Rising to the Occasion: A National Nursing Home Study Documenting Attempts to Address Social Isolation During the COVID-19 Pandemic.

OBJECTIVES: COVID-19-related policies introduced extraordinary social disruption in nursing homes. In response, nursing facilities implemented strategies to alleviate their residents' loneliness. This study sought to describe interventions nursing homes used, document the perceived effectiveness of efforts, and determine barriers to implementing strategies to mitigate social isolation and loneliness. DESIGN: National survey of nursing homes sampled in strata defined by facility size (beds: 30-99, 100+) and quality ratings (1, 2-4, 5). SETTINGS AND PARTICIPANTS: US Nursing Home Directors of Nursing/Administrators (n = 1676). METHODS: The survey was conducted between February and May 2022 (response rate: 30%; n = 504, weighted n = 14,506). Weighted analyses provided nationally representative results. RESULTS: One-third were extremely concerned about their home's ability to meet residents' medical and social needs during COVID-19 before vaccines were available and 13% after vaccines. Nearly all reported trying to mitigate residents' social isolation during the pandemic. Efforts tried, and perceived as most useful, included using technology (tablets, phones, emails), assigning staff as a family contact, and more staff time with residents. Most frequently cited barriers to implementation were related to staffing issues. CONCLUSIONS AND IMPLICATIONS: Despite multiple challenges, nearly all nursing homes tried to implement many different approaches to address residents' social needs, with some (eg, having an assigned family contact, use of tablets and phones) perceived as more useful than others. Staffing issues presented barriers for addressing the social needs of nursing home residents. Many strategies for addressing social isolation placed more demands on a workforce already stretched to the limit. While concerns about resident social isolation reduced after vaccine availability, administrators remained extremely concerned about staff burnout and mental health.

Methodological Challenges for Epidemiologic Studies of Deprescribing at the End of Life.

PURPOSE OF REVIEW: To describe approaches to measuring deprescribing and associated outcomes in studies of patients approaching end of life (EOL). RECENT FINDINGS: We reviewed studies published through 2020 that evaluated deprescribing in patients with limited life expectancy and approaching EOL. Deprescribing includes reducing the number of medications, decreasing medication dose(s), and eliminating potentially inappropriate medications. Tools such as STOPPFrail, OncPal, and the Unnecessary Drug Use Measure can facilitate deprescribing. Outcome measures vary and selection of measures should align with the operationalized deprescribing definition used by study investigators. SUMMARY: EOL deprescribing considerations include medication appropriateness in the context of patient goals for care, expected benefit from medication given life expectancy, and heightened potential for medication-related harm as death nears. Additional data are needed on how EOL deprescribing impacts patient quality of life, caregiver burden, and out-of-pocket medication-related costs to patients and caregivers. Investigators should design deprescribing studies with this information in mind.

National Trends in Statin Use among the United States Nursing Home Population (2011-2016).

