Objectives Hospital discharges to post-acute care (PAC) facilities have increased rapidly. This increase may lead to more hospital readmissions from PAC facilities, which are common and poorly understood. We sought to determine the risk factors and timing for hospital readmission from PAC facilities and evaluate the impact of readmission on patient outcomes. Design Retrospective analysis of Medicare Current Beneficiary Survey (MCBS) from 2003–2009. Setting The MCBS is a nationally-representative survey of beneficiaries matched with claims data. Participants Community-dwelling beneficiaries who were hospitalized and discharged to a PAC facility for rehabilitation. Intervention/Exposure Potential readmission risk factors included patient demographics, health utilization, active medical conditions at time of PAC admission, and PAC characteristics. Measurements Hospital readmission during the PAC stay, return to community residence, and all-cause mortality. Results Of 3246 acute hospitalizations followed by PAC facility stays, 739 (22.8%) included at least 1 hospital readmission. The strongest risk factors for readmission included impaired functional status (HR 4.78, 95% CI 3.21–7.10), markers of increased acuity such as need for intravenous medications in PAC (1.63, 1.39–1.92), and for-profit PAC ownership (1.43, 1.21–1.69). Readmitted patients had a higher mortality rate at both 30 days (18.9 vs. 8.6%, p<0.001) and 100 days (39.9 vs. 14.5%, p<0.001) even after adjusting for age, comorbidities, and prior health care utilization (30 days: OR 2.01, 95% CI 1.60–2.54; 100 days: OR 3.79, 95% CI 3.13–4.59). Conclusions Hospital readmission from PAC facilities is common and associated with a high mortality rate. Readmission risk factors may signify inadequate transitional care processes or a mismatch between patient needs and PAC resources.

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OBJECTIVE : There is inadequate evidence of long-term benefit and growing evidence of the risks of chronic opioid therapy (COT). Opioid dose reduction, or opioid tapering, may reduce these risks but may also worsen pain and quality of life. Our objective was to explore patients' perspectives on opioid tapering. DESIGN : Qualitative study using in-person, semistructured interviews. SETTING AND PATIENTS : English-speaking, adult primary care patients (N = 24) in three Colorado health care systems. METHODS : Interviews were audio recorded, transcribed, and analyzed in ATLAS.ti. We used a team-based, mixed inductive and deductive approach guided by the Health Belief Model. We iteratively refined emergent themes with input from a multidisciplinary team. RESULTS : Participants had a mean age of 52 years old, were 46% male and 79% white. Six participants (25%) were on COT and not tapering, 12 (50%) were currently tapering COT, and 6 (25%) had discontinued COT. Emergent themes were organized in four domains: risks, barriers, facilitators, and benefits. Patients perceived a low risk of overdose and prioritized the more immediate risk of increased pain with opioid tapering. Barriers included a perceived lack of effectiveness of nonopioid options and fear of opioid withdrawal. Among patients with opioid tapering experience, social support and a trusted health care provider facilitated opioid tapering. These patients endorsed improved quality of life following tapering. CONCLUSIONS : Efforts to support opioid tapering should elicit patients' perceived barriers and seek to build on relationships with family, peers, and providers to facilitate tapering. Future work should identify patient-centered, feasible strategies to support tapering of COT.

Medicare's payment reforms in the 1990s significantly affected hospital length of stay and post-acute care (PAC) (eg, skilled nursing or rehabilitation) facility use. 1 , 2 H o w e v e r , f e w s t u d i e s d e s c r i b e c o nt e m p o r a r y length of stay and postdisc h a rge c a r e t r e n d s i n a nationally representative sample of Medicare and non-Medicare patients. We sought to understand these trends using the National Hospital Discharge Survey (NHDS) from 1996 to 2010.Methods | The NHDS is a nationally representative annual probability sample of discharges from hospitals in all 50 states. 3 We included all hospital discharges of patients 18 years or older, excluding patients transferred to other hospitals, discharges against medical advice, discharges without a destination coded, or hospital lengths of stay more than 31 days (together, <7% of all discharges). We used NHDS definitions for discharge to home or a care facility.We evaluated trends in discharges to PAC facilities as well as length of stay over the 15-year period, then calculated relative percentage changes for each year, using 1996 rates as a baseline. To account for the aging of the population, all trends were age-adjusted by the US Census population in 2003 (www.census.gov). The derived age-specific estimates for each individual year were weighted to reflect the age distribution in 2003, the midpoint of our analysis. Analyses were conducted using SAS statistical software (version 9.

