A study of US skilled nursing facility (SNF) care for 4.3 million Medicare fee-for-service beneficiaries reveals that the proportion of those who received benefits without a preceding 3-day hospitalization rose from 3% to 18% from 2020 to 2021.

The Harvard Medical School-led study used Medicare fee-for-service claims and the Minimum Data Set for 4,299,863 Medicare beneficiaries reimbursed for SNF care before (January 2018 to February 2020) and during the first 1.5 years of the COVID-19 pandemic (March 2020 to September 2021). The research was published yesterday in JAMA Internal Medicine.

When the COVID-19 public health emergency (PHE) was declared in March 2020, Medicare waived its requirement that beneficiaries have a 3-day hospital stay before receiving SNF benefits.

Overall SNF spending remained stable

From 2020 to 2021, the use of acute-care waivers increased from 3% to 18%. Among long-term care (LTC) residents, waivers climbed from 4% to 49%, with 62% of episodes provided for COVID-19 patients. SNFs in the top quartile of waiver episodes were more often for profit (80% vs 68%) and had lower quality ratings (average overall star rating, 2.7 vs 3.2; average staffing rating, 2.5 vs 3.0) than other SNFs.

Monthly Medicare SNF care spending was $2.1 billion before the pandemic, compared with $2.0 billion during the PHE. Among LTC residents, monthly SNF spending rose from $301 million to $585 million, while hospitalization costs stayed relatively stable.

For [long-term care] residents, the waiver was applied primarily for COVID-19 care, suggesting the waiver's successful implementation.

"Although the effect of the waiver cannot be differentiated from that of the pandemic, overall SNF care costs did not increase substantially; for LTC residents, the waiver was applied primarily for COVID-19 care, suggesting the waiver's successful implementation," the authors wrote.

In a related commentary, Vincent Mor, PhD, of Brown University, said it might be time to rethink the 3-day hospitalization rule. "Almost all Medicare Advantage plans have dropped it, largely because with their existing utilization review processes they are able to deflect hospital admissions and have greater flexibility in reimbursing NHs [nursing homes] for their SNF-supported stays, all of which translates into savings for them," he wrote.

Nearly two thirds of antibiotics dispensed in community pharmacies around the world are given out without a prescription, according to a paper published yesterday in The Lancet Infectious Diseases.

The mixed-methods systematic review, conducted by a team of researchers from China, analyzed 162 studies on the dispensing of non-prescription antibiotics in community and retail pharmacies covering 52 countries. The pooled prevalence of community pharmacy non-prescription antibiotic dispensing was 63.4% (95% confidence interval [CI], 59.6% to 67.1%), with the highest prevalence seen in low-income nations (75.1%; 95% CI, 65.5% to 83.7%) and the lowest in high-income nations (48.4%; 95% CI, 40.5% to 56.4%).

Broken down by disease type, dispensing of non-prescription antibiotics was highest for urinary tract infections (71.2%; 95% CI, 58.4% to 82.5%), followed by upper respiratory tract infections (63.4%; 95% CI, 55.3% to 71.1%), diarrhea (60.3%; 95% CI, 51.5% to 68.7%), and bronchitis (48.0%; 95% CI, 12.1% to 85.1%). Additionally, non-prescriptions dispensing of antibiotics was more common in adults (70.8%; 95% CI, 64.3% to 76.9%) than children (52.2%; 95% CI, 43.2% to 61.1%).

The promotion of the appropriate use of antibiotics is a complicated process.

Quantitative studies indicated that pharmacies located in poorer economic areas, those staffed by pharmacy owners, and private pharmacies were more likely to dispense non-prescription antibiotics. Analysis of qualitative studies revealed four major factors driving dispensing of antibiotics without a prescription: strong customer demand for non-prescription antibiotics combined with a lack of relevant knowledge, pharmacy staff motivated by financial or personal viewpoints, expensive or inconvenient alternative healthcare services or irregular prescribing practices, and weak social, industry, and legal regulation. 

The analysis also found that there has been no significant improvement in dispensing of non-prescription antibiotics at community pharmacies over the last 20 years, despite implementation of policies related to antibiotic sales in several countries.

"The promotion of the appropriate use of antibiotics is a complicated process," the study authors wrote. "A systematic approach, enhanced multisectoral cooperation, and mechanisms for cross-sectoral collaboration are needed."

Today in Emerging Infectious Diseases, researchers describe the epidemiologic characteristics of 118 mpox patients in Los Angeles who were homeless at the time of their diagnosis and note that 60% also had HIV. All patients were identified from July to September 2022.

Los Angeles County is home to approximately 70,000 people experiencing homelessness (PEH), and 10% identify as gay, lesbian, or bisexual. During summer 2022, mpox outbreaks among PEH became a public health concern and triggered an epidemiologic review of cases.

Researchers found the age and sex of homeless people was similar to mpox cases in the general US population, with almost all cases occurring in men, and 53% of cases occurring in people ages 30 to 39.

A total of 64 case-patients (54%) identified as gay or lesbian, 21 (18%) as bisexual or another term, 14 (12%) as heterosexual, 5 (4%) preferred not to state, and sexual orientation was unknown for 14 (12%).

Seventy-one homeless case-patients (60%) were HIV-positive; among them, 36 (51%) had unsuppressed viral loads. Those percentages were higher than those of the general population. Hospitalization was more often required for homeless case-patients (25 [21%]) because of disease severity, and a total of 42 (35%) PEH mpox case-patients received treatment with tecovirimat (Tpoxx).

No transmission in encampments

Researchers were able to locate and interview 101 (86%) homeless patients; of them, 21% reported exposure to a known or symptomatic mpox case-patient, 24% attended a large event 3 weeks before symptoms appeared, 73% reported sexual activity in the weeks before symptom onset, and 23% denied sexual activity.

"No transmission in encampments, considered congregate settings by Los Angeles County, was identified despite potential sharing of sleeping bags, clothes, and utensils in settings with poor access to cleaning and laundry services" the authors said. "One PEH mpox case-patient did report exposure without sexual contact through wearing found clothing.

No transmission in encampments, considered congregate settings by Los Angeles County, was identified.

"Additional research is needed to identify nonsexual transmission among PEH, especially among encampment residents where follow-up and contact tracing are challenging."