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Disease Management in Skilled Nursing Facilities Improves Outcomes for Patients With a Primary Diagnosis of Heart Failure

Weerahandi, Himali; Chaussee, Erin L; Dodson, John A; Dolansky, Mary; Boxer, Rebecca S
OBJECTIVE:Skilled nursing facilities (SNFs) are common destinations after hospitalization for patients with heart failure (HF). Our objective was to determine if patients in SNFs with a primary hospital discharge diagnosis of HF benefit from an HF disease management program (HF-DMP). DESIGN/METHODS:This is a subgroup analysis of multisite, physician and practice blocked, cluster-randomized controlled trial of HF-DMP vs usual care for patients in SNF with an HF diagnosis. The HF-DMP standardized SNF HF care using HF practice guidelines and performance measures and was delivered by an HF nurse advocate. SETTING AND PARTICIPANTS/METHODS:Patients with a primary hospital discharge diagnosis of HF discharged to SNF. METHODS:Composite outcome of all-cause hospitalization, emergency department visits, and mortality were evaluated at 30 and 60 days post SNF admission. Linear mixed models accounted for patient clustering at the physician level. RESULTS:Of 671 individuals enrolled in the main study, 125 had a primary hospital discharge diagnosis of HF (50 HF-DMP; 75 usual care). Mean age was 79 ± 10 years, 53% women, and mean ejection fraction 46% ± 15%. At 60 days post SNF admission, the rate of the composite outcome was lower in the HF-DMP group (30%) compared with usual care (52%) (P = .02). The rate of the composite outcome at 30 days for the HF-DMP group was 18% vs 31% in the usual care group (P = .11). CONCLUSIONS AND IMPLICATIONS/CONCLUSIONS:Patients with a primary hospital discharge diagnosis of HF who received HF-DMP while cared for in an SNF had lower rates of the composite outcome at 60 days. Standardized HF management during SNF stays may be important for patients with a primary discharge diagnosis of HF.
PMID: 34478693
ISSN: 1538-9375
CID: 4999412

Six-Month Outcomes in Patients Hospitalized with Severe COVID-19

Horwitz, Leora I; Garry, Kira; Prete, Alexander M; Sharma, Sneha; Mendoza, Felicia; Kahan, Tamara; Karpel, Hannah; Duan, Emily; Hochman, Katherine A; Weerahandi, Himali
BACKGROUND:Previous work has demonstrated that patients experience functional decline at 1-3 months post-discharge after COVID-19 hospitalization. OBJECTIVE:To determine whether symptoms persist further or improve over time, we followed patients discharged after hospitalization for severe COVID-19 to characterize their overall health status and their physical and mental health at 6 months post-hospital discharge. DESIGN/METHODS:Prospective observational cohort study. PARTICIPANTS/METHODS:Patients ≥ 18 years hospitalized for COVID-19 at a single health system, who required at minimum 6 l of supplemental oxygen during admission, had intact baseline functional status, and were discharged alive. MAIN MEASURES/METHODS:Overall health status, physical health, mental health, and dyspnea were assessed with validated surveys: the PROMIS® Global Health-10 and PROMIS® Dyspnea Characteristics instruments. KEY RESULTS/RESULTS:Of 152 patients who completed the 1 month post-discharge survey, 126 (83%) completed the 6-month survey. Median age of 6-month respondents was 62; 40% were female. Ninety-three (74%) patients reported that their health had not returned to baseline at 6 months, and endorsed a mean of 7.1 symptoms. Participants' summary t-scores in both the physical health and mental health domains at 6 months (45.2, standard deviation [SD] 9.8; 47.4, SD 9.8, respectively) remained lower than their baseline (physical health 53.7, SD 9.4; mental health 54.2, SD 8.0; p<0.001). Overall, 79 (63%) patients reported shortness of breath within the prior week (median score 2 out of 10 (interquartile range [IQR] 0-5), vs 42 (33%) pre-COVID-19 infection (0, IQR 0-1)). A total of 11/124 (9%) patients without pre-COVID oxygen requirements still needed oxygen 6 months post-hospital discharge. One hundred and seven (85%) were still experiencing fatigue at 6 months post-discharge. CONCLUSIONS:Even 6 months after hospital discharge, the majority of patients report that their health has not returned to normal. Support and treatments to return these patients back to their pre-COVID baseline are urgently needed.
PMCID:8341831
PMID: 34355349
ISSN: 1525-1497
CID: 4966622

Discharge practices in skilled nursing facilities affected by COVID-19 [Meeting Abstract]

