Trends in COVID-19 cases, deaths, and staffing shortages in US nursing homes by rural and urban status.

The purpose of the study was to examine trends in COVID-19 cases, related deaths, and staffing shortages in nursing homes (NH) by rural and urban status from May 2020 to Feb 2021. Generalized linear mixed models with state-fixed effects were used to estimate the interaction effect of study period and rural/urban status on having at least: one COVID-19 case, one related death, and/or at least one week of staffing shortage using the NH COVID-19 data spanning the 40-week period. The findings revealed shortages in staff, particularly direct care providers, were greatly accelerated in rural NHs as the pandemic wore on over time. Conversely, staffing shortages in urban NHs were relatively stable despite the fluctuating COVID-19 cases over the same time period. The findings highlight the need of identifying effective strategies that prevent rural NHs from encountering staffing deficits in response to long-lasting natural disasters such as the COVID-19 pandemic.

Nursing Home Administrator's Job Satisfaction, Work Stressors, and Intent to Leave.

This study examines how job satisfaction in six subscales and select stressors and demographic covariates influence nursing home administrator's (NHA) intentions to quit. Quantitative and qualitative data were collected from 311 NHAs in five states. Adjusted odds ratios and 95% confidence intervals for the ordered logistic regression models indicated that NHAs with satisfying work demands, rewards, and coworkers, and who experienced less role conflict and had fewer prior nursing home jobs had lower turnover intentions. Although generally satisfied, roughly 24% reported intending to quit. Surprisingly, NHAs reporting higher job skills were more likely to consider leaving, suggesting that talented NHAs may choose career advancement eased by stigma-free job-hopping in an industry with high mobility norms. Qualitative data suggested that job satisfaction/dissatisfaction was influenced by a more nuanced interpretation of satisfying and more taxing job facets and quitting triggers, including themes such as helping residents and struggling with regulations.

Nurse Staffing and Skill Mix Patterns in Relation to Resident Care Outcomes in US Nursing Homes.

OBJECTIVES: The purpose of this study was to identify patterns of nurse staffing and skill mix and estimate the impact of these patterns on rehospitalization and emergency department (ED) visits in nursing home (NH) residents. We also estimated the relative contribution of unique staffing patterns on variations in hospital and ED use rates. DESIGN: Retrospective secondary data analysis at the facility level, using administrative data. SETTING AND PARTICIPANTS: Data from Medicare/Medicaid certified NHs in the 2018 Certification and Survey Provider Enhanced Reporting System were merged with the NH Compare Claims-Based Quality Measures file, for those facilities with complete data available (N = 14,325). METHODS: Cluster analysis was performed to identify groups of NHs with similar nursing skill mix patterns, using measures that captured hours per resident day (HPRD) for registered nurses (RNs), licensed practical nurses (LPNs), and certified nursing assistants (CNAs). We estimated the impact of cluster assignment on unplanned rehospitalization and ED visits using multivariate generalized estimating equations. Plots were generated to visualize simulation models that showed the relative contribution of unique staffing strategies to the outcomes, while holding other factors constant. RESULTS: We identified 3 nursing skill mix clusters: high-RN, high-LPN, and high-CNA, relative to national staffing averages. After controlling for regional and organizational characteristics, residents in NHs in the high-RN cluster had significantly lower rehospitalization and ED use compared with those in the high-LPN cluster, with a similar nonsignificant trend for the high-CNA vs high-LPN clusters. Though the high-RN cluster had CNA HPRD similar to the high-CNA cluster, it relied much less on LPN staffing. Whereas NHs in the high-LPN cluster had proportionally fewer hours of care by both CNAs and RNs. CONCLUSIONS AND IMPLICATIONS: NHs that emphasize LPN care in place of either RN or CNA care appears to exhibit higher rates of unplanned rehospitalization and ED visits among residents.

Speech-Language Pathologists' Comfort Providing Intervention to Children With Traumatic Brain Injury: Results From a National Survey.

