A commitment to change: revision of HCFA's RAI

Fewer referrals to Swedish emergency departments among nursing home patients with dementia, comprehensive cognitive decline and multicomorbidity

OBJECTIVES

The objective was to describe the extent to which nursing home patients had cognitive impairments and were diagnosed with dementia. Furthermore, to describe and compare multicomorbidity, health status and drug use in the three subgroups; dementia diagnosis/not referred, dementia diagnosis/referred and no dementia diagnosis/not referred to an emergency department (ED) over a one-year period.

METHODS

A cross-sectional follow-up study was carried out in Sweden. RAI/MDS assessments were conducted on 719 patients in 24 nursing homes, of whom 209 were referred to EDs during a one-year period, accounting for 314 visits. This study involved an extensive examination of the population.

RESULTS

The 719 patients were reported to suffer from comprehensive cognitive impairments, which not accorded with the dementia diagnoses, they were significantly fewer. Cognitive decline or dementia diagnosis contributed to a significant decrease of referrals to EDs. Patients with dementia diagnosis/not referred had difficulties understanding others, as well as impaired vision and hearing. Patients with dementia diagnosis/referred usually understood messages. Low BMI, daily pain, multicomorbidity and high drug consumption occurred in all groups. Patients with no dementia diagnosis/not referred had significantly less multicomorbidity. Neuroleptica was significantly more prevalent among those with dementia diagnosis.

CONCLUSION

Dementia remains undetected. Patients with cognitive decline and dementia are probably as sick as or even worse than others but may, due to low priority be undertreated or referrals avoided with the objective to provide good care in the setting. Observational studies are needed to identify what is done and could be done in referral situations.

Making the investment count: revision of the Minimum Data Set for nursing homes, MDS 3.0

BACKGROUND

The Minimum Data Set (MDS) is a potentially powerful tool for implementing standardized assessment in nursing homes (NHs). Its content has implications for residents, families, providers, researchers, and policymakers, all of whom have expressed concerns about the reliability, validity, and relevance of MDS 2.0. Some argue that because MDS 2.0 fails to include items that rely on direct resident interview, it fails to obtain critical information and effectively disenfranchises many residents from the assessment process.

PURPOSE

Design a major revision of the MDS, MDS 3.0, and evaluate whether the revision improves reliability, validity, resident input, clinical utility, and decreases collection burden.

DESIGN AND METHODS

In the form design phase, we gathered information from a wide range of experts, synthesized existing literature, worked with a national consortium of VA researchers to revise and test eight sections, pilot tested a draft MDS 3.0 and revised the draft based on results from the pilot. In the national validation and evaluation phase, we tested MDS 3.0 in 71 community NHs and 19 VHA NHs, regionally distributed throughout the United States. The sample was selected based on scheduled MDS 2.0 assessments. Comatose residents were excluded. A total 3822 residents of community NHs in eight states were included. The evaluation was designed to test and analyze inter-rater agreement (reliability) between research nurses and between facility staff and research nurses, validity of key sections, response rates for interview items, anonymous feedback on changes from participating nurses, and time to complete the MDS assessment.

RESULTS

The reliability for research nurse to research nurse and for research nurse to facility staff was good or excellent for most items. Response rates for the resident interview sections were high: 90% for cognitive, 86% for mood, 85% for preferences, and 87% for pain. Staff survey responses showed increased satisfaction with clinical relevance, validity and clarity compared with MDS 2.0. The test version of the MDS 3.0 took 45% less time for facilities to complete.

IMPLICATIONS

Improving the reliability, accuracy, and usefulness of the MDS has profound implications for NH care and public policy. Enhanced accuracy supports the primary legislative intent that MDS be a tool to improve clinical assessment and supports the credibility of programs that rely on MDS.

Methods to assess the validity of the interRAI Acute Care: a framework to guide clinimetric testing

The objective was to present an overview of methods to examine the validity of the minimum data set of the interRAI Acute Care (interRAI AC). Because of the multidimensional character of this comprehensive geriatric assessment tool, clinimetric testing of the interRAI AC can be more complex than that of one-dimensional instruments. Thus to facilitate testing of the interRAI AC, we translated this complexity into a structured methodological framework that outlines procedures to assess various lines of evidence. Our framework combined traditional clinimetric techniques and the standards of psychological testing. For each line of evidence, examples of hypotheses and research questions were summarized. Future clinimetric testing can use these guidelines as a basis to obtain and provide a wide and diverse body of evidence.

Beyond the 'iron lungs of gerontology': using evidence to shape the future of nursing homes in Canada

Institutionalization of the Elderly in Canada suggested that efforts to address the underlying causes of age-related declines in health might negate the need for nursing homes. However, the prevalence of chronic disease has increased, and conditions like dementia mean that nursing homes are likely to remain important features of the Canadian health care system. A fundamental problem limiting the ability to understand how nursing homes may change to better meet the needs of an aging population was the lack of person-level clinical information. The introduction of interRAI assessment instruments to most Canadian provinces/territories and the establishment of the national Continuing Care Reporting System represent important steps in our capacity to understand nursing home care in Canada. Evidence from eight provinces and territories shows that the needs of persons in long-term care are highly complex, resource allocations do not always correspond to needs, and quality varies substantially between and within provinces.

