of physical activity per week, and an improvement in knowledge and behavior.

The purpose of this article is to describe changes in hospital readmissions and costs for U.S. hospital patients who underwent Total Knee Replacement (TKR) in 2009 and 2014. Data comes from the Healthcare Cost and Utilization Project net-Nationwide Readmissions Database. Compared to 2009, overall 30-day rates of readmissions after TKR decreased by 15% in 2014. Rates varied by demographics: readmission rates were lower for younger patients, males, Medicare recipients, and those with higher incomes. Overall, costs rose 20% across TKR groups. This report is among the first to describe changes in hospital readmissions and costs for TKR patients in a national sample of U.S. acute care hospitals. Findings offer hospital managers a mechanism to benchmark their facilities’ performances.

OBJECTIVE: To determine the association of race and ethnicity with discharge destination among patients with traumatic brain injury (TBI) receiving inpatient rehabilitation facility (IRF) care. DESIGN: Secondary analysis using Uniform Data System for Medical Rehabilitation data from 75% of U.S. IRFs. METHODS: Patients (N = 99,614) diagnosed with TBI, age 18–64, admitted for IRF care between 2002–2018. Logistic regression was used to analyze data. OUTCOME: Discharge destination (home/community vs. subacute settings). RESULTS: Most younger adults (age 18–64) with TBI were discharged to home (89.24%) after IRF care vs. subacute settings (10.76%). Of those discharged home, 63.16% were White, 10.42% Black, 8.94% Hispanic/Latino, and 6.72% other races/ethnicities. After adjusting for covariates, patients who were Hispanic/Latino [OR=1.26; 95% CI: 1.15, 1.37] and other race/ethnicities [OR=1.10; 95% CI: 1.00, 1.21] (vs. White) had a higher likelihood of discharge home vs. subacute. There was no difference in discharge destination for Black patients (vs. White). Predictors of discharge destination for groups stratified by race/ethnicity varied. CONCLUSIONS: Younger adult patients with TBI who were Hispanic/Latino or other races/ethnicities (vs. White) were more likely to go home vs. subacute facilities after IRF discharge. Findings can be used to inform IRF planning, resource allocation, and transitional care planning.

The purpose of this study was to describe the pre- and postsurgical opioid prescription rates and average morphine milligram equivalents (MME) per day in patients undergoing total shoulder replacement (TSR) procedures.Patients undergoing TSR were identified from the electronic health records (EMR). In addition to patient demographics, opioid prescription 12-months presurgery and postsurgery were recorded. Patients were categorized into two groups: patients with no opioid prescriptions within 12 months before surgery and patients with an opioid prescription after surgery. McNemar tests were conducted to test for significant presurgical to postsurgical changes in opioid rate changes. The Wilcoxon signed rank test was used to test for significant pre- to postsurgical changes in average MME/day/person, and bivariate logistic regression analyses and covariate-adjusted logistic regressions were used to predict postsurgical opioid prescriptions.Overall, 1,076 patients underwent TSR. More than 900 patients received presurgical opioid prescriptions. There was a significant increase (p = .0015) in pre-surgical to postsurgical prescription rates. Postsurgical opioid prescriptions were 4.6 times more likely to be prescribed to a pre-surgical non-opioid patient than an opioid patient (p.0001). Among those prescribed an opioid, the median dosage was50 MME/day and over 82% of patients were at low overdose risk. Patients with comorbidities and without pre-surgical alcohol use were more likely to receive postsurgical opioids. Postsurgical opioid prescriptions were 4.6 times more likely to be prescribed to a presurgical non-opioid patient than an opioid patient (p.0001). More than 80% of patients undergoing TSR received presurgical opioids. Among those prescribed any opioid, the median dosage was50 MME/day and greater than 82% of patients were at low overdose risk.Although presurgical non-opioid patients were more likely to receive a postsurgical opioid prescription, based on dosage, most patients were at low risk for an opioid-related overdose or death according to CDC guidelines.

