Abstract
Objectives:
Skilled therapies (ST), including audiology, speech-language therapy, occupational therapy, and physical therapy, can address functional deficits in dementia. This study aims to quantify the association between ST and successful discharge after heart failure (HF) hospitalization in persons living with dementia.
Design:
Retrospective cohort study including.
Setting and Participants:
We included Veterans with dementia (VwD) hospitalized for HF in Veterans Affairs (VA) medical centers and then admitted to non-VA Skilled Nursing Facilities (SNFs) from January 2011 to June 2019.
Methods:
Follow-up continued 120 days after SNF admission. We measured ST hours per week using MDS admission assessments. We defined successful discharge as SNF discharge occurring within 90 days of SNF admission with MDS discharge status not hospital or institutional setting, and 30 days survival after discharge without Medicare or VA-paid rehospitalization or reinstitutionalization. We estimated relative risk using multiple variable regression to adjust for measured sources of confounding.
Results:
Our final sample included 8255 VwD. The mean (SD) age was 80 (10) years, and 8074 (98%) were male. Successful discharge occurred in 2776 (34%) of the sample. The median (IQR) weekly hours of ST was 10.4 (7.1–12.1). Sextile 1 received less than 5.2 hours per week of ST. The adjusted relative risk (95% confidence interval) for sextiles 2–6 compared with sextile 1 were, respectively, 2.20 (1.85–2.62), 2.48 (2.09–2.94), 2.52 (2.12–2.99), 2.62 (2.21–3.11), and 2.69 (2.27–3.19).
Discussion:
During SNF care after HF hospitalization, 5.3 or more hours of ST per week was associated with a higher rate of successful discharge, in a roughly dose-dependent fashion, up to a 170% increase in the highest sextile of ST hours.
Conclusions and Implications:
Higher ST hours are associated with successful discharge from SNF after HF hospitalization.
Keywords: Dementia, Heart Failure, Rehabilitation, Post-Acute, Successful Discharge
Brief Summary:
After hospitalization for medical conditions such as heart failure, persons with dementia may benefit from rehabilitation services that address the functional deficits of dementia.
INTRODUCTION
Skilled nursing facilities (SNFs) are the destination for 24% of heart failure (HF) hospitalizations in Medicare beneficiaries ≥65 years, after which the 1-year mortality rate exceeds 50%.1 Persons living with dementia hospitalized for HF are especially susceptible to adverse outcomes – dementia is associated with 78 fewer days of home time in the year after discharge.2 Recent scholarship has appropriately questioned whether skilled nursing care should hold rehabilitation as its primary goal after hospitalization for a serious illness such as HF.3,4
Yet therapy services remain a central component of SNF care, and occupational therapy, speech-language therapy, audiology, and physical therapy offer the potential to address functional deficits in persons with dementia. Appropriate audiology services can improve communication and quality of life in persons with dementia.5 A variety of occupational therapy interventions have demonstrated effectiveness in managing symptoms of dementia,6 and speech and language pathologists can offer cognitive interventions with evidence of effectiveness.7 Exercise improves neuropsychiatric symptoms and cognition in persons with Alzheimer’s Disease,8 dual-task exercise training improves dual-task performance in persons with dementia,9 and physical therapy is associated with improvements in physical and cognitive function in persons with dementia.10 Audiology, speech-language therapy, occupational therapy, and physical therapy comprise a set of services (ST) addressing functional deficits of dementia that skilled nursing facilities offer through typical staffing models.
Previous observational studies have found that higher rehabilitation intensity in SNF care, including physical, occupational, and speech-language therapy, is associated with a higher likelihood of community discharge in general Medicare populations.11–13 Higher rehabilitation intensity is also associated with increased functional independence and executive function in SNF patients with stroke, orthopedic, cardiovascular, and pulmonary conditions.14 However, there is no evidence of a clinically meaningful reduction in readmissions with increased rehabilitation service intensity in the SNF setting.11,15 Randomized controlled trial evidence demonstrates that increased rehabilitation intensity improves proximal functional outcomes such as gait speed.16 However, we know very little about the effect of ST on persons with dementia in SNFs after hospitalization for medical illnesses such as HF. Cognitive impairment presages an increased risk of readmission after HF hospitalization,17 and supportive interventions can decrease this risk in the skilled nursing setting.18,19 Therefore, SNF care after HF hospitalization in persons with dementia presents an ideal context to evaluate the effects of ST on rehabilitation outcomes. In this study, we test the hypothesis that increased ST time is associated with successful discharge home from nursing homes in Veterans with dementia (VwD) after HF hospitalization.
