Graphical Abstract
Transfer of Care
Four in 10 post-acute care patients do not have timely follow-up visits with their primary care physicians after discharge from skilled nursing facilities, a longitudinal cohort study by Rochester, NY, researchers found.
Led by Adam Simning, MD, PhD, of the University of Rochester, the researchers studied Medicare claims and other data for 25,357 New York state Medicare beneficiaries aged 65 and older who were admitted to a SNF for post-acute care and then discharged to the community. Specifically, they looked at whether individuals followed up with their primary care physicians (PCPs) within seven days of discharge, as recommended by the American Geriatrics Society, Society of General Internal Medicine, and AMDA – The Society for Post-Acute and Long-Term Care Medicine.
“We conducted this study because transitions of care are incredibly fraught with risks for our patients,” Dr. Simning said in an email. “There is surprisingly little research on the SNF-to-PCP transfer of care, and we thought this was an important topic to consider. Additionally, many SNF rehabilitation patients are medically, psychologically, and socially complex, and at risk of losing their ability to return to and live independently in the community. This is a very important population to better understand.”
The researchers found that 60.6% of the individuals visited their PCPs within seven days of discharge. Individuals with increased functional impairment and medical comorbidities were more likely to see a PCP, while nonwhite individuals and those from rural counties were more likely not to have timely follow up visits. The other individuals less likely to have timely follow-up evaluations were post-acute care residents of rural SNFs, patients discharged from for-profit SNFs and SNFs with a lower ratio of registered nurse/total nursing hours, individuals discharged from lower-quality SNFs, and patients with surgical hospital admissions.
The good news is that most medically complex patients were likely to be connected to their PCPs after discharge. “It was surprising and concerning, however, that 40% of the discharged SNF residents did not see their PCPs within seven days of discharge,” Dr. Simning said. “Additional research examining whether many of these patients had a surgical hospitalization and saw a surgical specialist (rather than a PCP) shortly after discharge is needed. Nonetheless, a timely SNF-to-PCP handoff does not appear to be happening for many patients, especially for those of color and from rural communities.”
The reasons why so many individuals did not receive timely PCP follow up are unclear. Dr. Simning recommended that the SNF discharge process include a scheduled PCP appointment and address potential barriers, such as transportation issues.
“Our findings from this and other studies also suggest that patients who receive home health care tend to do better following SNF discharge,” he added. “I would thereby recommend to SNF rehabilitation teams to consider referring more of their discharged patients to home health services.
Source: Simning A, et al. Receipt of Timely Primary Care Services Following Post-Acute Skilled Nursing Facility Care [published online: October 26, 2020]. J Am Med Dir Assoc. DOI: https://doi.org/10.1016/j.jamda.2020.09.016.
Frailty and Polypharmacy
Older adults who are frail and experience polypharmacy are at increased risk for adverse events, though the effects vary according to distinct groups, a population-based retrospective cohort study conducted in Taipei, Taiwan, found.
Yan-Zuo Chen, MS, and colleagues at National Taiwan University categorized study participants as fit or as having mild, moderate, or severe frailty based on the multimorbidity frailty index, and they determined 12 groups of combined effects according to frailty and polypharmacy status. The researchers examined the risk of all-cause and unplanned hospitalizations and mortality among 100,000 individuals aged 65 to 100 from Taiwan’s National Health Insurance Research Database.
Compared with a reference group of individuals who were considered fit with no polypharmacy, the researchers found that frailty and polypharmacy in the remaining individuals each increased the likelihood of the other to lead to adverse outcomes. For example:
The adjusted relative risk of all-cause mortality among those with polypharmacy, defined as five to nine medications, was 1.58 for fit subjects, 2.70 for mildly frail subjects, 4.62 for moderately frail subjects, and 6.81 for severely frail subjects.
The adjusted relative risk of all-cause hospitalizations among individuals with moderate frailty was 8.19 for those with polypharmacy and 8.54 for those with excessive polypharmacy, defined as 10 or more medications.
The adjusted relative risk of unplanned hospitalizations among those with moderate frailty was 11.42 for those with polypharmacy and 12.17 for those with excessive polypharmacy.
“In our investigations on the longitudinal impact of distinct combined effects of frailty and polypharmacy, we found that both of these factors possess the ability to modify the risk of adverse outcomes, which indicated that monitoring these indicators is warranted,” the researchers said.
Source: Chen YZ, et al. Combined Effects of Frailty and Polypharmacy on Health Outcomes in Older Adults: Frailty Outweighs Polypharmacy [published online: August 29, 2020]. J Am Med Dir Assoc. DOI: https://doi.org/10.1016/j.jamda.2020.07.019.
Postoperative Delirium
Nearly one in four geriatric patients experiences postoperative delirium (POD) after noncardiac surgery, according to a systematic literature review and meta-analysis conducted by Portuguese researchers. They found 10,173 cases of preoperative delirium and 26,472 cases of POD, for a pooled frequency of 23.4% and 23.8%, respectively.
“General anesthesia and prior cognitive impairment were factors associated with higher frequency of POD,” the researchers said. “In addition to prior cognitive impairment and the type of anesthesia, the heterogeneity in estimating the frequency of geriatric POD across studies can be related to the intrinsic difficulty in diagnosing delirium due to the acute and fluctuating nature of symptoms, the overlap with dementia and the assessment of patients under the post-anesthesia effects.”
Source: Silva AR, et al. Estimates of Geriatric Delirium Frequency in Noncardiac Surgeries and Its Evaluation Across the Years: A Systematic Review and Meta-analysis [published online: September 30, 2020]. J Am Med Dir Assoc. DOI: https://doi.org/10.1016/j.jamda.2020.08.017.
Jeffrey S. Eisenberg compiled this report.
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