An organizational culture that values diversity and inclusion is essential for the achievement of high-quality nursing education, yet little literature exists to guide schools of nursing (SON) in accomplishing this goal. All SONs, regardless of size, need a framework that provides specific steps for developing and nurturing a culture that values diversity and inclusion. Using our SON as an exemplar, the goal of this article was to (a) review the barriers we faced when building a diverse and inclusive environment, (b) share our school's strategic plan designed to promote diversity and inclusion, and (c) highlight successful strategies as part of the development and ongoing implementation of our school's strategic plan. This process requires continuous commitment and intentionality as well as flexibility to address unforeseen circumstances. For example, the goals we have adopted and the strategies we have put in place have allowed members of our SON community to acknowledge and address the urgency and validity of the Black Lives Matter movement, as well as the disproportionate impact of the coronavirus disease 2019 pandemic on racial and ethnic minority groups. Although we recognize that we still have work to do within our SON community, we believe our exemplar offers an action-oriented framework for increasing diversity and inclusion among students, faculty, staff, and leadership in SONs.

Assuring home care staff competencies through simulation has the potential to improve care transitions and clinical outcomes. Recreating a home environment can be used for orientation of home care staff and to meet other learning needs. Lessons learned from the use of simulation in a geriatric nursing course in a prelicensure program can be used to prepare clinicians for transitioning patients across care settings. With simulation, learners can identify challenges in patient safety, pain management, and management of patients’ cognitive decline as well as learn how to communication with patients, family members and the healthcare team. Simulation, as an interactive pedagogy, provides opportunities for learners to practice assessment, monitoring, and patient care in a controlled, safe, risk-free environment. Following participation in a simulation, learners are given the opportunity to reflect on ways to improve patient care when transitioning from acute to home care settings. Simulations described in this article can be used for orientation of staff to a home health care agency because they allow clinicians to hone the skills necessary for patient care in the home. Staff educators can also use simulation to validate staff competencies in caring for patients at home.

We sought to understand strategies reported by members of the nursing home management team used to prevent falls in short-stay nursing home patients. Using Donabedian's model of structure, process, and outcomes, we interviewed 16 managers from 4 nursing homes in central North Carolina. Nursing home managers identified specific barriers to fall prevention among short-stay patients including rapid changes in functional and cognitive status, staff unfamiliarity with short-stay patient needs and patterns, and policies impacting care. Few interventions for reducing falls among short-stay patients were used at the structure level (eg, specialized units, workload ratio, and staffing consistency); however, many process-level interventions were used (eg, patient education on problem solving, self-care/mobility, and safety). We described several barriers to fall prevention among short-stay patients in nursing homes. From these descriptions, we propose three interventions that might reduce falls for short-stay patients and could be tested in future research: (1) clustering short-stay patients within a physical location to permit higher staff-patient ratios and enhanced surveillance, (2) population-based prevention interventions to supplement existing individually tailored prevention strategies (eg, toileting schedules, medication review for all), and (3) transitional care interventions that transmit key information from hospitals to nursing homes.

Each day, nurses care for patients from diverse cultures and backgrounds, including those who self-identify as lesbian, gay, bisexual, transgender, or queer. To facilitate productive health partnerships, nurses need to be aware of a patient's sexual orientation, gender identity, and expression. Prelicensure nursing students employed cultural humility with the use of a video and a guided discussion. The purpose of this article is to describe teaching strategies that can be used by other nurse educators.

Objective To determine the sociodemographic and clinical characteristics as well as health services use associated with successful community discharge. Data Source Inpatient Rehabilitation Facility-Patient Assessment Instrument and Medicare Provider Analysis and Review files. Study Design We retrospectively examined 167,664 Medicare beneficiaries discharged from inpatient rehabilitation facilities (IRFs) in 2013 to determine the sociodemographic and clinical characteristics as well as health services use associated with successful community discharge. Principal Findings In the multivariable model, sociodemographic (younger age, no disability, social support), clinical (higher motor and cognitive functional status at admission), and health services use (fewer acute care days and longer IRF days) variables were associated with successful community discharge. Conclusions Remaining in the community is an important patient-centered outcome that could complement other postacute rehabilitation quality measures.

