Shed-MEDS: pilot of a patient-centered deprescribing framework reduces medications in hospitalized older adults being transferred to inpatient postacute care.

BACKGROUND: Polypharmacy is common in hospitalized older adults. Deprescribing interventions are not well described in the acute-care setting. The objective of this study was to describe a hospital-based, patient-centered deprescribing protocol (Shed-MEDS) and report pilot results. METHODS: This was a pilot study set in one academic medical center in the United States. Participants consisted of a convenience sample of 40 Medicare-eligible, hospitalized patients with at least five prescribed medications. A deprescribing protocol (Shed-MEDS) was implemented among 20 intervention and 20 usual care control patients during their hospital stay. The primary outcome was the total number of medications deprescribed from hospital enrollment. Deprescribed was defined as medication termination or dose reduction. Enrollment medications reflected all prehospital medications and active in-hospital medications. Baseline characteristics and outcomes were compared between the intervention and usual care groups using simple logistic or linear regression for categorical and continuous measures, respectively. RESULTS: There was no significant difference between groups in mean age, sex or Charlson comorbidity index. The intervention and control groups had a comparable number of medications at enrollment, 25.2 (±6.3) and 23.4 (±3.8), respectively. The number of prehospital medications in each group was 13.3 (±4.6) and 15.3 (±4.6), respectively. The Shed-MEDS protocol compared with usual care significantly increased the mean number of deprescribed medications at hospital discharge and reduced the total medication burden by 11.6 versus 9.1 (p = 0.032) medications. The deprescribing intervention was associated with a difference of 4.6 [95% confidence interval (CI) 2.5-6.7, p < 0.001] in deprescribed medications and a 0.5 point reduction (95% CI -0.01 to 1.1) in the drug burden index. CONCLUSIONS: A hospital-based, patient-centered deprescribing intervention is feasible and may reduce the medication burden in older adults.

Potentially Avoidable Readmissions of Patients Discharged to Post-Acute Care: Perspectives of Hospital and Skilled Nursing Facility Staff.

BACKGROUND: Hospital readmissions from skilled nursing facilities (SNFs) are common. Previous research has not examined how assessments of avoidable readmissions differ between hospital and SNF perspectives. OBJECTIVES: To determine the percentage of readmissions from post-acute care that are considered potentially avoidable from hospital and SNF perspectives. DESIGN: Prospective cohort study. SETTING: One academic medical center and 23 SNFs. PARTICIPANTS: We included patients from a quality improvement trial aimed at reducing hospital readmissions among patients discharged to SNFs. We included Medicare patients who were discharged to one of 23 regional SNFs between January 2013 and January 2015, and readmitted to the hospital within 30 days. MEASUREMENTS: Hospital-based physicians and SNF-based staff performed structured root-cause analyses (RCA) on a sample of readmissions from a participating SNF to the index hospital. RCAs reported avoidability and factors contributing to readmissions. RESULTS: The 30-day unplanned readmission rate to the index hospital from SNFs was 14.5% (262 hospital readmissions of 1,808 discharges). Of the readmissions, 120 had RCA from both the hospital and SNF. The percentage of readmissions rated as potentially avoidable was 30.0% and 13.3% according to hospital and SNF staff, respectively. Hospital and SNF ratings of potential avoidability agreed for 73.3% (88 of the 120 readmissions), but readmission factors varied between settings. Diagnostic problems and improved management of changes in conditions were the most common avoidable readmission factors by hospitals and SNFs, respectively. CONCLUSION: A substantial percentage of hospital readmissions from SNFs are rated as potentially avoidable. The ratings and factors underlying avoidability differ between hospital and SNF staff. These data support the need for joint accountability and collaboration for future readmission reduction efforts between hospitals and their SNF partners.

Preventability of Hospital Readmissions From Skilled Nursing Facilities: A Consumer Perspective.