BACKGROUND: Little is known about trends in statin use in United States (US) nursing homes. OBJECTIVES: The aim of this study was to describe national trends in statin use in nursing homes and evaluate the impact of the introduction of generic statins, safety warnings, and guideline recommendations on statin use. METHODS: This study employed a repeated cross-sectional prevalence design to evaluate monthly statin use in long-stay US nursing home residents enrolled in Medicare fee-for-service using the Minimum Data Set 3.0 and Medicare Part D claims between April 2011 and December 2016. Stratified by age (65-75 years, ≥ 76 years), analyses estimated trends and level changes with 95% confidence intervals (CI) following statin-related events (the availability of generic statins, American Heart Association/American College of Cardiology guideline updates, and US FDA safety warnings) through segmented regression models corrected for autocorrelation. RESULTS: Statin use increased from April 2011 to December 2016 (65-75 years: 38.6-43.3%; ≥ 76 years: 26.5% to 30.0%), as did high-intensity statin use (65-75 years: 4.8-9.5%; ≥ 76 years: 2.3-4.5%). The introduction of generic statins yielded little impact on the prevalence of statins in nursing home residents. Positive trend changes in high-intensity statin use occurred following national guideline updates in December 2011 (65-75 years: ß = 0.16, 95% CI 0.09-0.22; ≥ 76 years: ß = 0.09, 95% CI 0.06-0.12) and November 2013 (65-75 years: ß = 0.11, 95% CI 0.09-0.13; ≥ 76 years: ß = 0.04, 95% CI 0.03-0.05). There were negative trend changes for any statin use concurrent with FDA statin safety warnings in March 2012 among both age groups (65-75 years: ß trend change = - 0.06, 95% CI - 0.10 to - 0.02; ≥ 76 years: ß trend change = - 0.05, 95% CI - 0.08 to - 0.01). The publication of the results of a statin deprescribing trial yielded a decrease in any statin use among the ≥ 76 years age group (ß level change = - 0.25, 95% CI - 0.48 to - 0.09; ß trend change = - 0.03, 95% CI - 0.04 to - 0.01), with both age groups observing a positive trend change with high-intensity statins (65-75 years: ß = 0.11, 95% CI 0.02-0.21; ≥ 76 years: ß = 0.05, 95% CI 0.01-0.09). CONCLUSION: Overall, statin use in US nursing homes increased from 2011 to 2016. Guidelines and statin-related events appeared to impact use in the nursing home setting. As such, statin guidelines and messaging should provide special consideration for nursing home populations, who may have more risk than benefit from statin pharmacotherapy.

Geographic Variation of Statin Use Among US Nursing Home Residents With Life-limiting Illness.

BACKGROUND: Medically compromised nursing home residents continue to be prescribed statins, despite questionable benefits. OBJECTIVE: To describe regional variation in statin use among residents with life-limiting illness. RESEARCH DESIGN: Cross-sectional study using 2016 Minimum Data Set 3.0 assessments linked to Medicare administrative data and health service utilization area resource files. SETTING: Nursing homes (n=14,147) within hospital referral regions (n=306) across the United States. SUBJECTS: Long-stay residents (aged 65 y and older) with life-limiting illness (eg, serious illness, palliative care, or prognosis <6 mo to live) (n=361,170). MEASURES: Prevalent statin use was determined by Medicare Part D claims. Stratified by age (65-75, 76 y or older), multilevel logistic models provided odds ratios with 95% confidence intervals. RESULTS: Statin use was prevalent (age 65-75 y: 46.0%, 76 y or more: 31.6%). For both age groups, nearly all resident-level variables evaluated were associated with any and high-intensity statin use and 3 facility-level variables (ie, higher proportions of Black residents, skilled nursing care provided, and average number of medications per resident) were associated with increased odds of statin use. Although in residents aged 65-75 years, no associations were observed, residents aged 76 years or older located in hospital referral regions (HRRs) with the highest health care utilization had higher odds of statin use than those in nursing homes in HRRs with the lowest health care utilization. CONCLUSIONS: Our findings suggest extensive geographic variation in US statin prescribing across HRRs, especially for those aged 76 years or older. This variation may reflect clinical uncertainty given the largely absent guidelines for statin use in nursing home residents.

Statin Discontinuation and Life-Limiting Illness in Non-Skilled Stay Nursing Homes at Admission.