Effective pain management for orthopaedic major joint replacement is key to achieving earlier recovery, better functioning, and high rates of patient satisfaction. In an effort to decrease opioid dependency, practitioners are turning to multimodal pain management, which involves the use of multiple analgesic agents and techniques. To utilize this technique, a patient's history of and preoperative consumption of medications to treat pain impacts the success of this regimen. Multimodal pain management involves the use of nonsteroidal anti-inflammatory drugs, acetaminophen, N-methyl-D-aspartate antagonists, gabapentin, serotonin inhibitors, regional techniques, and opioids as needed. It is necessary for the nurse to understand the mechanism of pain and how the multimodal adjuncts target the pain response to benefit the patient's perioperative course as well as his or her postoperative and discharge management.

Older African Americans consistently report diminished capacities to perform activities of daily living (ADL) compared to other race groups. It remains unclear the extent to which bodily pain is related to declining abilities to perform ADL/ADL disability in African Americans and if this relationship exists in both African American men and women to the same degree. In order for nurses to provide optimal care for older African Americans, a better understanding of the relationship between bodily pain and ADL disability and how it may differ by gender is needed. The aim of this study was to examine if pain, age, education, income, marital status and/or comorbid conditions were associated with ADL disabilities in older African American women and men. This was a cross-sectional descriptive study. The sample included 598 participants (446 women, 152 men) from the first wave of the Baltimore Study on Black Aging. African American women (Odds Ratio (OR) = 4.06; 95% confidence interval [CI] 2.63–6.26) and African American men (OR= 6.44; 95% CI =2.84–14.57) who reported bodily pain had greater ADL disability than those who did not report bodily pain. Having two or more comorbid conditions was also significantly associated with ADL disability in African American women (OR=3.95; 95% CI: 2.09–7.47). Further work is needed to understand pain differences between older African American women and men in order to develop interventions that can be tailored to meet the individual pain needs of both groups.

Objective To examine contextual (facility and community) and individual factors associated with self-care and mobility outcomes among Medicare hip fracture patients receiving inpatient rehabilitation. Design Retrospective cohort study of 3 linked data files: Inpatient Rehabilitation Facility–Patient Assessment Instrument, Provider of Services, and Area Health Resources. Multilevel modeling was used to examine the effects of contextual and individual factors on self-care and mobility outcomes. Setting Inpatient rehabilitation facilities (IRFs). Participants Medicare hip fracture patients (N=35,264; mean age, 81y) treated in IRFs (N=1072) in 2012. Interventions Not applicable. Main Outcome Measures Self-care (eating, grooming, bathing, upper and lower body dressing, toileting) and mobility (walk/wheelchair, stairs) at discharge. Results Mean ± SD self-care and mobility scores at admission were 3.17±.87 and 1.24±.51, respectively; mean ± SD self-care and mobility scores at discharge were 5.03±1.09 and 3.31±1.54, respectively. Individual and contextual levels explained 44.4% and 21.6% of the variance in self-care at discharge, respectively, and 19.5% and 1.9% of the variance in mobility at discharge, respectively. At the individual level, age, race/ethnicity, cognitive and motor FIM scores at admission, and tier comorbidities explained variance in self-care and mobility; sex and length of stay explained variance only in self-care. At the contextual level, facilities' case mix (mean patient age, percent non-Hispanic white, mean self-care score at admission) and structural characteristics (rural location, freestanding, for-profit ownership) explained variance only in self-care; facilities' case mix (mean patient age, percent non-Hispanic white, percent living with social support, mean mobility score at admission) explained variance in mobility. Community variables were nonsignificant. Conclusions Individual and facility factors were significant predictors of discharge self-care and mobility among Medicare hip fracture patients in IRFs. The findings may improve quality of IRF services to hip fracture patients and inform risk adjustment methods.

