Dataset Information

Outcomes in heart failure patients discharged to skilled nursing facilities with delirium.

ABSTRACT:

Aim

Heart failure (HF) outcomes are disproportionately worse in patients discharged to skilled nursing facilities (SNF) as opposed to home. We hypothesized that dementia and delirium were key factors influencing these differences. Our aim was to explore the associations of dementia and delirium with risk of hospital readmission and mortality in HF patients discharged to SNF.

Methods and results

The study population included Veterans hospitalized for a primary diagnosis of HF and discharged to SNFs between 2010 and 2015. Pre-existing dementia was identified based on International Classification of Diseases-9 codes. Delirium was determined using the Minimum Data Set 3.0 Confusion Assessment Method algorithm. Proportional hazard regression analyses were used to model outcomes and were adjusted for covariates of interest. Patients (n = 21 655) were older (77.0 ± 10.5 years) and predominantly male (96.9%). Four groups were created according to presence (+) or absence (-) of dementia and delirium. Relative to the dementia-/delirium- group, the dementia-/delirium+ group was associated with increased 30 day mortality [adjusted hazard ratio (HR) = 2.2, 95% confidence interval (CI) = 1.7, 3.0] and 365 day mortality (adjusted HR = 1.5, 95% CI = 1.3, 1.7). Readmission was highest in the dementia-/delirium+ group after 30 days (HR = 1.2, 95% CI = 1.0, 1.5). In the group with dementia (delirium-/dementia+), 30 day mortality (12.8%; HR = 0.7, 95% CI = 0.7, 0.8) and readmissions (5.3%; HR = 1.0, 95% CI = 0.8, 1.1) were not different relative to the reference group.

Conclusions

Delirium, independent of pre-existing dementia, confers increased risk of hospital readmission and mortality in HF patients discharged to SNFs. Managing HF after hospitalization is a complex cognitive task and an increased focus on mental status in the acute care setting prior to discharge is needed to improve HF management and transitional care, mitigate adverse outcomes, and reduce healthcare costs.

SUBMITTER: Lafo J

PROVIDER: S-EPMC9065834 | biostudies-literature | 2022 Jun

REPOSITORIES: biostudies-literature

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Publications

Outcomes in heart failure patients discharged to skilled nursing facilities with delirium.

Lafo Jacob J Singh Mriganka M Jiang Lan L Correia Stephen S Madrigal Caroline C Clements Rachel R Wu Wen-Chih WC Erqou Sebhat S Rudolph James L JL

ESC heart failure 20220315 3

<h4>Aim</h4>Heart failure (HF) outcomes are disproportionately worse in patients discharged to skilled nursing facilities (SNF) as opposed to home. We hypothesized that dementia and delirium were key factors influencing these differences. Our aim was to explore the associations of dementia and delirium with risk of hospital readmission and mortality in HF patients discharged to SNF.<h4>Methods and results</h4>The study population included Veterans hospitalized for a primary diagnosis of HF and d ...[more]

PMID: 35293145

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Project description:ImportanceA substantial number of patients discharged to skilled nursing facilities (SNFs) after heart failure (HF) hospitalization experience regression in function or do not improve. Delirium is one of few modifiable risk factors in this patient population. Therefore, understanding the role of delirium in functional recovery may be useful for improving outcomes.ObjectiveTo assess the association of delirium with 30-day functional improvement in patients discharged to SNFs after HF hospitalization.Design, setting, and participantsThis retrospective cohort study included patients hospitalized for HF in 129 US Department of Veterans Affairs hospitals who were discharged to SNFs from October 1, 2010, to September 30, 2015. Data were analyzed from June 14 to December 18, 2020.ExposuresDelirium, as determined by the Minimum Data Set (MDS) 3.0 Confusion Assessment Method, with dementia as a covariate, determined via International Classification of Diseases, Ninth Revision (ICD-9) coding.Main outcomes and measuresThe difference between admission and 30-day MDS 3.0 Activities of Daily Living (ADL) scores.ResultsA total of 20 495 patients (mean [SD] age, 78 [10.3] years; 78.9% White; and 97% male) were included in the analysis. Of the total sample, 882 patients (4.3%) had delirium on an SNF admission. The mean (SD) baseline ADL score on admission to SNF was significantly worse among patients with delirium than without (18.3 [4.7] vs 16.1 [5.2]; P < .001; d = 0.44.). On the 30-day repeated assessment, mean (SD) function (ADL scores) improved for both patients with delirium (0.6 [2.9]) and without delirium (1.8 [3.6]) (P < .001; d = -0.38). In the multivariate adjusted model, delirium was associated with statistically significant lower ADL improvement (difference in ADL score, -1.07; 95% CI, -1.31 to -0.83; P < .001).Conclusions and relevanceIn this retrospective cohort study, patients with HF discharged to SNFs with delirium were less likely to show improvement in function compared with patients without delirium. Findings suggest a potential need to reexamine how and when health care professionals assess delirium in HF patients throughout their hospitalization and SNF course. Identifying and treating delirium for HF patients earlier in their care trajectory may play an important role in improving care and long-term functional outcomes in this population. Future research is warranted to further investigate the association between delirium and functional recovery for HF and other patient populations.

