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      Potentially Avoidable Hospitalizations of Nursing Home Residents: Frequency, Causes, and Costs : [See editorial comments by Drs. Jean F. Wyman and William R. Hazzard, pp 760-761]

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          Abstract

          To examine the frequency and reasons for potentially avoidable hospitalizations of nursing home (NH) residents. Medical records were reviewed as a component of a project designed to develop and pilot test clinical practice tools for reducing potentially avoidable hospitalization. NHs in Georgia. In 10 NHs with high and 10 with low hospitalization rates, 10 hospitalizations were randomly selected, including long- and short-stay residents. Ratings using a structured review by expert NH clinicians. Of the 200 hospitalizations, 134 (67.0%) were rated as potentially avoidable. Panel members cited lack of on-site availability of primary care clinicians, inability to obtain timely laboratory tests and intravenous fluids, problems with quality of care in assessing acute changes, and uncertain benefits of hospitalization as causes of these potentially avoidable hospitalizations. In this sample of NH residents, experienced long-term care clinicians commonly rated hospitalizations as potentially avoidable. Support for NH infrastructure, clinical practice and communication tools for health professionals, increased attention to reducing the frequency of medically futile care, and financial and other incentives for NHs and their affiliated hospitals are needed to improve care, reduce avoidable hospitalizations, and avoid unnecessary healthcare expenditures in this population.

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          Most cited references18

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          Beyond advance directives: importance of communication skills at the end of life.

          Patients and their families struggle with myriad choices concerning medical treatments that frequently precede death. Advance directives have been proposed as a tool to facilitate end-of-life decision making, yet frequently fail to achieve this goal. In the context of the case of a man with metastatic cancer for whom an advance directive was unable to prevent a traumatic death, I review the challenges in creating and implementing advance directives, discuss factors that can affect clear decision making; including trust, uncertainty, emotion, hope, and the presence of multiple medical providers; and offer practical suggestions for physicians. Advance care planning remains a useful tool for approaching conversations with patients about the end of life. However, such planning should occur within a framework that emphasizes responding to patient and family emotions and focuses more on goals for care and less on specific treatments.
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            Effect of a clinical pathway to reduce hospitalizations in nursing home residents with pneumonia: a randomized controlled trial.

            Nursing home residents with pneumonia are frequently hospitalized. Such transfers may be associated with multiple hazards of hospitalization as well as economic costs. To assess whether using a clinical pathway for on-site treatment of pneumonia and other lower respiratory tract infections in nursing homes could reduce hospital admissions, related complications, and costs. A cluster randomized controlled trial of 680 residents aged 65 years or older in 22 nursing homes in Hamilton, Ontario, Canada. Nursing homes began enrollment between January 2, 2001, and April 18, 2002, with the last resident follow-up occurring July 4, 2005. Residents were eligible if they met a standardized definition of lower respiratory tract infection. Treatment in nursing homes according to a clinical pathway, which included use of oral antimicrobials, portable chest radiographs, oxygen saturation monitoring, rehydration, and close monitoring by a research nurse, or usual care. Hospital admissions, length of hospital stay, mortality, health-related quality of life, functional status, and cost. Thirty-four (10%) of 327 residents in the clinical pathway group were hospitalized compared with 76 (22%) of 353 residents in the usual care group. Adjusting for clustering of residents in nursing homes, the weighted mean reduction in hospitalizations was 12% (95% confidence interval [CI], 5%-18%; P = .001). The mean number of hospital days per resident was 0.79 in the clinical pathway group vs 1.74 in the usual care group, with a weighted mean difference of 0.95 days per resident (95% CI, 0.34-1.55 days; P = .004). The mortality rate was 8% (24 deaths) in the clinical pathway group vs 9% (32 deaths) in the usual care group, with a weighted mean difference of 2.9% (95% CI, -2.0% to 7.9%; P = .23). There were no significant differences between the groups in health-related quality of life or functional status. The clinical pathway resulted in an overall cost savings of US 1016 dollars per resident (95% CI, 207 dollars-1824 dollars) treated. Treating residents of nursing homes with pneumonia and other lower respiratory tract infections with a clinical pathway can result in comparable clinical outcomes, while reducing hospitalizations and health care costs. clinicaltrials.gov Identifier: NCT00157612.
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              Nursing home characteristics and potentially preventable hospitalizations of long-stay residents.

              To examine the association between having a nurse practitioner/physician assistant (NP/PA) on staff, other nursing home (NH) characteristics, and the rate of potentially preventable/avoidable hospitalizations of long-stay residents, as defined using a list of ambulatory care-sensitive (ACS) diagnoses. Cross-sectional prospective study using Minimum Data Set (MDS) assessments, Centers for Medicare and Medicaid Services inpatient claims and eligibility records, On-line Survey Certification Automated Records, (OSCAR) and Area Resource File (ARP). Freestanding urban NHs in Maine, Kansas, New York, and South Dakota. Residents of 663 facilities with a quarterly or annual MDS assessment in the 2nd quarter of 1997, who had a prior MDS assessment at least 160 days before, and who were not health maintenance organization members throughout 1997 (N=54,631). A 180-day multinomial outcome was defined as having any hospitalization with primary ACS diagnosis, otherwise having been hospitalized, otherwise died, and otherwise remained in the facility. Multilevel models show that facilities with NP/PAs were associated with lower hospitalization rates for ACS conditions (adjusted odds ratio (AOR)=0.83), but not with other hospitalizations. Facilities with more physicians were associated with higher ACS hospitalizations (ACS, AOR=1.14, and non-ACS, AOR=1.10). Facilities providing intravenous therapy, and those that operate a nurses' aide training program were associated with fewer hospitalizations of both types. Employment of NP/PAs in NHs, the provision of intravenous therapy, and the operation of certified nurse assistant training programs appear to reduce ACS hospitalizations, and may be feasible cost-saving policy interventions.
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                Author and article information

                Journal
                Journal of the American Geriatrics Society
                Wiley
                00028614
                April 2010
                April 2010
                April 01 2010
                : 58
                : 4
                : 627-635
                Article
                10.1111/j.1532-5415.2010.02768.x
                20398146
                2e1124c8-24c7-4967-9544-a8adddfbcfd7
                © 2010

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