Objectives To identify and describe potentially preventable emergency department (ED) visits by nursing home (NH) residents in the United States. These visits are important because they are common, frequently lead to hospitalization, and can be associated with significant cost to the patient and the health care system. Design Retrospective analysis of the 2005-2010 National Hospital Ambulatory Care Survey (NHAMCS), comparing ED visits by nursing home residents that did not lead to hospital admission (potentially preventable) to those that led to admission (less likely preventable). Setting Nationally representative sample of United States EDs; Federal hospitals and hospitals with less than six beds were excluded. Participants Older (age ≥65 years) nursing home residents with an ED visit during this time period. Measurements Patient demographics, ED visit information including testing performed, interventions (both procedures and medications) provided, and diagnoses treated. Results Older NH residents accounted for 3,857 of 208,956 ED visits during the time period of interest (1.8%). When weighted to be nationally representative, these represent 13.97 million ED visits, equivalent to 1.8 ED visits annually per NH resident in the United States. More than half of visits (53.5%) did not lead to hospital admission; of those discharged from the ED, 62.8% had normal vital signs on presentation and 18.9% did not have any diagnostic testing prior to ED discharge. Injuries were 1.78 times more likely to be discharged than admitted (44.8% versus 25.3%, respectively, p<0.001), while infections were 2.06 times as likely to be admitted as discharged (22.9% versus 11.1%, respectively). CT scans were performed in 25.4% and 30.1% of older NH residents who were discharged from the ED and admitted to the hospital, respectively, and more than 70% of these were CTs of the head. NH residents received centrally acting, sedating medications prior to ED discharge in 9.4% of visits. Conclusion This nationally representative sample of older nursing home residents suggests ED visits for injury, those that are associated with normal triage vital signs, and those that are not associated with any diagnostic testing are potentially preventable. Those discharged from the ED often undergo important testing and receive medications that may alter their physical exam on return to the nursing facility, highlighting the need for seamless communication of the ED course to nursing homes.

Aggressive care within the last month of life is common among patients with NSCLC and is associated with lower family evaluations of end-of-life care. Specialized care provided within an HPC unit may mitigate the negative effects of aggressive care on these outcomes. Cancer 2017;123:3186-94. © 2017 American Cancer Society.

While discussing and implementing opioid tapering present significant challenges, primary care providers described key facilitators. These findings suggest a need to develop and test the effectiveness of resources to support patient-centered opioid tapering and locally developed policies to support and standardize providers' approaches to opioid prescribing.

PURPOSE Primary care needs new models to facilitate advance care planning conversations. These conversations focus on preferences regarding serious illness and may involve patients, decision makers, and health care providers. We describe the feasibility of the first primary care-based group visit model focused on advance care planning. METHODSWe conducted a pilot demonstration of an advance care planning group visit in a geriatrics clinic. Patients were aged at least 65 years. Groups of patients met in 2 sessions of 2 hours each facilitated by a geriatrician and a social worker. Activities included considering personal values, discussing advance care planning, choosing surrogate decision-makers, and completing advance directives. We used the RE-AIM framework to evaluate the project. RESULTSTen of 11 clinicians referred patients for participation. Of 80 patients approached, 32 participated in 5 group visit cohorts (a 40% participation rate) and 27 participated in both sessions (an 84% retention rate). Mean age was 79 years; 59% of participants were female and 72% white. Most evaluated the group visit as better than usual clinic visits for discussing advance care planning. Patients reported increases in detailed advance care planning conversations after participating (19% to 41%, P = .02). Qualitative analysis found that older adults were willing to share personal values and challenges related to advance care planning and that they initiated discussions about a broad range of relevant topics.CONCLUSION A group visit to facilitate discussions about advance care planning and increase patient engagement is feasible. This model warrants further evaluation for effectiveness in improving advance care planning outcomes for patients, clinicians, and the system. 2016;14:125-132. doi: 10.1370/afm.1906. Ann Fam Med INTRODUCTIOND espite the benefits of advance care planning for patients, primary care clinicians face barriers to effective counseling on the issue, including their limited time and a lack of clinic-based support. [1][2][3][4] The Dying in America report 5 emphasized the need to integrate advance care planning into clinical care, and the Centers for Medicare and Medicaid Services recently approved reimbursement for counseling on advance care planning. 6 Advance care planning is an ongoing process that involves multiple conversations among individuals, family members, and health care professionals. 1,7 Studies show that many US decedents had not discussed preferences for end-of-life care with someone close to them, completed a living will, or established a durable power of attorney for health care. 8,9 Primary care clinics are uniquely positioned to implement new models that engage patients in advance care planning. 10 The American Academy of Family Physicians recognizes group medical visits (GMVs) as a strategic approach within the patient-centered medical home. 11,12 GMVs, also called shared medical appointments, engage patients in health promotion and disease management. [13][14][15][16][17][18] care, a...