Weerahandi, H; Mak, W; Burack, O; Canter, B; Reinhardt, J P; Boockvar, K
BACKGROUND: Many patients require post-acute care at skilled nursing facilities (SNF) after hospital discharge. While returning from SNF to home is often the ultimate goal for these patients, a safe discharge from SNF often requires additional support from home health care agencies or from patients' families. However, the COVID-19 pandemic affected all aspects of the healthcare industry, complicating transition home. To understand how post-acute SNF throughput was affected by the COVID-19 pandemic, we conducted a study of discharge processes of patients with COVID-19 at a skilled nursing facility.
METHOD(S): This was a retrospective study of all residents at our SNF with a positive COVID-19 PCR test between 3/1/20-6/1/20. We defined post-acute patients as those who were admitted to the nursing home 100 days or less before the positive test. Using the facility's electronic medical record, we reviewed all medical, nursing, social work and other notes to identify discharge planning processes. Specifically, we identified if discharge planning was initiated, whether the patient was successfully discharged, and whether there was evidence that the discharge was complicated by COVID-19 related challenges.
RESULT(S): Of 350 residents with a positive COVID-19 PCR, 121 were postacute patients who were admitted to our facility within 30 days of positive PCR or symptom onset. Median age was 79 (interquartile range [IQR], 69-86), 59 (49%) were female, 16 (13%) were Black, 8 (7%) were White, 8 (7%) were Hispanic and 84 (70%) did not report race. Over an average follow-up time of 185 days, 98 (81%) post-acute patients had discharge planning initiated, of which 81 were discharged to the community. Median length of stay for those discharged was 38 days (IQR 23-98). Discharge sites included home (66 [81%]), assisted living facilities (9 [7%]), and hotels (2 [2%]). Discharge planning was affected by COVID-19 for 49 (41%) patients. These included symptom development that precluded discharge; logistical issues related to establishing home oxygen; unwillingness for assisted living facilities, home care services, or families to receive COVID-19 positive patients; challenges establishing home care services due to staffing shortages; and family members sick with COVID-19 themselves.
CONCLUSION(S): The COVID-19 pandemic had a multi-layered effect on the ability of nursing home residents to be discharged safely home. LEARNING OBJECTIVE #1: Practice-Based Learning and Improvement: A diagnosis of COVID-19 has a substantial impact on the ability to safely discharge patients from SNF due to concerns from assisted living facilities, home care services, and families about directly caring for someone with COVID-19. LEARNING OBJECTIVE #2: Systems-Based Practice: Delayed discharge from SNF may impact their ability to accept new patients, which may have further upsteam effects on other aspects of the healthcare continuum such as hospital length of stay
EMBASE:635796784
ISSN: 1525-1497
CID: 4984922

Measuring Equity in Readmission as a Distinct Assessment of Hospital Performance

Nash, Katherine A; Weerahandi, Himali; Yu, Huihui; Venkatesh, Arjun K; Holaday, Louisa W; Herrin, Jeph; Lin, Zhenqiu; Horwitz, Leora I; Ross, Joseph S; Bernheim, Susannah M
IMPORTANCE:Equity is an essential domain of health care quality. The Centers for Medicare & Medicaid Services (CMS) developed 2 Disparity Methods that together assess equity in clinical outcomes. OBJECTIVES:To define a measure of equitable readmissions; identify hospitals with equitable readmissions by insurance (dual eligible vs non-dual eligible) or patient race (Black vs White); and compare hospitals with and without equitable readmissions by hospital characteristics and performance on accountability measures (quality, cost, and value). DESIGN, SETTING, AND PARTICIPANTS:Cross-sectional study of US hospitals eligible for the CMS Hospital-Wide Readmission measure using Medicare data from July 2018 through June 2019. MAIN OUTCOMES AND MEASURES:We created a definition of equitable readmissions using CMS Disparity Methods, which evaluate hospitals on 2 methods: outcomes for populations at risk for disparities (across-hospital method); and disparities in care within hospitals' patient populations (within-a-single-hospital method). EXPOSURES:Hospital patient demographics; hospital characteristics; and 3 measures of hospital performance-quality, cost, and value (quality relative to cost). RESULTS:Of 4638 hospitals, 74% served a sufficient number of dual-eligible patients, and 42% served a sufficient number of Black patients to apply CMS Disparity Methods by insurance and race. Of eligible hospitals, 17% had equitable readmission rates by insurance and 30% by race. Hospitals with equitable readmissions by insurance or race cared for a lower percentage of Black patients (insurance, 1.9% [IQR, 0.2%-8.8%] vs 3.3% [IQR, 0.7%-10.8%], P < .01; race, 7.6% [IQR, 3.2%-16.6%] vs 9.3% [IQR, 4.0%-19.0%], P = .01), and differed from nonequitable hospitals in multiple domains (teaching status, geography, size; P < .01). In examining equity by insurance, hospitals with low costs were more likely to have equitable readmissions (odds ratio, 1.57 [95% CI, 1.38-1.77), and there was no relationship between quality and value, and equity. In examining equity by race, hospitals with high overall quality were more likely to have equitable readmissions (odds ratio, 1.14 [95% CI, 1.03-1.26]), and there was no relationship between cost and value, and equity. CONCLUSION AND RELEVANCE:A minority of hospitals achieved equitable readmissions. Notably, hospitals with equitable readmissions were characteristically different from those without. For example, hospitals with equitable readmissions served fewer Black patients, reinforcing the role of structural racism in hospital-level inequities. Implementation of an equitable readmission measure must consider unequal distribution of at-risk patients among hospitals.
PMID: 38193960
ISSN: 1538-3598
CID: 5626522