Purpose This exploratory study examined speech-language pathologists' (SLPs) clinical experience and work environment characteristics impacting comfort with providing intervention to children with traumatic brain injury (TBI). Method This study included 162 SLPs who responded to a national survey about their comfort providing intervention to children with TBI, clinical experience (i.e., years of experience treating children with TBI, TBI preprofessional training and professional development, and licensure/credentialing), and work environment (i.e., work setting, caseload size, geographic location). Results Findings from latent class analysis revealed 3 distinct groups of SLPs based on their comfort with providing services to children with TBI: those with low comfort, moderate comfort, and high comfort. Further analyses revealed statistically significant differences across the 3 groups in the areas of years of experience treating children with TBI, professional development, work setting, TBI caseload size, and geographic location. Conclusions Our findings reveal that most SLPs feel comfortable providing intervention to children with TBI; however, differences in characteristics across groups suggest that specific steps can be taken to ensure increased comfort for all SLPs working with this population. Practicing SLPs may increase their level of comfort through professional development and hands-on, mentored experience with TBI. Efforts such as these may influence the quality of service provision and expand the population of SLPs who feel comfortable treating children with TBI. Future research is needed to further examine how comfort and SLP characteristics directly impact the quality of speech and language intervention and long-term outcomes of children with TBI.

Increasing Rates of Opioid Misuse Among Older Adults Visiting Emergency Departments.

OBJECTIVE: This study sought to investigate factors associated with opioid misuse-related emergency department (ED) visits among older adults and changes in outcomes associated with these visits, using multiple years of nationally representative data. METHODS: A retrospective analysis of the Nationwide Emergency Department Sample was conducted. Study inclusion was limited to adults aged 65 years and older. Diagnostic codes were used to identify opioid misuse disorder; sampling weights were used to adjust standard estimates of the errors. Descriptive and multivariate procedures were used to describe risk and visit outcomes. RESULTS: ED visits by older adults with opioid misuse identified in the ED increased sharply from 2006 to 2014, representing a nearly 220% increase over the study period. Opioid misuse was associated with an increased number of chronic conditions, greater injury risk, and higher rates of alcohol dependence and mental health diagnoses. CONCLUSION: The steep increase in opioid misuse observed among older adult ED visits underscores the critical need for additional research to better understand the national scope and impact of opioid misuse on older adults, as well as to better inform policy responses to meet the needs of this particular age group.

Object play in infants with autism spectrum disorder: A longitudinal retrospective video analysis.

BACKGROUND AND AIMS: Early play behaviors may provide important information regarding later-diagnosed developmental delays. Play behaviors of young children with autism spectrum disorder (ASD) are restricted in diversity, frequency, and complexity. Most ASD research focuses on play in children over 18 months of age. This study examined three groups of infants (later diagnosed with ASD, later diagnosed with other developmental disorders, and typically developing) with the aims of: (1) describing the play behaviors of the three groups of infants at two time points (9-12 months and 15-18 months); (2) examining group differences in four hierarchical levels of play at both time points; (3) comparing groups with respect to the highest level of play achieved; and (4) determining if the highest level of play achieved by infants with developmental delays, including ASD, correlated with later developmental outcomes. METHODS: The current study used longitudinal retrospective video analysis to examine object play behaviors of the three groups of infants (total n=92) at two time points (time 1: 9-12 months of age, and time 2: 15-18 months of age). Coding of play behaviors was based on existing literature and distribution of data from the current study. Developmental outcomes examined were measured using the Vineland Adaptive Behavior Scales, Childhood Autism Rating Scale, and a non-verbal developmental quotient calculated using visual reception scores from the Mullen Scales for Early Learning. RESULTS: Results indicate group differences in play, with infants later diagnosed with ASD showing significantly less sophisticated play than those with typical development. In addition, modest but significant correlations were found between highest level of play achieved at time 2 (15-18 months) and later outcomes for those with developmental disorders, including ASD. CONCLUSIONS AND IMPLICATIONS: Results suggest that examination of infant play behaviors is important for early screening and intervention planning to potentially mitigate effects on later developmental outcomes.