Purpose To describe trends in the length of stay (LOS), costs, mortality, and discharge destination among a national sample of total hip replacement (THR) patients between 1997 and 2012. Design Longitudinal retrospective design Methods Descriptive analysis of the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample data. Findings A total of 3,516,636 procedures were performed over the study period. Most THR patients were women, and the proportion aged 44–65 years increased. LOS decreased from 5 to 3 days. Charges more than doubled, from $22,184 to $53,901. Deaths decreased from 43 to 12 deaths per 10,000 patients. THR patients discharged to an institutional setting declined, while those discharged to the community increased. Conclusion We found an increase in THR patients, who were younger, women, had private insurance, and among those discharged to community-based settings. Clinical Relevance Findings have implications for patient profiles, workplace environments, quality improvement, and educational preparation of nurses in acute and postacute settings.

Introduction Compared with other racial/ethnic groups, African Americans have higher rates of chronic conditions and suffer a disproportionate burden of disability. We aimed to examine the effects of social support on physical functioning among older African Americans. Methods We analyzed a sample of 448 urban, community-dwelling, older African Americans (aged 48–98 years) from the Baltimore Study of Black Aging. Baseline physical functioning was collected between 2006 and 2008 (wave 1), and change in physical functioning was collected between 2009 and 2011 (wave 2), physical functioning was assessed by self-reported limitations in 7 activities of daily living—eating, dressing, grooming, walking, bathing, using the toilet, and transferring in and out of bed—using a binary variable to indicate whether the individual had difficulty performing each specific activity. Social support was measured by how frequently participants provided/received goods and services, financial assistance, transportation, companionship, advice, or encouragement (never [0], rarely [1], sometimes [2], frequently [3]). Negative binomial regression models were used to test the effects of social support given, received, and a ratio (support received/support given) on physical functioning for those who improved and those who declined in physical functioning. Results Participants reported physical functioning at wave 1 (1.24, standard deviation [SD] = 1.98) and at wave 2 (0.34, SD = 0.83). Average social support given was 7.49 (SD = 3.26), and average social support received was 7.81 (SD = 3.17). Those who improved in physical function gave less social support and had lower social support ratios; social support received had no effect. Those who remained stable or declined in physical function gave more social support; neither social support received nor social ratio had an effect. Conclusion Social support given and social support received as well as the ratio should be considered when seeking to understand how physical functioning changes over time among older African Americans.

Objective To document changes in 30-day hospital readmission rates and causes for returning to the hospital for care in THR patients. Design Retrospective cross-sectional descriptive design. Setting Community-based acute care hospitals. Participants Total sample size (N=142,022) included THR patients (identified as ICD-9-CM procedure code 81.51) in 2009 (n=31,232) and (n=32,863) in 2014. Interventions Not applicable. Main Outcome Measures 30-Day hospital readmission. Results The overall readmission rate decreased by 1.3% from 2009 to 2014. The decrease in readmission rates varied by groups, with lesser improvements seen in THR patients who were younger, with private insurance, and residing in lower-income and rural communities. Device complications were the leading cause of readmission in THR patients, increasing from 19.8% in 2009 to 23.9% in 2014. Conclusions There has been little decrease in hospital 30-day readmission rates for US community hospitals between 2009 and 2014. Findings from this brief report indicate patient groups at greater risk for 30-day hospital readmission as well as leading causes for readmission in THR patients which can inform the development of tailored interventions for reduction.