Purpose of the Study: A structured interview was conducted with Medicare patients readmitted to a private, tertiary teaching hospital from skilled nursing facilities (SNFs) to assess their perspectives of readmission preventability and their role in the readmission. Design and Methods: Data were collected at Vanderbilt University Medical Center using a 6-item interview administered at the bedside to Medicare beneficiaries with unplanned hospital readmissions from 23 SNFs within 60 days of a previous hospital discharge. Mixed analytical methods were applied, including a content analysis that evaluated factors contributing to hospital readmission as perceived by consumers. Results: Among 208 attempted interviews, 156 were completed, of which 53 (34%) respondents rated their readmission as preventable. 28.3% of the 53 consumers attributed the readmission to hospital factors, 52.8% attributed it to the SNF, and 18.9% believed both sites could have prevented the readmission. The primary driver of the readmission was a family member/caregiver in 31 cases and the patient in 24 of the 156 cases, amounting to 55 (35.3%) consumer-driven readmissions. Contributing factors included: premature hospital discharge (16.3%); poor discharge planning (16.3%); a clinical issue not resolved in the hospital (14.3%); inadequate treatment at the SNF (69.4%); improper medication management at the SNF (20.4%); and poor decision-making regarding the transfer (14.3%). Conclusions and Implications: Interviewing readmitted patients provides information relevant to reducing readmissions that may otherwise be omitted from hospital and SNF records. Consumers identified quality issues at both the hospital and SNF and perceived themselves as initiating a significant number of readmissions.

Medications associated with geriatric syndromes and their prevalence in older hospitalized adults discharged to skilled nursing facilities.

BACKGROUND: More than half of the hospitalized older adults discharged to skilled nursing facilities (SNFs) have more than 3 geriatric syndromes. Pharmacotherapy may be contributing to geriatric syndromes in this population. OBJECTIVES: Develop a list of medications associated with geriatric syndromes and describe their prevalence in patients discharged from acute care to SNFs. DESIGN: Literature review and multidisciplinary expert panel discussion, followed by cross-sectional analysis. SETTING: Academic medical center in the United States PARTICIPANTS: One hundred fifty-four hospitalized Medicare beneficiaries discharged to SNFs. MEASUREMENTS: Development of a list of medications that are associated with 6 geriatric syndromes. Prevalence of the medications associated with geriatric syndromes was examined in the hospital discharge sample. RESULTS: A list of 513 medications was developed as potentially contributing to 6 geriatric syndromes: cognitive impairment, delirium, falls, reduced appetite or weight loss, urinary incontinence, and depression. Medications included 18 categories. Antiepileptics were associated with all syndromes, whereas antipsychotics, antidepressants, antiparkinsonism, and opioid agonists were associated with 5 geriatric syndromes. In the prevalence sample, patients were discharged to SNFs with an overall average of 14.0 (±4.7) medications, including an average of 5.9 (±2.2) medications that could contribute to geriatric syndromes, with falls having the most associated medications at discharge at 5.5 (±2.2). CONCLUSIONS: Many commonly prescribed medications are associated with geriatric syndromes. Over 40% of all medications ordered upon discharge to SNFs were associated with geriatric syndromes and could be contributing to the high prevalence of geriatric syndromes experienced by this population. Journal of Hospital Medicine 2016;11:694-700. © 2016 Society of Hospital Medicine.

Pain and Satisfaction With Pain Management Among Older Patients During the Transition From Acute to Skilled Nursing Care.

PURPOSE: Approximately 20% of hospitalized Medicare beneficiaries are discharged from the hospital to skilled nursing facilities (SNFs); and up to 23% of SNF patients return to the hospital within 30 days of hospital discharge, with pain as one of the most common symptoms precipitating hospital readmission. We sought to examine the prevalence of moderate to severe pain at hospital discharge to SNF, the incidence of new moderate to severe pain (relative to prehospitalization), and satisfaction with pain management among older acute care patients discharged to SNF. DESIGN AND METHODS: Structured patient interviews were conducted with 188 Medicare beneficiaries discharged to 23 area SNFs from an academic medical center. Pain level (0-10) and satisfaction with pain management were assessed upon hospital admission, discharge, and within 1 week after transition to SNF. RESULTS: There was a high prevalence of moderate to severe pain at each time point including prehospital (51%), hospital discharge (38%), and following SNF admission (53%). Twenty-eight percent of participants reported new moderate to severe pain at hospital discharge, whereas 44% reported new moderate to severe pain following SNF admission. Most participants reported being "satisfied" with their pain treatment, even in the context of moderate to severe pain. IMPLICATIONS: Moderate to severe pain is a common problem among hospitalized older adults discharged to SNF and continues during their SNF stay. Pain assessment and management should involve a specific, planned process between hospital and SNF clinicians at the point of care transition, even if patients express "satisfaction" with current pain management.