METHODS
Study Setting and Dates
We designed a retrospective cohort study to estimate the relative risk of successful discharge associated with ST time reported on Minimum Data Set 3.0 (MDS) admission assessments. We included VwD hospitalized for HF and then discharged to nursing homes from January 2011 to June 2019. Follow-up continued 90 days after nursing home admission. The Providence Veterans Affairs Medical Center Institutional Review Board approved the study as a secondary data analysis.
Participants
We included VwD discharged from a Veterans Affairs (VA) medical center after treatment for HF and admitted to a nursing home within 7 days. We measured dementia using the Veterans Health Administration Dementia Diagnostic Code List (Table S1 and Table S2).20,21 To obtain a representative sample of HF hospitalizations across stages of disease progression and to avoid repeated observations of individual Veterans, we used random selection in cases where individual Veterans had multiple eligible admissions. We excluded VwD who had resided in a nursing home or VA Community Living Center within 30 days before their hospitalization (Figure 1) to focus on cases where discharge home would represent a return to the previous level of functional independence. We also excluded nursing home admissions that lacked MDS admission assessments.
Figure 1:
Flow diagram of cohort selection. Abbreviations: HF, Heart Failure; SNF, Skilled Nursing Facility; ICD, International Classification of Diseases; MDS, Minimum Data Set 3.0
Data Sources
We obtained hospital admission and comorbidity data from the Veterans Health Administration Corporate Data Warehouse (CDW) linked to Centers for Medicare and Medicaid Services (CMS) data, including MDS, MEDPAR, inpatient, outpatient, and carrier files. We obtained demographic characteristics and death dates from CDW.
Exposure
The primary predictor variable was the combined weekly duration of audiology, speech-language therapy, occupational therapy, and physical therapy reported in the admission MDS assessment. We identified admission assessments using MDS item A0310A. We identified Prospective Payment System (PPS) assessments from the first 14 days of admission for a sensitivity analysis using MDS items A0310A and B (type of assessment).
To measure ST hours, we first obtained the total number of combined speech-language therapy and audiology minutes administered in the preceding 7 days by adding items O0400A1–3. We added the total number of occupational therapy minutes administered in the preceding 7 days, obtained by adding items O0400B1–3. We then added the total number of physical therapy minutes administered in the preceding 7 days, obtained by adding items O0400C1–3. Finally, we divided the total by 60 to convert the units of measure to hours. We converted to hours because one hour per week is a clinically meaningful increment in therapy duration.12,14
Outcome
We measured the primary outcome of successful discharge using linked VA and CMS data sources, including MDS. We defined a SNF discharge as successful if it occurred within 90 days of admission, the MDS discharge status was not a hospital or institutional setting, and the Veteran survived 30 days after discharge without Medicare or VA-paid rehospitalization or reinstitutionalization.
Covariates
We measured activities of daily living (ADL) using items from MDS section G to calculate the MDS ADL long-form scale. Lower scores indicate more independence on this 0–28 point scale summarizing performance on bed mobility, transfer, locomotion on unit, dressing, eating, toilet use, and personal hygiene.22,23 We assessed cognitive function using the MDS Cognitive Function Scale (CFS), which categorizes individuals as cognitively intact or with mild, moderate, or severe impairment.24 We measured the Elixhauser-defined comorbid conditions as binary variables using International Classification of Diseases (ICD) codes from the VA CDW and summed the comorbid conditions to form an Elixhauser comorbidity count. We obtained age and patient-reported sex and race from the VA CDW.
Statistical Analysis
Our primary estimand was the relative risk of successful discharge associated with sextiles 2–6 of ST hours, compared with sextile 1 (lowest). We estimated relative risk using a generalized linear model with a Poisson distribution and robust error variance,25 selecting covariates based on a theorized causal structure interrelating the primary predictor variable and covariates with the outcome of successful discharge (Figure 2). We addressed confounding bias by including age, race, sex, CFS, the MDS ADL long-form scale, Elixhauser comorbidity count. Our model included VA Medical Center as a fixed effect to account for differing patterns of discharge and follow-up within each Center and its referral network of SNFs. Statistical analyses used Microsoft SQL Server Management Studio version 18 (Microsoft Corporation) and SAS Enterprise Guide version 7.1 (SAS Institute).
Figure 2:
A directed acyclic graph representing the theorized causal structure relating audiology, speech-language therapy, occupational therapy, and physical therapy (ST) to successful discharge and the other study covariates. We theorize that age, race, sex, activities of daily living (ADL) function, and cognitive function (CFS) influence PT, ST, and successful discharge. Under these assumptions, levels of ST are exchangeable conditional on measured covariates.
Sensitivity Analysis
As a reference for comparison in sensitivity analyses, we modeled ST hours as a continuous predictor variable. For the first sensitivity analysis, we included VwD excluded from the main analysis due to lack of an admission assessment but who had a PPS assessment from the first 14 days of their SNF admission. For the second sensitivity analysis, we modeled the occupational therapy component, combined audiology plus speech hours, and physical therapy hours as separate predictor variables in a single model, which also contained the covariates in the primary analysis.