Investigating the long-term consequences of adverse medical events among older adults.

OBJECTIVE: To investigate the long-term effect of medically serious adverse medical events (AMEs) among older adults. METHODS: We linked nationally representative survey and claims data from the Medicare Current Beneficiary Survey (1998-2004) with non-response files (1999-2005) and the Area Resource File, providing 12,541 beneficiaries with 428,373 person-months for analysis. Latent class analysis was used to assign severity status to episodes. Multinomial logistic regression was used to identify AME risk factors. The long-term consequences of AMEs on Medicare expenditures were examined by population average models. Survival analyses examined the long-term risk of death. RESULTS: Nearly 19% of participants experienced at least one AME, with 62% from outpatient claims. The risk of AMEs is greater among participants in poorer health, and increases with comorbidity and with impairment in performing activities of daily living or instrumental activities of daily living. Medicare expenditures during an AME episode increased sharply and remained higher than what would have otherwise been expected in quarters following an AME episode, and failed to return to pre-AME expenditure levels. Differences in survival rates were observable long after the AME episode concluded, with only 55% of the patients sustaining an AME surviving to the end of the study. In contrast, nearly 80% of those without an AME were estimated to have survived. CONCLUSIONS: The impacts of AMEs are observable over extended periods of time and are associated with considerable excess mortality and costs. Efforts to monitor and prevent AMEs in both acute care and outpatient settings are warranted.

ED use by older adults attempting suicide.

OBJECTIVE: The objective of this study was to describe patterns of older adult patient visits to emergency departments (EDs) for self-harm and suicide-related injuries. METHODS: A retrospective, secondary data analysis of the Nationwide Emergency Department Sample was conducted. Nationally representative estimates of patient visits by older adults attempting suicide were calculated using available sampling weights. Population estimates were calculated using estimates from the US Census Bureau. RESULTS: Findings suggest that 22,444 ED patient visits were made by adults aged 65 years and older for suicide-related injuries, representing an estimated population rate of 63 ED patient visits per 100000 adults aged 65 years and older, with nearly half of all visits involving substance use. Total ED and hospital charges exceeded $353.9 million. CONCLUSIONS: Effort is needed to better integrate and deliver suicide screening and support services in the ED, while also connecting at-risk older adults with mental health services before and after the ED encounter.

Risk of mortality and nursing home institutionalization after injury.

OBJECTIVES: To evaluate the effects of unintentional injuries on the risks of nursing home institutionalization and mortality in older adults. DESIGN: A retrospective analysis of data from the Medicare Current Beneficiary Survey, a nationally representative survey of Medicare beneficiaries. SETTING: Noninstitutionalized community residents. PARTICIPANTS: Older adult panel members (N = 12,031) with continuous Medicare eligibility not enrolled in managed care in a cohort starting between 1998 and 2001. MEASUREMENTS: Cox regression and competing risk survival models were estimated using time-varying injury-status dummy variables and control variables for outcomes measured as time until death and institutionalization, respectively. RESULTS: Almost 4% of persons were institutionalized, 15% died, 14% had a sentinel injury, and 3% had two or more minor nonsentinel injuries within 1-year period. Persons hospitalized for sentinel injury had elevated institutionalization and mortality risks during an injury episode and after the episode ended. Persons receiving outpatient treatment for sentinel injuries had elevated institutionalization risk during injury episodes (subhazard ratio [SHR] = 6.78, 95% confidence interval [CI] = 3.72-12.37) and elevated mortality risk after episodes (hazard ratio [HR] = 1.60, 95% CI = 1.28-2.00). Persons with multiple minor nonsentinel injuries within a year also had elevated mortality (HR = 1.56, 95% CI = 1.15-2.11) and institutionalization (SHR = 3.55, 95% CI = 2.25-5.67) risks. CONCLUSION: Mortality and institutionalization risks extend well beyond the acute episode of treatment for sentinel and repeated minor injuries. More research is needed on longer-term health outcomes of injury survivors to inform development of evidence-based quality-of-care indicators.