OBJECTIVES: To estimate 30-day statin discontinuation among newly admitted nursing home residents overall and within categories of life-limiting illness. DESIGN: Retrospective cohort using Minimum Data Set 3.0 nursing home admission assessments from 2015 to 2016 merged to Medicare administrative data files. SETTING: U.S. Medicare- and Medicaid-certified nursing home facilities (n = 13,092). PARTICIPANTS: Medicare fee-for-service beneficiaries, aged 65 years and older, newly admitted to nursing homes for non-skilled nursing facility stays on statin pharmacotherapy at the time of admission (n = 73,247). MEASUREMENTS: Residents were categorized using evidence-based criteria to identify progressive, terminal conditions or limited prognoses (<6 months). Discontinuation was defined as the absence of a new Medicare Part D claim for statin pharmacotherapy in the 30 days following nursing home admission. RESULTS: Overall, 19.9% discontinued statins within 30 days of nursing home admission, with rates that varied by life-limiting illness classification (no life-limiting illness: 20.5%; serious illness: 18.6%; receipt of palliative care consult: 34.5%; clinician designated as end-of-life: 45.0%). Relative to those with no life-limiting illness, risk of 30-day statin discontinuation increased with life-limiting illness severity (serious illness: adjusted risk ratio (aRR) = 1.06; 95% confidence interval (CI) = 1.02-1.10; palliative care index diagnosis: aRR = 1.15; 95% CI = 1.10-1.21; palliative care consultation: aRR = 1.58; 95% CI = 1.43-1.74; clinician designated as end of life: aRR = 1.59; 95% CI = 1.42-1.79). Nevertheless, most remained on statins after entering the nursing home regardless of life-limiting illness status. CONCLUSION: Statin use continues in a large proportion of Medicare beneficiaries after admission to a nursing home. Additional deprescribing research, which identifies how to engage nursing home residents and healthcare providers in a process to safely and effectively discontinue medications with questionable benefits, is warranted.

Prevalence of Pain on Admission by Level of Cognitive Impairment in Nursing Homes.

PURPOSE: To provide contemporary estimates of pain by level of cognitive impairment among US nursing home residents without cancer. METHODS: Newly admitted US nursing home residents without cancer assessed with the Minimum Data Set 3.0 at admission (2010-2016) were eligible (n=8,613,080). The Cognitive Function Scale was used to categorize level of cognitive impairment. Self-report or staff-assessed pain was used based on a 5-day look-back period. Estimates of adjusted prevalence ratios (aPR) were derived from modified Poisson models. RESULTS: Documented prevalence of pain decreased with increased levels of cognitive impairment in those who self-reported pain (68.9% no/mild, 32.9% severe) and those with staff-assessed pain (50.6% no/mild, 37.2% severe staff-assessed pain). Relative to residents with no/mild cognitive impairment, pharmacologic pain management was less prevalent in those with severe cognitive impairment (self-reported: 51.3% severe vs 76.9% in those with no/mild; staff assessed: 52.0% severe vs 67.7% no/mild). CONCLUSION: Pain was less frequently documented in those with severe cognitive impairment relative to those with no/mild impairments. Failure to identify pain may result in untreated or undertreated pain. Interventions to improve evaluation of pain in nursing home residents with cognitive impairment are needed.

Cancer Pain in Relation to Metropolitan Area Segregation and Nursing Home Racial and Ethnic Composition.

OBJECTIVES: To estimate pain reporting among residents with cancer in relation to metropolitan area segregation and NH racial and ethnic composition. DESIGN: Cross-sectional study. SETTING AND PARTICIPANTS: 383,757 newly admitted black (B), Hispanic (H), or white (W) residents with cancer in 12,096 US NHs (2011-2013). METHODS: Using the Minimum Data Set 3.0, pain in past 5 days was determined by self-report or use of pain management. The Theil entropy index, a measure of metropolitan area segregation, was categorized [high (up to 0.20), very high (0.20-0.30), or extreme (0.30-0.53)]. RESULTS: Pain prevalence decreased across segregation level (black: high = 77%, very high = 75%, extreme = 72%; Hispanic: high = 79%, very high = 77%, extreme = 70%; white: high = 80%, very high = 77%, extreme = 74%). In extremely segregated areas, all residents were less likely to have recorded pain [adjusted prevalence ratios: blacks, 4.6% less likely, 95% confidence interval (CI) 3.1%-6.1%; Hispanics, 6.9% less likely, 95% CI 4.2%-9.6%; whites, 7.4% less likely, 95% CI 6.5%-8.2%] than in the least segregated areas. At all segregation levels, pain was recorded more frequently for residents (black or white) in predominantly white (>80%) NHs than in mostly black (>50%) NHs or residents (Hispanic or white) in predominantly white NHs than mostly Hispanic (>50%) NHs. CONCLUSIONS AND IMPLICATIONS: We observed decreased pain recording in metropolitan areas with greater racial and ethnic segregation. This may occur through the inequitable distribution of resources between NHs, resident-provider empathy, provider implicit bias, resident trust, and other factors.