Effects of patient characteristics on rehabilitation outcomes (functional status at discharge, discharged home) were assessed in a retrospective study of Medicare beneficiaries admitted to Medicare-certified inpatient rehabilitation facilities (IRFs) following hospitalization for hip fracture in 2009 ( N = 34,984). Hierarchical regression analysis showed significantly higher functional status at discharge ( p < .0001) for patients with these characteristics: White or Asian, younger, female, lived alone, higher functional status at admission, fewer comorbidities, no tier comorbidities, and longer IRF length of stay (LOS). Likelihood of discharged home was higher for patients with these characteristics: Hispanic (1.49 [1.32, 1.68]), Asian (1.35 [1.04, 1.74]), or Black (1.28 [1.12, 1.47]); younger (0.96 [0.96, 0.96]); female (1.14 [1.08, 1.20]); lived with others (2.12 [2.01, 2.23]); higher functional status at admission (1.06 [1.06, 1.06]); fewer comorbidities, no tier comorbidities; and longer LOS (1.61 [1.56, 1.67]). Functional status at admission, tier comorbidities, and race/ethnicity contributed the most to variance in functional status at discharge. Living with others contributed the most to variance in discharged home.

Background: Moderator analyses may be helpful for evaluating intervention effects. The objective of this study was to evaluate whether the effect of a caregiver skills training intervention – Helping Invested Families Improve Veterans' Experience Study (HI-FIVES) – on care recipient outcome and caregiver outcome is moderated by the veteran’s risk for hospitalization or level of functional impairment. Methods: Secondary data analysis of HI-FIVES. Outcomes included community days (cumulative days in the community at 12 months alive and not in the emergency department, hospital, or post-acute facility) and caregiver burden (Zarit Burden Interview at baseline, 3, 6, and 12 months). Moderators, risk for hospitalization and functional impairment, was assessed using their Care Assessment Need (CAN) score the Older Americans Resources and Services (OARS) Questionnaire, respectively. Negative binomial and linear mixed models were used to assess intervention effects on community days and caregiver burden, respectively. Results: Of 241 dyads, veteran (caregiver) mean age was 73 (61) years, 53% (54%) were Black, and 4% (89%) were female. Medium hospitalization-risk (91-98 CAN score) participants who received HI-FIVES had 3.75 times more community days vs. medium risk participants in the control group. By contrast, the high hospitalization-risk (99+ CAN score) participants who received HI-FIVES had 4.39 times fewer community days vs. high-risk participants in the control group. The CAN score did not have a significant moderating effect on caregiver burden. OARS did not have a significant moderating effect on community days or caregiver burden. Conclusions: Targeting the HI-FIVES based on hospitalization risk may be an effective strategy for keeping veterans in the community longer.

Chronic hepatitis C (CHC) is the most common blood-borne infection in the United States. Patients with CHC undergoing treatment face many challenges including adherence to medications and management of symptoms; health care practitioners are well positioned to facilitate patients’ ability to address these challenges. We used the Adaptive Leadership for Chronic Illness Framework to investigate the difficulties inherent in affecting behavior change in patients undergoing treatment. We enrolled 11 patient participants and 10 provider participants. We used data from the first clinical encounter between patients and providers during which treatment was discussed. We found examples of adaptive leadership and categorized these behaviors into three themes: support for medication, coping with family/home life, and strategizing to manage employment. We also saw examples of what we termed missed opportunities for adaptive leadership. This study illustrates the contributions of adaptive leadership behaviors by health care providers and the potential risk to patients in their absence.

Background: National and global initiatives to address the social determinants of health (SDH) are on the rise. On a parallel trajectory, increased cultural awareness is emerging as an integral strategy to improve the understanding of these social contributions to disease states, health inequities, and health disparities. Method: Undergraduate nursing students developed modalities and role-played simulations as a teaching and learning strategy. The simulations demonstrated how nurses assess patients' unique needs and offer support and resources regarding patients' socioeconomic, cultural, and environmental needs. Results: The student-developed simulations were an interactive teaching and learning strategy that offered several benefits, such as improved interpersonal skills, learned specific nursing roles, and improved cultural awareness. Conclusion: Student-developed simulations are an innovative teaching strategy for improving cultural awareness and learning more about SDH. [ J Nurs Educ. 2017;56(4):243–246.]