Project description:ObjectivesPrior studies have reported mixed findings about the existence of racial disparities in readmission rates among Medicare Advantage beneficiaries, but these studies used data from one state, focused on black-white disparities, and did not focus on patients discharged to skilled nursing facilities (SNFs). The objective of the study was to characterize racial and ethnic disparities in rates of 30-day rehospitalization directly from SNFs among fee-for-service and Medicare Advantage patients.DesignA cross-sectional study of admissions to SNFs in 2015 was conducted.SettingSNFs across the United States.ParticipantsThe sample included 1 500 334 white, 213 848 African American, and 99 781 Hispanic Medicare patients who were admitted to 13 375 SNFs.MeasurementsThe main outcome of interest was readmission, identified as patients sent back to any hospital directly from the SNF within 30 days of admission, as indicated on the Minimum Data Set discharge assessment.ResultsOverall readmission rates for fee-for-service patients were 16.7% (95% confidence interval [CI] = 16.7%-16.8%) for whites, 18.8% (95% CI = 18.7%-19.0%) for African Americans, and 17.4% (95% CI = 17.1%-17.7%) for Hispanics. Readmission rates in Medicare Advantage were 14.7% (95% CI = 14.5%-14.8%) for whites, 16.8% (95% CI = 16.6%-17.1%) for African Americans, and 15.3% (95% CI = 14.9%-15.6%) for Hispanics. We also found that African Americans had about 1% higher readmission rates than whites, even when they received care within the same SNF. No statistically significant differences were found in the magnitude of within-SNF racial disparities in Medicare Advantage compared with Medicare fee-for-service.ConclusionWe found racial disparities in readmission rates even within the same facility for both Medicare Advantage and fee-for-service beneficiaries. Intervention to reduce disparities in readmission rates, as well as more comprehensive quality measures that incorporate outcomes for Medicare Advantage enrollees, are needed. J Am Geriatr Soc 67:1672-1679, 2019.

Project description:ImportanceThe 2014 Improving Medicare Post-Acute Care Transformation (IMPACT) Act aimed to improve postacute care quality and outcomes. This study examines changes in delirium, a key quality indicator, over 5 years following its implementation.ObjectiveTo compare the persistence and resolution of delirium within skilled nursing facilities (SNFs) between 2014 and 2019.Design, setting, and participantsThis cross-sectional study included SNF admissions from a 5% Medicare random sample, with delirium assessments conducted between January 1 and December 31 in 2014 and 2019. The analysis of persistent delirium consisted of patients with delirium at SNF admission and a subsequent delirium assessment during their SNF stay. Analyses were conducted from December 2023 to October 2024.ExposuresYear 2019 compared with year 2014.Main outcomes and measuresDelirium was measured using the Minimum Data Set (MDS) Confusion Assessment Method at SNF admission and at a subsequent assessment within 30 days of admission. Multinomial logistic regression was used to compare the rates of resolved delirium, persistent delirium, and death between 2014 and 2019 after adjusting for patient characteristics and SNF care factors.ResultsThe sample included a total of 432 037 SNF admissions before exclusions and 306 998 after exclusions. For SNF admissions in 2014, 6933 of 162 161 patients (4.3%) had delirium at admission, compared with 3595 of 144 837 patients (2.5%) in 2019. In 2014, there were 6096 patients (mean [SD] age, 80.6 [11.0] years; 3565 women [58.5%]), and in 2019, there were 2778 patients (mean [SD] age, 80.2 [10.7] years; 1546 women [55.7%]) with delirium and follow-up assessments. The adjusted prevalence of persistent delirium decreased from 3347 of 6096 patients (62.3%; 95% CI, 60.2%-64.4%) in 2014 to 1316 of 2778 patients (54.7%; 95% CI, 52.0%-57.4%) in 2019, whereas delirium resolution increased from 1734 of 6096 patients (29.1%; 95% CI, 27.1%-31.1%) in 2014 to 1010 of 2778 patients (37.4%; 95% CI, 34.7%-40.0%) in 2019.Conclusions and relevanceThis cross-sectional study found a reduction in the prevalence of delirium at SNF admission and an improvement in delirium resolution during the stay in the 5 years following the IMPACT Act. However, the high prevalence of persistent delirium warrants further efforts to improve delirium management in SNF.

Project description:ObjectivePatients 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.DesignCluster-randomized controlled trial.ParticipantsThe trial was conducted in 47 SNFs, and 671 patients were enrolled (329 HF-DMP; 342 to usual care).MethodsThe 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.ResultsMean 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.Conclusions and implicationsThe 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.

Dataset Information

Outcomes in heart failure patients discharged to skilled nursing facilities with delirium.

Aim

Methods and results

Conclusions

Publications

Outcomes in heart failure patients discharged to skilled nursing facilities with delirium.

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