Preoperative Point-of-Care Ultrasound to Identify Frailty and Predict Postoperative Outcomes: A Diagnostic Accuracy Study

Background Frailty is increasingly being recognized as a public health issue, straining healthcare resources and increasing costs to care for these patients. Frailty is the decline in physical and cognitive reserves leading to increased vulnerability to stressors such as surgery or disease states. The goal of this pilot diagnostic accuracy study was to identify whether point-of-care ultrasound measurements of the quadriceps and rectus femoris muscles can be used to discriminate between frail and not-frail patients and predict postoperative outcomes. This study hypothesized that ultrasound could discriminate between frail and not-frail patients before surgery. Methods Preoperative ultrasound measurements of the quadriceps and rectus femoris were obtained in patients with previous computed tomography scans. Using the computed tomography scans, psoas muscle area was measured in all patients for comparative purposes. Frailty was identified using the Fried phenotype assessment. Postoperative outcomes included unplanned intensive care unit admission, delirium, intensive care unit length of stay, hospital length of stay, unplanned skilled nursing facility admission, rehospitalization, falls within 30 days, and all-cause 30-day and 1-yr mortality. Results A total of 32 patients and 20 healthy volunteers were included. Frailty was identified in 18 of the 32 patients. Receiver operating characteristic curve analysis showed that quadriceps depth and psoas muscle area are able to identify frailty (area under the curve–receiver operating characteristic, 0.80 [95% CI, 0.64 to 0.97] and 0.88 [95% CI, 0.76 to 1.00], respectively), whereas the cross-sectional area of the rectus femoris is less promising (area under the curve–receiver operating characteristic, 0.70 [95% CI, 0.49 to 0.91]). Quadriceps depth was also associated with unplanned postoperative skilled nursing facility discharge disposition (area under the curve 0.81 [95% CI, 0.61 to 1.00]) and delirium (area under the curve 0.89 [95% CI, 0.77 to 1.00]). Conclusions Similar to computed tomography measurements of psoas muscle area, preoperative ultrasound measurements of quadriceps depth shows promise in discriminating between frail and not-frail patients before surgery. It was also associated with skilled nursing facility admission and postoperative delirium. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Looking for a bright side: Tales from a recreational therapy virtual service-learning project during a pandemic

The everchanging policies and inability to utilize university students due to COVID-19 impacted both residents living in long-term care as well as the next generation of students pursuing careers in the field. University Wisconsin-La Crosse (UWL) faculty strategized solutions as restrictions threatened to impact hands-on opportunities for students. Was there a safe and effective solution to offer residents evidence-based programming while also providing students with vital field experience? Simply stated, the answer was yes. Thus, the UWL Happiness Project was born. This session will outline the UWL Happiness Project, a ten-week, telehealth program implemented between a skilled nursing facility in rural Wisconsin and the UWL Therapeutic Recreation Program, an AGHE Program of Merit for Health Professions designated program. The evidence-based curriculum was developed by an emerging UWL graduate student scholar with faculty mentorship. The innovative curriculum focuses on increasing feelings of happiness using PERMA, a theoretical model grounded in positive psychology. During virtual sessions, older adult residents (ages 65-85) and students built connection while working through weekly focus areas (e.g. vitality, mindfulness, friendship). An overview of AGHE competencies addressed within the project, online course demonstration, and assignment development will be discussed along with information about how these connections fostered an opportunity for students to see aging from a different perspective. This is the first time we are presenting results from the newly developed program. In this, we look forward to sharing student measurements and outcomes, as well as lessons learned during this meaningful, stimulating, and insightful educational session.

Nursing Facility and Health Care Service Use and Costs Under the CMS Financial Alignment Initiative

The Centers for Medicare & Medicaid Services created the Financial Alignment Initiative (FAI) to test the impact of integrated care and financing models for dually eligible Medicare-Medicaid beneficiaries. Using Medicare claims, the Minimum Data Set 3.0, and state-provided enrollment files, we evaluated demonstration impacts on long-stay nursing facility (NF) use, other health care service utilization, and costs for the overall eligible population in two FAI demonstration States with managed fee-for-service models, Colorado and Washington. We used quasi-experimental, difference-in-differences regression models for the impact analyses. In Colorado, there was a 7.2 percent decrease (p<0.001) in long-stay NF use, relative to the comparison group. Otherwise, the demonstration showed unfavorable service utilization results—increases in preventable emergency department (ED) visits and declines in 30-day follow-up after mental health discharge (MHFU)—and no impact on Medicare costs. In Washington, there was also a decrease in long-stay NF use (12.4 percent, p<0.001) and skilled NF admissions (21.7 percent, p<0.001). However, the demonstration resulted in decreases in physician visits and 30-day MHFU. There was a favorable decrease in Medicare costs. The impact of the FAI demonstrations on NF use was favorable for both States, while the impact on service utilization and Medicare costs was mixed and more favorable in Washington. Washington’s care coordination model was intensive and targeted to high-cost individuals while Colorado provided minimal care coordination. Coordinated care and integrated long-term services and support may help postpone NF institutionalization, but there is no evidence these activities reduced preventable hospitalizations or ED visits.