RESULTS
After applying inclusion and exclusion criteria and randomly sampling from VwD with multiple HF hospitalizations, our sample contained 8255 VwD. The mean (SD) age was 80 (10) years old (Table 1). Subjects self-identified as White in 6100 (74%) and Black in 1537 (19%). The mean (SD) MDS ADL long form score was 16.9 (4.8). The median (IQR) ST duration was 10.4 (7.1–12.1) hours per week. The distribution of ST hours was multimodal, with the largest peak at 12.0 to 12.2 hours containing 1407 (17%) VwD (Figure S1). Successful discharge occurred in 2776 (34%) of the sample. The percentage of Veterans who died during the first 90 days of the SNF stay was 20% in the first sextile, compared with 3–6% in the other sextiles (Table S3). The adjusted relative risk (95% confidence interval) for sextiles 2–6 compared with sextile 1 were, respectively, 2.20 (1.85–2.62), 2.48 (2.09–2.94), 2.52 (2.12–2.99), 2.62 (2.21–3.11), and 2.69 (2.27–3.19) (Figure 3). Model covariates (RR [95% confidence interval]) associated with decreased successful discharge were comorbidity count (0.97 [0.96–0.98]); ADL dependency (0.97 [0.96–0.98]); and cognitive impairment (0.79 [0.75–0.83]).
Table 1:
Baseline characteristics of the analytic sample.
| Characteristic | N=8255 |
|---|---|
| Age, mean (SD) | 80.1 (9.5) |
| <65, no (%) | 444 (5.4) |
| 66–74, no (%) | 2026 (24.5) |
| 75–84, no (%) | 2616 (31.7) |
| 85 and over, no (%) | 3169 (38.4) |
| Male, No. (%) | 8074 (97.8%) |
| Race | |
| White, no (%) | 6100 (73.9%) |
| Black, no (%) | 1537 (18.6%) |
| Hispanic, no (%) | 605 (7.3%) |
| Elixhauser comorbidity count, mean (SD) | 6.4 (3.1) |
| ADLa score, Mean (SD) | 16.9 (4.8) |
| 0–16, no (%) | 2823 (34.2) |
| 17–19, no (%) | 3246 (39.3) |
| 20, no (%) | 2178 (26.4) |
| MDS 3.0 Cognitive Function Scale | |
| Intact, no (%) | 3558 (43.1) |
| Mild impairment, no (%) | 2371 (28.7) |
| Moderate impairment, no (%) | 2000 (24.2) |
| Severe impairment, no (%) | 233 (2.8) |
Activities of Daily Living
Figure 3:
Relative risk of successful discharge in quantiles 2 through 6 of weekly skilled therapy (ST) hours, compared with the first quantile. The quantiles divide the sample evenly according to weekly ST hours, which include physical therapy, occupational therapy, speech therapy, and audiology.
Sensitivity Analysis
In the reference model, the adjusted relative risk (95% confidence interval) of successful discharge was 1.08 (1.07–1.09) per hour of ST. For the first sensitivity analysis, we included VwD who had PPS assessments during the first 14 days of the SNF admission and those included in the primary analysis. The sample size for this sensitivity analysis was 9772, and 3061 (31%) had a successful discharge. In this expanded sample, the adjusted relative risk (95% confidence interval) of successful discharge was similar: 1.08 (1.07–1.09) per hour of ST. For the second sensitivity analysis, we modeled occupation therapy (OT), combined audiology and speech and language therapy (audiology plus speech), and physical therapy (PT) as separate predictors in one model, including the covariates of the main analysis. The relative risk (95% confidence interval) of successful discharge was 1.08 (1.04–1.12) for each additional hour of OT, and 1.02 (0.99–1.05) for each additional hour of audiology plus speech, and 1.10 (1.07–1.14) for each additional hour of PT.