"I Am Not the Same as I Was Before": A Qualitative Analysis of COVID-19 Survivors

Duan, Emily; Garry, Kira; Horwitz, Leora I; Weerahandi, Himali
BACKGROUND:Little is known about the illness experience of patients' long-term emotional and physical recovery from severe COVID-19 infection. This study aimed to expand upon the recovery process of COVID-19 survivors up to 6 months after hospital discharge. METHODS:Qualitative analysis of free-response answers from a cohort study of 152 patients ≥ 18 years hospitalized with laboratory-confirmed SARS-CoV-2 surveyed at 1-month post hospital discharge and 6-months post hospital discharge. Responses were analyzed with a grounded theory approach to identify overarching themes. RESULTS:Participants described persistent complications, both physical and mental, that have affected their recovery from COVID-19. Five overarching themes of post-acute patient experiences were generated: (1) an increased awareness of a mind and body connection, (2) feelings of premature aging, (3) an overall decline in quality of life, (4) a continued fear of infection, and (5) methods of coping. CONCLUSIONS:Patients described lasting changes to their mental health and overall quality of life in connection to physical complications after severe COVID-19 infection. Patients' reports of their experience call for a greater awareness of the psychological aspects of COVID-19 recovery to provide both physical and psychological rehabilitation services. Additional resources such as education around re-infection and financial resources are needed.
PMCID:9559269
PMID: 36227557
ISSN: 1532-7558
CID: 5361052

Post-acute sequelae of SARS-CoV-2 infection in nursing homes: Do not forget the most vulnerable

Weerahandi, Himali; Rao, Mana; Boockvar, Kenneth S
PMID: 35323991
ISSN: 1532-5415
CID: 5197742

Development of an Electronic Trigger to Identify Delayed Follow-up HbA1c Testing for Patients with Uncontrolled Diabetes

Knoll, Brianna; Horwitz, Leora I; Garry, Kira; McCloskey, Jeanne; Nagler, Arielle R; Weerahandi, Himali; Chung, Wei-Yi; Blecker, Saul
PMID: 35037176
ISSN: 1525-1497
CID: 5131352

When silence is not golden: Crying and other responses to microaggressions and implicit bias in academic medicine

Weerahandi, Himali
PMID: 35504545
ISSN: 1553-5606
CID: 5216092

A library of induced pluripotent stem cells from clinically well-characterized, diverse healthy human individuals

Schaniel, Christoph; Dhanan, Priyanka; Hu, Bin; Xiong, Yuguang; Raghunandan, Teeya; Gonzalez, David M; Dariolli, Rafael; D'Souza, Sunita L; Yadaw, Arjun S; Hansen, Jens; Jayaraman, Gomathi; Mathew, Bino; Machado, Moara; Berger, Seth I; Tripodig, Joseph; Najfeld, Vesna; Garg, Jalaj; Miller, Marc; Surlyn, Colleen S; Michelis, Katherine C; Tangirala, Neelima C; Weerahandi, Himali; Thomas, David C; Beaumont, Kristin G; Sebra, Robert; Mahajan, Milind; Schadt, Eric; Vidovic, Dusica; Schürer, Stephan C; Goldfarb, Joseph; Azeloglu, Evren U; Birtwistle, Marc R; Sobie, Eric A; Kovacic, Jason C; Dubois, Nicole C; Iyengar, Ravi
A library of well-characterized human induced pluripotent stem cell (hiPSC) lines from clinically healthy human subjects could serve as a useful resource of normal controls for in vitro human development, disease modeling, genotype-phenotype association studies, and drug response evaluation. We report generation and extensive characterization of a gender-balanced, racially/ethnically diverse library of hiPSC lines from 40 clinically healthy human individuals who range in age from 22 to 61 years. The hiPSCs match the karyotype and short tandem repeat identities of their parental fibroblasts, and have a transcription profile characteristic of pluripotent stem cells. We provide whole-genome sequencing data for one hiPSC clone from each individual, genomic ancestry determination, and analysis of mendelian disease genes and risks. We document similar transcriptomic profiles, single-cell RNA-sequencing-derived cell clusters, and physiology of cardiomyocytes differentiated from multiple independent hiPSC lines. This extensive characterization makes this hiPSC library a valuable resource for many studies on human biology.
PMID: 34739849
ISSN: 2213-6711
CID: 5038502

Co-Occurring Dehydration and Cognitive Impairment During COVID-19 in Long-Term Care Patients [Letter]

Boockvar, Kenneth S; Mak, Wingyun; Burack, Orah R; Canter, Benjamin E; Reinhardt, Joann P; Spinner, Ruth; Farber, Jeffrey; Weerahandi, Himali
PMCID:8429357
PMID: 34599885
ISSN: 1538-9375
CID: 5037652