Implications of Racial Differences in the Shifts in the Setting of Care for Alzheimer’s Disease and Related Dementias

The prevailing setting of care has strong associations with the progression of a disease at time of first diagnosis, subsequent treatment, resulting health outcomes as well as both long-term and short-term costs. The care of Alzheimer’s Disease (AD) and Related Dementias (ADRD) has been experiencing a shift from skilled nursing facility to home health care. However, changes in practice do not disseminate equally across the race/ethnicity spectrum of the U.S. and disadvantaged race/ethnicity-related groups often encounter differing conditions from those experienced by the majority. In this study, we calculated the race/ethnicity-related direct healthcare costs of individuals with AD and ADRD, stratified by care-provider structure (physician, inpatient, outpatient, skilled nursing facility, home health, hospice), and modeled the trends and the relative contributions of each setting over the 1991-2017 period using administrative claims from a 5% sample of Medicare beneficiaries. Inflation and the gradual switch of Medicare compensation to the HCC model between 2004 and 2007 were accounted for. We then applied an inverse probability weighting algorithm to propensity-score-match the AD/ADRD race/ethnicity-specific groups to Medicare beneficiaries to make them comparable in demographics and co-morbidity status but without AD/ADRD. Finally, we performed a comparison of the Medicare costs and associated survival within (AD/ADRD vs. No AD/ADRD) and between (Black vs. White vs. Hispanic) race/ethnicity-related groups. Comparisons were done for: i)1-year before; ii) 1-year after iii) years 2-11; iv)years 12-21 and v) years 22+ after an AD/ADRD diagnosis. We found significant race/ethnicity-related differences in costs and survival both before and after propensity score matching.

Functional Trajectories and Quality of Life in Post-Acute Skilled Nursing Facility care after hospitalization

Frailty predicts readmissions and mortality after acute hospitalizations. Understanding whether frailty predicts functional recovery after acute hospitalizations may help guide post-acute care and rehabilitation. This feasibility study enrolled 24 adults aged ≥65 years from a skilled nursing facility (SNF) after acute hospitalization. We calculated a deficit-accumulation frailty index (FI range: 0-1; non-frail [≤0.25], mild frailty [0.26-0.35], moderate [0.36-0.45], and severe [>0.45]) via in-person assessment on SNF admission. We measured weekly functional improvement with modified Barthel Index, as well as quality of life. Modified Barthel Index and quality of life were measured weekly by Patient-Reported Outcome Measurement Information System (PROMIS) (standardized score with mean 50 and SD 10, higher is better). The mean age was 83.3 years [SD 8.0], and 17 (71.8%) were female. Length of stay for those with severe frailty (FI>0.45) was 26.8 days [10.7] compared to those who were not frail, mildly frail, or moderately frail (13.3 [7.3], 9.4 [4.4], and 15.2 [4.9] respectively). Those with severe frailty also had delayed functional improvement (mean Barthel Index 48.6, 53.4, and 56.6 on admission, week 1, and week 2 of SNF admission respectively), compared to those with moderate frailty (mean Barthel Index 47.5, 69, 73) or mild frailty (68.3, 86, 90.5). Self-reported mental and physical health-related quality of life was relatively unchanged across SNF episode for all frailty categories. These findings suggest that older adults with moderate or severe frailty may experience a typical course of delayed functional recovery and that further monitoring may be necessary for prognostication.

Case Study - Candida auris in Skilled Nursing Facility

Candida Auris (C. auris), is a multidrug-resistant organism, first described in Japan 2009, and now a serious, emerging global health threat1. C. auris pathogen can potentiate morbidity and mortality, i.e. lifelong contact precaution isolation, intravenous antifungal treatment, hospitalization and mortality rate of 30-60%1. Los Angeles County (LAC) developed 15 new cases in May 2020, and 73 cases in July 2020, amidst COVID-19 pandemic2. A 88 year old Black female had a positive skin test for C. auris by LAC Department of Public Health (DPH) during skilled nursing facility (SNF) admission for hip fracture in September 2020. Patient’s risk factors for C. auris included: age, kidney transplantation (1998) immunosuppression on tacrolimus, fungal infection on fluconazole, drug-drug interaction between tacrolimus-fluconazole including nephrotoxicity and neurotoxicity, malnutrition, bedbound, Stage 4 sacrococcyx pressure ulcer, osteomyelitis on broad-spectrum antibiotics, chronic indwelling catheter, and healthcare setting. Our multimorbid and frail patient remained asymptomatic with C. auris under an interdisciplinary team approach, including geriatricians, infectious disease, pharmacists, SNF team and local DPH. Our patient’s psychosocial isolation and family distress with local DPH guidelines for COVID-19 SNF visitation restrictions were compounded by multifaceted coordination of patient-centered care between SNF team and specialists via telehealth. Further research in the prevention, detection, and management of C. auris is warranted to protect our vulnerable SNF residents. 1. Centers for Disease Control and Prevention. (2020). Tracking Candida auris. https://www.cdc.gov/fungal/candida-auris/tracking-c-auris.html 2. Los Angeles County Health Alert Network. (2020). CDPH Health Advisory: Resurgence of Candida auris in Healthcare Facilities in the Setting of COVID-19. http://publichealth.lacounty.gov/eprp/lahan/alerts/CAHANCauris082020.pdf