Prevalent Statin Use in Long-Stay Nursing Home Residents with Life-Limiting Illness.

OBJECTIVES: To evaluate the prevalence and factors associated with statin pharmacotherapy in long-stay nursing home residents with life-limiting illness. DESIGN: Cross-sectional. SETTING: US Medicare- and Medicaid-certified nursing home facilities. PARTICIPANTS: Long-stay nursing home resident Medicare fee-for-service beneficiaries aged 65 years or older with life-limiting illness (n = 424 212). MEASUREMENTS: Prevalent statin use was estimated as any low-moderate intensity (daily dose low-density lipoprotein-cholesterol [LDL-C] reduction <30%-50%) and high-intensity (daily dose LDL-C reduction >50%) use via Medicare Part D claims for a prescription supply on September 30, 2016, with a 90-day look-back period. Life-limiting illness was operationally defined to capture those near the end of life using evidence-based criteria to identify progressive terminal conditions or limited prognoses (<6 mo). Poisson models provided estimates of adjusted prevalence ratios and 95% confidence intervals for resident factors. RESULTS: A total of 34% of residents with life-limiting illness were prescribed statins (65-75 y = 44.0%, high intensity = 11.1%; >75 y = 31.1%, high intensity = 5.4%). Prevalence of statins varied by life-limiting illness definition. Of those with a prognosis of less than 6 months, 23% of the 65 to 75 and 12% of the older than 75 age groups were on statins. Factors positively associated with statin use included minority race or ethnicity, use of more than five concurrent medications, and atherosclerotic cardiovascular disease or risk factors. CONCLUSION: Despite having a life-limiting illness, more than one-third of clinically compromised long-stay nursing home residents remain on statins. Although recent national guidelines have expanded indications for statins, the benefit of continued therapy in an advanced age population near the end of life is questionable. Efforts to deprescribe statins in the nursing home setting may be warranted. J Am Geriatr Soc 68:708-716, 2020.

Improving Advanced Care Planning through Physician Orders for Life-Sustaining Treatment (POLST) Expansion across the United States: Lessons Learned from State-Based Developments.

BACKGROUND: The Physician Orders for Life-Sustaining Treatment (POLST) Paradigm is an effective advance care planning tool. However, barriers to implementation persist. In the United States, POLST program development occurs at the state-level. Substantial differences between states has left POLST implementation largely unstandardized. No peer-reviewed studies to date have evaluated state-based POLST program development over time. OBJECTIVE: To assess and learn from the successes and barriers in state-based POLST program development over time to improve the reach of POLST or similar programs across the United States. DESIGN: An exploratory, prospective cohort study that utilized semistructured telephone interviews was conducted over a 3-year period (2012-2015). Stakeholder representatives from state POLST coalitions (n = 14) were repeatedly queried on time-relevant successes, barriers, and innovations during POLST program development with levels of legislative and medical barriers rated 1 to 10. Interviews were transcribed and analyzed using techniques grounded in qualitative theory. RESULTS: All coalition representatives reported continuous POLST expansion with improved outreach and community partnerships. Significant barriers to expansion included difficulty in securing funding for training and infrastructure, lack of statewide metric systems to adequately assess expansion, lack of provider support, and legislative concerns. Medical barriers (mean [standard deviation]: 5.0 [0.2]) were rated higher than legislative (3.0 [0.6]; P < .001). CONCLUSION: POLST programs continue to grow, but not without barriers. Based on the experiences of developing coalitions, we were able to identify strategies to expand POLST programs and overcome barriers. Ultimately the "lessons learned" in this study can serve as a guide to improve the reach of POLST or similar programs.