Background Little is known about the sustainability of behavioral change interventions in long-term care (LTC). Following a cluster randomized trial of an intervention to improve staff communication (CONNECT), we conducted focus groups of direct care staff and managers to elicit their perceptions of factors that enhance or reduce sustainability in the LTC setting. The overall aim was to generate hypotheses about how to sustain complex interventions in LTC. Methods In eight facilities, we conducted 15 focus groups with 83 staff who had participated in at least one intervention session. Where possible, separate groups were conducted with direct care staff and managers. An interview guide probed for staff perceptions of intervention salience and sustainability. Framework analysis of coded transcripts was used to distill insights about sustainability related to intervention features, organizational context, and external supports. Results Staff described important factors for intervention sustainability that are particularly challenging in LTC. Because of the tremendous diversity in staff roles and education level, interventions should balance complexity and simplicity, use a variety of delivery methods and venues (e.g., group and individual sessions, role-play/storytelling), and be inclusive of many work positions. Intervention customizability and flexibility was particularly prized in this unpredictable and resource-strapped environment. Contextual features noted to be important include addressing the frequent lack of trust between direct care staff and managers and ensuring that direct care staff directly observe manager participation and support for the program. External supports suggested to be useful for sustainability include formalization of changes into facility routines, using “train the trainer” approaches and refresher sessions. High staff turnover is common in LTC, and providing materials for new staff orientation was reported to be important for sustainability. Conclusions When designing or implementing complex behavior change interventions in LTC, consideration of these particularly salient intervention features, contextual factors, and external supports identified by staff may enhance sustainability. Trial registration ClinicalTrial.gov, NCT00636675

Importance New approaches are needed to enhance implementation of complex interventions for geriatric syndromes such as falls. Objective To test whether a complexity science–based staff training intervention (CONNECT) promoting high-quality staff interactions improves the impact of an evidence-based falls quality improvement program (FALLS). Design, Setting, and Participants Cluster-randomized trial in 24 nursing homes receiving either CONNECT followed by FALLS (intervention), or FALLS alone (control). Nursing home staff in all positions were asked to complete surveys at baseline, 3, 6, and 9 months. Medical records of residents with at least 1 fall in the 6-month pre- and postintervention windows (n = 1794) were abstracted for fall risk reduction measures, falls, and injurious falls. Interventions CONNECT taught staff to improve their connections with coworkers, increase information flow, and use cognitive diversity in problem solving. Intervention components included 2 classroom sessions, relationship mapping, and self-monitoring. FALLS provided instruction in the Agency for Healthcare Research and Quality’s Falls Management Program. Main Outcomes and Measures Primary outcomes were (1) mean number of fall risk reduction activities documented within 30 days of falls and (2) median fall rates among residents with at least 1 fall during the study period. In addition, validated scales measured staff communication quality, frequency, timeliness, and safety climate. Results Surveys were completed by 1545 staff members, representing 734 (37%) and 811 (44%) of eligible staff in intervention and control facilities, respectively; 511 (33%) respondents were hands-on care workers. Neither the CONNECT nor the FALLS-only facilities improved the mean count of fall risk reduction activities following FALLS (3.3 [1.6] vs 3.2 [1.5] of 10); furthermore, adjusted median recurrent fall rates did not differ between the groups (4.06 [interquartile range {IQR}, 2.03-8.11] vs 4.06 [IQR, 2.04-8.11] falls/resident/y). A modest improvement in staff communication measures was observed overall (mean, 0.03 [SE, 0.01] points on a 5-point scale; P = .03) and for communication timeliness (mean, 0.8 [SE, 0.03] points on a 5-point scale; P = .02). There was wide variation across facilities in intervention penetration. Conclusions and Relevance An intervention targeting gaps in staff communication and coordination did not improve the impact of a falls quality improvement program. New approaches to implementing evidence-based care for complex conditions in the nursing home are urgently needed. Trial Registration clinicaltrials.gov Identifier:NCT00636675