The effect of sentinel injury on Medicare expenditures over time.

OBJECTIVES: To examine the long-term effect of sentinel injury (unintentional injury involving serious health-related consequences) among older adults on Medicare expenditures. DESIGN: Secondary data analysis of the Medicare Current Beneficiary Survey, a nationally representative survey of Medicare Beneficiaries. SETTING: Noninstitutionalized community dwellers. PARTICIPANTS: Older adults (N = 12,318) continuously enrolled in Medicare Fee-for-Service under Old Age Survivors Insurance Benefits surveyed between October 1998 and December 2004. MEASUREMENTS: Monthly total Medicare expenditures served as the dependent variable. Injury status (preinjury, injury episode, postinjury) was identified from Medicare claims and specified as a set of dummy variables. Injury episodes began with the first index injury claim identified and ended when no further injury claims were found within 180 days. Population-averaged models using generalized estimating equation techniques were estimated to explore changes in Medicare expenditures over time after adjusting for casemix differences. A case-crossover design was used to compare monthly Medicare expenditures before and after sentinel injury events. RESULTS: Fifteen percent of beneficiaries sustained at least one sentinel injury. Medicare expenditures increased sharply during sentinel injury episodes (ß = 1.703, P < .001) and remained at least 28% higher than would otherwise be expected for 27 uninterrupted months following injury. Additive Medicare expenditures associated with sentinel injury over 3 years were estimated at $28,885. CONCLUSION: Consequences of sentinel injury in older adults extend well beyond the period typically considered to be an acute injury episode. Better understanding of the long-term consequences of injury-related outcomes is needed to achieve public health goals of reducing injury and improving injury-related medical care.

Implications of conducting trend analyses of emergency department visits using publicly released masked design variables.

STUDY OBJECTIVE: We examine whether using public National Hospital Ambulatory Medical Care Survey (NHAMCS) data with masked design variables produces different estimates, standard errors, and confidence intervals (CIs) for the temporal trend of overall and injury-related emergency department (ED) visits compared with using unmasked data housed at the Centers for Disease Control and Prevention. METHODS: We obtained counts of ED visits with their standard errors for unmasked data from published summaries from 1999 through 2006. Public files with masked design variables were used to estimate visit counts and rates with standard errors for each year, using the Taylor series linearization method. Weighted least squares linear regressions were used for trend analysis to estimate the annual change in visits. RESULTS: Compared with using unmasked data, using masked data produced similar estimates of overall ED visit counts and rates for each year from 1999 through 2006 but overestimated standard errors by 27% on average (range 12% to 45%). According to unmasked data, overall ED visit counts increased by 1.973 million annually (standard error 0.747; 95% CI 0.505 to 3.440 million [corrected] ). With masked data, the estimated change was 1.977 million visits annually (standard error 0.894; 95% CI -0.221 to 3.733 million [corrected] ). As for injury-related ED visit counts, masked data overestimated the standard error by 16% for trend. Although neither unmasked nor masked data suggested a statistically significant annual increase of overall or injury-related ED visit rate, masked data overestimated the standard error by 16%. CONCLUSION: Using masked public data overestimated standard errors for trend of counts and rates for overall and injury-related ED visits and resulted in wider CIs.

Principles of good care for long-term care facilities.

BACKGROUND: The International Psychogeriatric Association Task Force on Mental Health Services in Long-Term Care Facilities aims to support and strengthen mental health services in the long-term care sector. The purpose of this paper is to identify broad principles that may underpin the drive towards meeting the mental health needs of residents of long-term care facilities and their families, as well as to enhance the overall delivery of residential care services. METHODS: Principles of good care are extrapolated from an analysis of international consensus documents and existing guidelines and discussed in relation to the research and practice literature. RESULTS: Although the attention to principles is limited, this review reveals an emerging consensus that: (1) residential care should be situated within a continuum of services which are accessible on the basis of need; (2) there should be an explicit focus on quality of care in long-term care facilities; and (3) quality of life for the residents of these facilities should be a primary objective. We take a broad perspective on the challenges associated with actualizing each of these principles, taking into consideration key issues for families, facilities, systems and societies. CONCLUSIONS: Recommendations for practice, policy and advocacy to establish an internationally endorsed principles-based framework for the evolution and development of good mental health care within long-term care facilities are provided.