Racial Segregation Across U.S. Nursing Homes: A Systematic Review of Measurement and Outcomes.

BACKGROUND AND OBJECTIVES: Nursing homes remain subjected to institutional racial segregation in the United States. However, a standardized approach to measure segregation in nursing homes does not appear to be established. A systematic review was conducted to identify all formal measurement approaches to evaluate racial segregation among nursing home facilities, and to then identify the association between segregation and quality of care in this context. RESEARCH DESIGN AND METHODS: PubMed, Scopus, and Web of Science databases were searched (January 2018) for publications relating to nursing home segregation. Following the PRISMA guidelines, studies were included that formally measured racial segregation of nursing homes residents across facilities with regional-level data. RESULTS: Eight studies met the inclusion criteria. Formal segregation measures included the Dissimilarity Index, Disparities Quality Index, Modified Thiel's Entropy Index, Gini coefficient, and adapted models. The most common data sources were the Minimum Data Set (MDS; resident-level), the Certification and Survey Provider Enhanced Reporting data (CASPER; facility-level), and the Area Resource File/ U.S. Census Data (regional-level). Most studies showed evidence of racial segregation among U.S. nursing home facilities and documented a negative impact of segregation on racial minorities and facility-level quality outcomes. DISCUSSION AND IMPLICATIONS: The measurement of racial segregation among nursing homes is heterogeneous. While there are limitations to each methodology, this review can be used as a reference when trying to determine the best approach to measure racial segregation in future studies. Moreover, racial segregation among nursing homes remains a problem and should be further evaluated.

Screening Mammography Among Older Women: A Review of United States Guidelines and Potential Harms.

In the United States, older women (aged ≥65 years) continue to receive routine screening mammography surveillance, despite limited evidence supporting the benefits to this subpopulation. This article reviews screening mammography guidelines and the potential harms of such screening for older women in the United States. Published guidelines and recommendations on screening mammography for older women from professional medical societies and organizations in the United States were reviewed from the mid-20th century to present. Observational data were then synthesized to present the documented harms from screening mammography among older women. In 1976, the American Cancer Society recommended to screen all women aged ≥40 years with no upper age limit. With time, other major U.S. medical societies adopted their own screening guidelines without a consensus on age of screening cessation. A population-wide screening effort has largely continued without an upper age limit and with it, a growing body of literature on the harms of screening older women. Reported harms from screening mammography procedures have included physical pain, psychological distress, excessive use of health services from overdiagnoses/false positives, and undue financial expenses. These costs are particularly pronounced among special populations with limited life expectancies such as those of very advanced age ≥80 years, long-term nursing home residents, and the cognitively impaired. When potential harms, remaining life years, and the viability of available treatments are considered, the burdens of screening mammography often outweigh the benefits for older women. For some cases, an individualized approach to recommendations would be appropriate. National guidelines should be updated to provide clear guidance for screening women of advanced age, especially those in special populations with limited life expectancies.

Screening mammography among nursing home residents in the United States: Current guidelines and practice.

OBJECTIVE: United States (US) guidelines regarding when to stop routine breast cancer screening remain unclear. No national studies to-date have evaluated the use of screening mammography among US long-stay nursing home residents. This cross-sectional study was designed to identify prevalence, predictors, and geographic variation of screening mammography among that population in the context of current US guidelines. MATERIALS AND METHODS: Screening mammography prevalence, identified with Physician/Supplier Part B claims and stratified by guideline age classification (65-74, ≥75 years), was estimated for all women aged ≥65 years residing in US Medicare- and Medicaid- certified nursing homes (≥1 year) with an annual Minimum Data Set (MDS) 3.0 assessment, continuous Medicare Part B enrollment, and no clinical indication for screening mammography as of 2011 (n = 389,821). The associations between resident- and regional- level factors, and screening mammography, were estimated by crude and adjusted prevalence ratios from robust Poisson regressions clustered by facility. RESULTS: Women on average were 85.4 (standard deviation ±8.1) years old, 77.9% were disabled, and 76.3% cognitively impaired. Screening mammography prevalence was 7.1% among those aged 65-74 years (95% Confidence Interval (CI): 6.8%-7.3%) and 1.7% among those ≥75 years (95% CI, 1.7%-1.8%), with geographic variation observed. Predictors of screening in both age groups included race, cognitive impairment, frailty, hospice, and some comorbidities. CONCLUSIONS: These results shed light on the current screening mammography practices in US nursing homes. Thoughtful consideration about individual screening recommendations and the implementation of more clear guidelines for this special population are warranted to prevent overscreening.

