Frequency and Diagnoses Associated With 7- and 30-Day Readmission of Skilled Nursing Facility Patients to a Nonteaching Community Hospital. Ouslander JG, Diaz S, et al: The Journal of the American Medical Directors Association 2011; 12(March): 195-203
Objectives: To determine the frequency and diagnoses associated with 7- and 30-day acute hospital readmissions of patients discharged to a skilled nursing facility (SNF) from an acute hospital.
Design: A quality improvement project focusing on 30-day hospital readmissions, using retrospective data derived from the hospital’s electronic data repository.
Setting: A 350-bed nonteaching community hospital in southeast Florida.
Measurements: Data were collected on all discharges of Medicare fee-for-service patients age 75 and older for a 17-month period in 2007 and 2008. The primary source of data was the hospital’s electronic data repository. Seven and 30-day hospital readmission rates were calculated for all discharges to SNFs. Index hospital and readmission diagnoses were determined by hospital coders and categorized by the physician coauthors.
Results: Among 10,777 discharges of patients age 75 and older, 3254 (30%) were discharged to an SNF, and of these, 584 (18%) were readmitted to the hospital within 30 days; 191 (33%) of these readmissions occurred within 7 days. The index diagnostic categories with the highest readmission rates were genitourinary disorders (30%) and cardiovascular disorders (25%). Specific diagnoses associated with the highest readmission rates included congestive heart failure (CHF) (31%), urinary tract infection (28%), renal failure (27%), and pneumonia and chronic obstructive pulmonary disease (23% each). Infections and cardiovascular disorders were the primary diagnoses for 63% of the hospital readmissions (36% and 27% respectively). The most frequent readmission primary diagnosis was the same as the index admission primary diagnosis in less than half the cases.
Conclusion: In this community hospital population, close to 1 in 5 discharges to an SNF resulted in a hospital readmission within 30 days. CHF, renal failure, UTI, pneumonia, and COPD were common index hospital and readmission diagnoses. Care paths and guidelines are available for these conditions that should be helpful to SNFs in initiatives designed to improve transitional care and reduce potentially avoidable hospital readmissions, as well as their associated morbidity and cost.
Kevin’s Comments: This study reports on the substantial number of hospital discharges to skilled nursing facilities that result in hospital readmissions within 30 days. Many of these readmissions are potentially avoidable with better care transitions between the hospital and skilled nursing facility and with the use of tools that facilitate early identification of changes in condition. Beginning in 2012, the Center of Medicare and Medicaid Services (CMS) launches the Hospital Readmission Reduction Program. Hospitals will be penalized for readmissions from skilled nursing or home (including assisted living facilities) occurring within 30 days of hospital discharge for certain conditions such as congestive heart failure, myocardial infarction (heart attack), pneumonia, urinary tract infection, and chronic obstructive pulmonary disease. Last month, Geriatric News reported on INTERACT II (Interventions to Reduce Acute Care Transfers), tools developed by Dr. Ouslander and colleagues to assist skilled nursing communities in early recognition of change in condition and care paths that may reduce transfers to the hospital.
Short-Term, Light- to Moderate-Intensity Exercise Training Improves Leg Muscle Strength in the Oldest Old: A Randomized Controlled Trial. Serra-Rexach JA, Bustamante-Ara N, et al: The Journal of the American Geriatrics Society 2011; 59 (April): 594-602
Objectives: To assess the effects of an 8-week exercise training program with a special focus on light- to moderate intensity resistance exercises (30–70% of one repetition maximum, 1RM) and a subsequent 4-week training cessation period (detraining) on muscle strength and functional capacity in participants aged 90 and older.
Design: Randomized controlled trial performed during March to September 2009.
Setting: Geriatric nursing home.
Participants: Forty nonagenarians (90–97) were randomly assigned to an intervention or control group (16 women and 4 men per group).
Intervention: Eight-week muscle strength exercise intervention focused on lower limb strength exercises of light to moderate intensity.
Measurements: Primary outcome: 1RM leg press. Secondary outcomes: handgrip strength, 8-m walk test, 4- step stairs test, Timed Up and Go test, and number of falls.
Results: A significant group by time interaction effect (P5.02) was observed only for the 1RM leg press. In the intervention group, 1RM leg press increased significantly with training by 10.6 kg [95% confidence interval (CI)54.1–17.1 kg; P5.01]. Except for the mean group number of falls, which were 1.2 falls fewer per participant in the intervention group (95% CI50.0–3.0; P5.03), no significant training effect on the secondary outcome measures was found.
Conclusion: Exercise training, even of short duration and light to moderate intensity, can increase muscle strength while decreasing fall risk in nonagenarians.
Kevin’s Comments: Falls are a major public health problem occurring in one third of those over age 65 and one half of those over age 80. Exercise, especially leg strengthening, may reduce the risk of falls. This study demonstrates that light to moderate resistance exercised can improve leg strength and reduce fall risk in even the oldest old. Studies such as this hopefully will help overcome ageist attitudes of professionals as well as objections of older adults themselves. Muscles can be strengthened no matter how old. A key message to older adults should be, "It does not matter how old you are or what shape you are in right now." The benefits of strength training two or three days a week can be realized within a matter of a few weeks.
Sleep Optimizes Motor Skill in Older Adults. Tucker M, McKinley S, Stickgold R: The Journal of the American Geriatrics Society 2011; 59 (April): 603-609
Objectives: To determine whether sleep benefits motor memory in healthy elderly adults and, if so, whether the observed sleep-related benefits are comparable with those observed in healthy young adults.
Design: Repeated-measures cross-over design.
Setting: Boston, Massachusetts (general community) and Harvard University.
Participants: Sixteen healthy older and 15 healthy young participants.
Measurements: Motor sequence task (MST) performance was assessed at training and at the beginning and end of the retest session; polysomnographic sleep studies were recorded for the elderly participants.
Results: After 12 hours of daytime wakefulness, elderly participants showed a dramatic decline in MST performance on the first three retest trials, and only a nonsignificant improvement by the end of retest (the last 3 retest trials). In contrast, when the same participants trained in the morning but were retested 24 hours after training, after a day of wake plus a night of sleep, they maintained their performance at the beginning of retest and demonstrated a highly significant 17.4% improvement by the end of the retest session, essentially identical to the 17.3% improvement seen in young participants. These strikingly similar improvements occurred despite the presence of other age-related differences, including overall slower motor speed, a lag in the appearance of sleep-dependent improvement, and an absence of correlations between overnight improvement and sleep architecture or sleep spindle density in the elderly participants.
Conclusion: These findings provide compelling evidence that sleep optimizes motor skill performance across the adult life span.
Kevin’s Comments: Sleep disorders are common among older adults. The high prevalence of medical and psychosocial conditions such as arthritis, sleep apnea, anxiety, and depression are contributing causes. Medications can also have effects on sleep. High blood pressure, cardiovascular and cerebrovascular diseases, and depression are more likely in persons with sleep disorders. This study demonstrates that sleep optimizes motor performance in older adults to levels proportional to those seen in healthy young persons. Sleep problems require a thorough evaluation with interventions targeted to contributing causes.
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