ATV deaths among older adults in West Virginia: evidence suggesting that "60 is the new 40!".

OBJECTIVES: Describe the epidemiology of all-terrain vehicle (ATV) deaths among persons > or =65 years of age in West Virginia from 1999-2007. MATERIAL AND METHODS: We conducted a review of death certificates identifying ATV fatalities from ICD-10 diagnostic codes V86.0, V86.1, V86.3, V86.5, V86.6, and V86.9. RESULTS: ATV deaths increased 155% from 11% during 1985-1998 to 28% during 1999-2007. Injuries to the upper and lower trunk (62%) were the most common injuries, followed by head and neck injuries (28%). Fatality rates increased substantially from 0.37 deaths per 100,000 in 1990 to 2.14 in 2007, with a twofold increase from 1.08 to 2.14 noted from 2005 to 2007. CONCLUSION: An increase in the number of ATV riders and fatality patterns among older adults suggests an increasing propensity for older adults to engage in activities associated most often with younger age groups. Safety and training efforts sensitive to the specific needs of older ATV drivers is warranted.

Characteristics and outcomes of injury-related ED visits among older adults.

OBJECTIVES: The objectives of this study were to examine the epidemiology of injury among older adults treated in emergency departments (EDs) and to explore the effect of advanced age and nursing home residence on associated outcomes. METHODS: A secondary data analysis of a nationally representative sample from the National Hospital Ambulatory Care Survey was conducted using available sampling weights and data from the US Census Bureau. Weighted multivariate logistic regression was used to explore factors associated with injury outcomes, including hospitalization and receipt of potentially inappropriate medications. RESULTS: Nearly 21 million injury-related ED patient visits were made by older adults during the study period. Nearly 10% of episodes were identified as adverse events, which increased hospitalization risk 3-fold. Potentially inappropriate medications were provided during nearly 12% of encounters. CONCLUSIONS: Injury reductions among elders could be achieved by reducing adverse events, whereas quality could be improved by reducing potentially inappropriate medication use in the ED.

ED visits by older adults for ambulatory care-sensitive and supply-sensitive conditions.

OBJECTIVES: The aim of this study was to examine the effect of advanced age on ED outcomes, including hospitalization for any reason, ambulatory care-sensitive hospitalizations (ACSHs), and supply-sensitive hospitalizations. METHODS: A secondary data analysis of the National Hospital Ambulatory Care Survey was conducted. National estimates of patient visits were obtained using available sampling weights from National Hospital Ambulatory Care Survey, and population estimates were calculated using estimates published by the US Census Bureau. RESULTS: Older adults made 48 million patient visits to ED between 2000 and 2002. Overall, 20.3% was for an ambulatory care-sensitive condition, yielding 5 million ACSH, whereas 62% was for a supply-sensitive condition, yielding 9.5 million supply-sensitive hospitalizations. Residents from nursing homes and patients aged 85 years or older were more likely to be hospitalized for any reason, for ACSH, and for supply-sensitive conditions. CONCLUSIONS: Further research is needed to understand how comorbidity contributes to increasing ED and hospital use among older adults.

Nursing home performance on select publicly reported quality indicators and resident risk of hospitalization: grappling with policy implications.

This study examines how resident risk of hospitalization varies in relation to facility performance on select quality indicators (QIs). Using a 15% sample, three years of Medicaid reimbursement data from over 525 nursing homes (NHs) were linked with four years of hospital claims data and facility-level data to investigate whether residents of NHs with worse (better) than expected performance on QIs experienced increased (decreased) risk of hospitalization. Logistic regression results indicate that variations in hospitalization risk among NH residents are explained in part by facility performance on QIs. Residents from NHs with more decubitus ulcers, with greater use of physical restraints, and with a higher than expected incidence of unexplained weight loss/gain experienced increased risk of hospitalization.