Non-Hispanic Black-White disparities in pain and pain management among newly admitted nursing home residents with cancer.

BACKGROUND: Racial disparities in pain management persist across health care settings and likely extend into nursing homes. No recent studies have evaluated racial disparities in pain management among residents with cancer in nursing homes at time of admission. METHODS: Using a cross-sectional study design, we compared reported pain and pain management between non-Hispanic White and non-Hispanic Black newly admitted nursing home residents with cancer (n=342,920) using the de-identified Minimum Data Set version 3.0. Pain management strategies included the use of scheduled analgesics, pro re nata analgesics, and non-pharmacological methods. Presence of pain was based on self-report when residents were able, and staff report when unable. Robust Poisson models provided estimates of adjusted prevalence ratios (aPR) and 95% CIs for reported pain and pain management strategies. RESULTS: Among nursing home residents with cancer, ~60% reported pain with non-Hispanic Blacks less likely to have both self-reported pain (aPR [Black versus White]: 0.98, 95% CI: 0.97-0.99) and staff-reported pain (aPR: 0.89, 95% CI: 0.86-0.93) documentation compared with Non-Hispanic Whites. While most residents received some pharmacologic pain management, Blacks were less likely to receive any compared with Whites (Blacks: 66.6%, Whites: 71.1%; aPR: 0.98, 95% CI: 0.97-0.99), consistent with differences in receipt of non-pharmacologic treatments (Blacks: 25.8%, Whites: 34.0%; aPR: 0.98, 95 CI%: 0.96-0.99). CONCLUSION: Less pain was reported for Black compared with White nursing home residents and White residents subsequently received more frequent pain management at admission. The extent to which unequal reporting and management of pain persists in nursing homes should be further explored.

Cognitive Impairment and Pain Among Nursing Home Residents With Cancer.

CONTEXT: The prevalence of pain and its management has been shown to be inversely associated with greater levels of cognitive impairment. OBJECTIVES: To evaluate whether the documentation and management of pain varies by level of cognitive impairment among nursing home residents with cancer. METHODS: Using a cross-sectional study, we identified all newly admitted U.S. nursing home residents with a cancer diagnosis in 2011-2012 (n = 367,462). Minimum Data Set 3.0 admission assessment was used to evaluate pain/pain management in the past five days and cognitive impairment (assessed via the Brief Interview for Mental Status or the Cognitive Performance Scale for 91.6% and 8.4%, respectively). Adjusted prevalence ratios with 95% CI were estimated from robust Poisson regression models. RESULTS: For those with staff-assessed pain, pain prevalence was 55.5% with no/mild cognitive impairment and 50.5% in those severely impaired. Pain was common in those able to self-report (67.9% no/mild, 55.9% moderate, and 41.8% severe cognitive impairment). Greater cognitive impairment was associated with reduced prevalence of any pain (adjusted prevalence ratio severe vs. no/mild cognitive impairment; self-assessed pain 0.77; 95% CI 0.76-0.78; staff-assessed pain 0.96; 95% CI 0.93-0.99). Pharmacologic pain management was less prevalent in those with severe cognitive impairment (59.4% vs. 74.9% in those with no/mild cognitive impairment). CONCLUSION: In nursing home residents with cancer, pain was less frequently documented in those with severe cognitive impairment, which may lead to less frequent use of treatments for pain. Techniques to improve documentation and treatment of pain in nursing home residents with cognitive impairment are needed.