The United States is undergoing a demographic shift and the health profile of its citizens will largely reflect the health of minorities. African Americans represent the second largest minority group in the United States. This entry describes the health profile of African Americans using key health status indicators, discuss social determinants of health and how interventions might play a critical role in improving the health of African Americans, and conclude with recommendations. Keywords: disability; ethnicity; health psychology; race

To examine the influence of facility and aggregate patient characteristics of inpatient rehabilitation facilities (IRFs) on performance-based rehabilitation outcomes in a national sample of IRFs treating Medicare beneficiaries with hip fracture.Secondary data analysis.U.S. Medicare-certified IRFs (N=983).Data included patient records of Medicare beneficiaries (N=34,364) admitted in 2009 for rehabilitation after hip fracture.Not applicable.Performance-based outcomes included mean motor function on discharge, mean motor change (mean motor score on discharge minus mean motor score on admission), and percentage discharged to the community.Higher mean motor function on discharge was explained by aggregate characteristics of patients with hip fracture (lower age [P=.009], lower percentage of blacks [P.001] and Hispanics [P.001], higher percentage of women [P=.030], higher motor function on admission [P.001], longer length of stay [P.001]) and facility characteristics (freestanding [P.001], rural [P.001], for profit [P=.048], smaller IRFs [P=.014]). The findings were similar for motor change, but motor change was also associated with lower mean cognitive function on admission (P=.008). Higher percentage discharged to the community was associated with aggregate patient characteristics (lower age [P.001], lower percentage of Hispanics [P=.009], higher percentage of patients living with others [P.001], higher motor function on admission [P.001]). No facility characteristics were associated with the percentage discharged to the community.Performance-based measurement offers health policymakers, administrators, clinicians, and consumers a major opportunity for securing health system improvement by benchmarking or comparing their outcomes with those of other similar facilities. These results might serve as the basis for benchmarking and quality-based reimbursement to IRFs for 1 impairment group: hip fracture.

Pathway information is vital for successful quantitative modeling of biological systems. The almost 170 online pathway databases vary widely in coverage and representation of biological processes, making their use extremely difficult. Future pathway information systems for querying, visualization and analysis must support standard exchange formats to successfully integrate data on a large scale. Such integrated systems will greatly facilitate the constructive cycle of computational model building and experimental verification that lies at the heart of systems biology.

Pathguide: the Pathway Resource List (http://pathguide.org) is a meta-database that provides an overview of more than 190 web-accessible biological pathway and network databases. These include databases on metabolic pathways, signaling pathways, transcription factor targets, gene regulatory networks, genetic interactions, protein-compound interactions, and protein-protein interactions. The listed databases are maintained by diverse groups in different locations and the information in them is derived either from the scientific literature or from systematic experiments. Pathguide is useful as a starting point for biological pathway analysis and for content aggregation in integrated biological information systems.

BioPAX (Biological Pathway Exchange) is a standard language to represent biological pathways at the molecular and cellular level. Its major use is to facilitate the exchange of pathway data (http://www.biopax.org). Pathway data captures our understanding of biological processes, but its rapid growth necessitates development of databases and computational tools to aid interpretation. However, the current fragmentation of pathway information across many databases with incompatible formats presents barriers to its effective use. BioPAX solves this problem by making pathway data substantially easier to collect, index, interpret and share. BioPAX can represent metabolic and signaling pathways, molecular and genetic interactions and gene regulation networks. BioPAX was created through a community process. Through BioPAX, millions of interactions organized into thousands of pathways across many organisms, from a growing number of sources, are available. Thus, large amounts of pathway data are available in a computable form to support visualization, analysis and biological discovery.