The effect of direct-to-consumer advertising on prescription drug use by older adults.

BACKGROUND AND OBJECTIVE: Although older adults are frequent consumers of prescription drugs and increasingly the intended audience of direct-to-consumer advertising (DTCA) marketing efforts, little is known about the effect of DTCA on older adults' prescription drug-seeking behaviour. In response, the objective of this study is to examine factors associated with requesting a prescription drug from a physician following exposure to DTCA among older adults, and whether the drug or other medical treatment was prescribed during the encounter. METHODS: A secondary data analysis of the "Public Health Impact of Direct-to-Consumer Advertising of Prescription Drugs", a data set publicly available through the Inter-university Consortium for Political and Social Research (ICPSR 3687), was conducted. For the purposes of this study, only those respondents who indicated that they had been exposed to DTCA (n = 2601) were included in the study sample. Using a two-step weighted logistic regression approach, separate models were estimated to examine first, whether a request for the advertised drug was made following exposure to DTCA and secondly, the outcomes of any patient-physician encounters that occurred following exposure to DTCA. RESULTS: Descriptive analysis of the outcome variables revealed that, among respondents exposed to DTCA, 31% (n = 801) requested a prescription drug from their physician. Approximately 5% of those who made a request were > or =75 years of age. Among respondents requesting a prescription drug, 69% (n = 556) received a prescription in response to their request, of whom, approximately 5% were > or =75 years of age. Multivariate findings suggest that although adults > or =75 years of age are less likely to request a prescription drug following exposure to DTCA (odds ratio [OR] = 0.58; p = 0.032), when they do approach their physicians, they are more likely to receive recommendations for further treatment, with ORs indicating a 250% (OR = 3.507; p = 0.002) increase in the odds of further referral among adults > or =75 years of age. CONCLUSION: Overall, results from the study suggest that DTCA influences the patient-doctor relationship and prescription drug acquisition behaviour of patients; however, the nature of the effect of DTCA on older adults is complex. Because future cohorts of older adults may be more comfortable about requesting prescription drugs and the consumer-driven approach to obtaining medical care, understanding the impact of DTCA on older consumers represents an important area for further inquiry.

Emerging services for community-based long-term care in urban China: a systematic analysis of Shanghai's community-based agencies.

China's rapid economic reforms, coupled with the changes in age composition of the demographic structure, have greatly affected the traditional family support system. In response to these changes, efforts to develop new models of community-based long-term care (CBLTC) for elders in China have received growing attention. This paper provides a systematic analysis of the current status of emerging CBLTC systems in Shanghai, China. It covers several domains of the system: service delivery, workforce, financing, and quality of care management. Several main issues involved in the development of the emerging system are addressed, and relevant policy implications are presented in the paper.

Perceived barriers to health care access among rural older adults: a qualitative study.

CONTEXT: Many rural elders experience limited access to health care. The majority of what we know about this issue has been based upon quantitative studies, yet qualitative studies might offer additional insight into individual perceptions of health care access. PURPOSE: To examine what barriers rural elders report when accessing needed health care, including how they cope with the high cost of prescription medication. METHODS: During Spring 2001, thirteen 90-minute focus groups were conducted in 6 rural West Virginia communities. A total of 101 participants, aged 60 years and older, were asked several culminating questions about their perceptions of health care access. FINDINGS: Five categories of barriers to health care emerged from the discussions: transportation difficulties, limited health care supply, lack of quality health care, social isolation, and financial constraints. In addition, 6 diverse coping strategies for dealing with the cost of prescription medication were discussed. They included: reducing dosage or doing without, limiting other expenses, relying on family assistance, supplementing with alternative medicine, shopping around for cheapest prices, and using the Veteran's Administration. CONCLUSIONS: Overall, rural older adults encounter various barriers to accessing needed health care. Qualitative methodology allows rural elders to have a voice to expound on their experiences. Research can contribute valuable information to shape policy by providing a forum where older adults can express their concerns about the current health care delivery system.