DISCUSSION
After acute illness, most people want to return home and function independently;26 sometimes the pathway includes a SNF stay to restore function. Using the integrated data systems of the VA, we identified a sample of VwD discharged to non-VA SNFs after HF hospitalization and found that 5.3 or more weekly hours of ST was associated with a 2.5-fold increase in successful discharge from SNF to home compared with fewer than 5.3 hours. Clinically, these findings highlight the importance of engaging VwD in therapies for returning to function - Veterans and caregivers (and our healthcare system) depend on this recovery and return to home. As SNF payment models in Medicare and VA evolve,27,28 these findings can help define the importance of post-acute rehabilitation such as ST in VwD recovering from HF hospitalization. This study’s findings align with prior work demonstrating associations between skilled nursing home rehabilitation intensity and improved outcomes.11–14
The prior literature on rehabilitation intensity and outcomes does not address the specific case of rehabilitation in persons with dementia. Indeed, uncertainty remains regarding the most appropriate goals of short-term SNF care in persons with dementia and serious comorbid conditions such as HF.3,4 In our study, VwD receiving 5.3 hours of ST per week or more had higher rates of successful discharge, even after adjustment for cognition, ADL function, and comorbidities. The estimated relative risk of successful discharge increased successively through sextiles 2–6. This suggests a dose-dependent relationship between ST hours and successful discharge, though the confidence intervals are also compatible with a plateau above the 2nd sextile and other interpretations. Therefore, we conclude that VwD receiving more hours of ST after heart failure hospitalization are more likely to be successfully discharged home from nursing homes. We agree with Flint and co-authors3,4 that post-acute care of persons with dementia and HF should emphasize advance care planning and that ‘getting stronger’ is not always a realistic objective in post-acute care. Our study helps clarify the role of ST in achieving realistic patient-centered goals in persons with dementia recovering from serious illness hospitalizations. Our results suggest that audiology, speech, occupational therapy, and physical therapy may benefit persons with dementia and comorbid serious illnesses who wish to return home and avoid further hospitalization and institutionalization.
We also observed local maxima in the distribution of ST hours across our sample, which correspond to thresholds between therapy levels in the Resource Utilization Group (RUG-IV) system.29 In particular, the high concentration of our sample at 12.0–12.2 (sextile 5) weekly hours of therapy corresponds to the RUG-IV threshold for ultrahigh therapy. In our model, ST hours were more strongly associated with successful discharge through successive sextiles of ST hours, including through sextiles 4, 5, and 6. Although the high concentration of cases in the 12.0–12.2 hour range suggests that the therapy hours were, in part, financially motivated, Veterans in this sextile were more likely to experience successful discharge than Veterans below the threshold. This aligns with prior research on therapy thresholds, which reports that increased therapy time is associated with positive outcomes, even when the therapy dose appears to be influenced by the payment model.30
Limitations
A causal interpretation of this study would make several strong assumptions. First, this would require the untestable assumption that the set of covariates used in regression adjustment is sufficient to achieve conditional exchangeability across levels of ST intensity. We determined this set of covariates through deliberation by a multidisciplinary team of investigators and clinicians. Unmeasured patient factors, such as willingness to engage in therapy may have been associated with ST hours and successful discharge home, hence a source of bias by confounding. Death in SNF occurred most frequently in the first sextile, Veterans receiving few or no hours of therapy, an observation that is suggestive of confounding. The distribution of ST hours contains local maxima corresponding to RUG-IV thresholds, evidence of financial motivation. However, we did not find evidence that therapy at the ultrahigh threshold adversely influenced outcomes, and we did not replicate the RUG-IV method of accounting for group and concurrent therapy. A causal interpretation of our findings would require an assumption supporting the condition of consistency: that one hour of either audiology, speech-language therapy, occupational therapy, or physical therapy is interchangeable with one hour of the other services and that an MDS-reported hour of ST is equivalent across SNFs. When we queried this assumption by modeling OT, PT, and audiology plus speech as separate predictors, we obtained similar results to those of our main analysis. These results merit further investigation in future studies of therapy services for persons with dementia after serious illness hospitalization, for instance, in a study using prospective data collection on the specific methods and goals of therapy services. Our study population contained primarily men, and most identified as white; our results may not be generalizable to non-Veteran populations.
CONCLUSIONS and IMPLICATIONS
During SNF care after HF hospitalization, VwD receiving 5.3 or more hours of ST per week were 2.5-fold more likely to have a successful discharge to the community than VwD receiving less than 5.3 hours. Persons with dementia receiving post-acute facility care after hospitalization for a serious illness such as heart failure may, in many cases, reasonably consider successful discharge home as a treatment goal. PT, OT, audiology, and speech and language therapy may help persons with dementia achieve successful discharge from SNF after medical hospitalization for a serious comorbid illness. This work can help inform the important efforts of healthcare providers to deliver age-friendly care in the post-acute setting by considering what matters most to their patients with dementia and serious comorbid illnesses such as heart failure.
Supplementary Material
Acknowledgments
Sponsor’s Role: This report does not represent the views of the Department of Veterans Affairs or the United States Federal Government.
Funding:
This work was supported by VA Health Services Research and Development Center of Innovation in Long-Term Services and Supports (CIN-13-419), and the Providence Evidence Synthesis Program (ESP-22-116), VA HSR&D 23- SWIFT-1
Dr. Browne is supported by a VA Rehabilitation Research and Development Career Development Award (IK1RX003904).
Drs. Bayer, Browne, Nubong, Singh, Kunicki, McGeary, Kelso, Rudolph, and Ms. Jiang are employed by the Veterans Health Administration.
Footnotes
CONFLICTS OF INTEREST
None
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