Differences in the Racial Contribution of Dementia and Chronic Conditions to Hospitalization, SNF Admission

We estimate the contribution for experiencing hospitalization, skilled nursing facility admission and mortality using a measure of attributable fraction that incorporates both the prevalence, incidence and risk called Longitudinal Extension of the Average Attributable Fraction (LE-AAF). We estimate the LE-AAF for Non-Hispanic whites and Non-Hispanic Blacks for dementia and 10 chronic conditions, for three outcomes. This approach analyses the temporal relationships among conditions to estimate their population-level average attributable fractions. Unlike standard measures of attributable fraction, the sum of the contribution of each condition based on the LE-AAF will not exceed 100 percent, enabling us to compute the contribution of pairs, triads or any combination of conditions. Furthermore, in studying multimorbidity, the LE-AAF has the desirable feature of being based on all combinations of the risk factors and covariates present in the data with final values for the individual LE-AAFs obtained by averaging across these observed combinations of predictors.

Outcomes and Treatment Costs of Skilled Nursing Facility Patients with Pressure Injuries and Malnutrition

Skilled nursing facilities (SNF) provide care for individuals requiring skilled care while transitioning to a more permanent residence post hospitalization. This analysis shows that diagnosed malnutrition and pressure injuries (PI) adversely impact SNF patients’ health and recovery. Length of SNF stay, total charges, and discharge disposition were analyzed using SNF claims from 2016-2020 Centers for Medicare & Medicaid Services (CMS) Standard Analytical File databases. An average of 4.5% SNF patients had diagnosed PIs, and 4.9% had diagnosed malnutrition. Patients with diagnosed malnutrition were more likely to have PIs than patients without diagnosed malnutrition (11.9% vs 4.1%). Patients with PIs had higher charges ($12,304 vs. $10,937), were less likely to be discharged home (11.1% vs 18.9%), and more likely to be discharged to a hospital (15.8% vs 11.0%) or deceased (2.8% vs 1.6%). Patients with diagnosed malnutrition displayed a similar pattern for charges ($11,587 vs $10,969), and discharge to home (14.5% vs 18.8%), hospital (13.5 vs 11.1%) or deceased (2.8% vs 1.6%). Length of SNF stay did not differ between patients with and without PIs (18.5 vs 18.6) and was slightly shorter for patients with diagnosed malnutrition (17.3 vs 18.9). While higher probability of rehospitalization or death could impact these results, drivers behind these differences need further investigation. Because malnourished patients were more likely to have PIs and both PI and malnutrition are associated with poorer patient discharge outcomes and higher costs, efforts to identify malnutrition and implement proper nutrition interventions should be prioritized as part of SNF quality improvement initiatives.

Frailty and Functional Status improvement after Skilled Nursing Facility based Post-Acute Care

People admitted to a skilled nursing facility (SNF) for post-acute care undergo comprehensive evaluation and rehabilitation, potentially enabling prediction of future functional recovery. We identified the first SNF admission per beneficiary (n=250,159) between 07/01/2014 – 06/30/2016 in a 5% Medicare sample, using the Minimum Data Set (MDS) and the Outcome and Assessment Information Set (OASIS). Episodes were excluded for non-community discharge (n=43,397) or no OASIS admission assessment within 14 days of SNF discharge (n=77,989). A deficit accumulation Frailty Index (FI) was measured on admission MDS assessment and categorized into robust (MDS-FI<0.15), pre-frailty (MDS-FI0.15-0.24), mild frailty (MDS-FI0.25-0.34), and moderate or worse frailty (MDS-FI≥0.35). Outcomes were functional decline obtained from OASIS, readmission, or death after initiation of home care. Functional status was measured by activities of daily living from OASIS assessments. A total of 135,310 SNF episodes were matched to OASIS episodes. Of these, there were 6,472 (4.8%) robust patients, 38,923 (28.8%) pre-frail, 63,727 (47.1%) mildly frail and 26,053 (19.3%) moderately frail or worse. In a logistic regression after adjustment for OASIS admission function, compared to robust status, frailty was associated with hospital readmission or death within 30 days of OASIS admission, (mild frailty OR1.33 [95%CI 1.23-1.45] and moderate or worse OR1.81 [95%CI 1.66-1.97]). Frailty was also associated with functional decline at OASIS discharge, after adjustment for OASIS admission function (mild frailty OR1.50 [95%CI 1.38-1.63] and moderate or worse OR2.30 [95%CI 2.11-2.50]). Among those discharged from SNF with home services, a SNF-based MDS-FI is associated with increased likelihood of poor community outcomes.