Does information matter? Competition, quality, and the impact of nursing home report cards

OBJECTIVE

We evaluate the effects of the Nursing Home Quality Initiative (NHQI), which introduced quality measures to the Centers for Medicare and Medicaid Services' Nursing Home Compare website, on facility performance and consumer demand for services.

DATA SOURCES

The nursing home Minimum Data Set facility reports from 1999 to 2005 merged with facility-level data from the On-Line Survey, Certification, and Reporting System.

STUDY DESIGN

We rely on the staggered rollout of the report cards across pilot and nonpilot states to examine the effect of report cards on market share and quality of care. We also exploit differences in nursing home market competition at baseline to identify the impacts of the new information on nursing home quality.

RESULTS

The introduction of the NHQI was generally unrelated to facility quality and consumer demand. However, nursing homes facing greater competition improved their quality more than facilities in less competitive markets.

CONCLUSIONS

The lack of competition in many nursing home markets may help to explain why the NHQI report card effort had a minimal effect on nursing home quality. With the introduction of market-based reforms such as report cards, this result suggests policy makers must also consider market structure in efforts to improve nursing home performance.

The effectiveness of case management for comorbid diabetes type 2 patients; the CasCo study. Design of a randomized controlled trial

Background

More than half of the patients with type 2 diabetes (T2DM) patients are diagnosed with one or more comorbid disorders. They can participate in several single-disease oriented disease management programs, which may lead to fragmented care because these programs are not well prepared for coordinating care between programs. Comorbid patients are therefore at risk for suboptimal treatment, unsafe care, inefficient use of health care services and unnecessary costs. Case management is a possible model to counteract fragmented care for comorbid patients. It includes evidence-based optimal care, but is tailored to the individual patients' preferences.

The objective of this study is to examine the effectiveness of a case management program, in addition to a diabetes management program, on the quality of care for comorbid T2DM patients.

Methods/Design

The study is a randomized controlled trial among patients with T2DM and at least one comorbid chronic disease (N = 230), who already participate in a diabetes management program. Randomization will take place at the level of the patients in general practices. Trained practice nurses (case managers) will apply a case management program in addition to the diabetes management program. The case management intervention is based on the Guided Care model and includes six elements; assessing health care needs, planning care, create access to other care providers and community resources, monitoring, coordinating care and recording of all relevant information. Patients in the control group will continue their participation in the diabetes management program and receive care-as-usual from their general practitioner and other care providers.

Discussion

We expect that the case management program, which includes better structured care based on scientific evidence and adjusted to the patients' needs and priorities, will improve the quality of care coordination from both the patients' and caregivers' perspective and will result in less consumption of health care services.

Trial registration

Netherlands Trial Register (NTR): NTR1847

Using the RUG-III classification system for understanding the resource intensity of persons with intellectual disability residing in nursing homes

Since 1991, the Minimum Data Set 2.0 (MDS 2.0) has been the mandated assessment in US nursing homes. The Resource Utilization Groups III (RUG-III) case-mix system provides person-specific means of allocating resources based on the variable costs of caring for persons with different needs. Retrospective analyses of data collected on a sample of 9707 nursing home residents (2.4% had an intellectual disability) were used to examine the fit of the RUG-III case-mix system for determining the cost of supporting persons with intellectual disability (intellectual disability). The RUG-III system explained 33.3% of the variance in age-weighted nursing time among persons with intellectual disability compared to 29.6% among other residents, making it a good fit among persons with intellectual disability in nursing homes. The RUG-III may also serve as the basis for the development of a classification system that describes the resource intensity of persons with intellectual disability in other settings that provide similar types of support.

Methodological issues in fall prevention research involving older adults in long-term care facilities

The purpose of this study was to conduct a systematic review of the current fall prevention literature, examining methodological issues resulting from variations in fall definitions, methods of data collection, and standards for reporting fall rates in studies involving older adults in long-term care settings. This systematic review used the five stages of Whittemore and Knafl's review methodology to extract data from the databases, summarize, and synthesize the findings of the 10 studies included. The Critical Appraisal Skill Program checklist for randomized controlled trials criteria was used to appraise the methodological quality of the studies. Inconsistencies in fall definitions, methods of data collection, and standards for reporting fall rates were apparent across the studies reviewed. Standardized approaches to defining falls, collecting data, and reporting fall rates are necessary to interpret, make comparisons among, and disseminate the findings of studies.

Temporal and Geographic variation in the validity and internal consistency of the Nursing Home Resident Assessment Minimum Data Set 2.0

Background

The Minimum Data Set (MDS) for nursing home resident assessment has been required in all U.S. nursing homes since 1990 and has been universally computerized since 1998. Initially intended to structure clinical care planning, uses of the MDS expanded to include policy applications such as case-mix reimbursement, quality monitoring and research. The purpose of this paper is to summarize a series of analyses examining the internal consistency and predictive validity of the MDS data as used in the "real world" in all U.S. nursing homes between 1999 and 2007.

Methods

We used person level linked MDS and Medicare denominator and all institutional claim files including inpatient (hospital and skilled nursing facilities) for all Medicare fee-for-service beneficiaries entering U.S. nursing homes during the period 1999 to 2007. We calculated the sensitivity and positive predictive value (PPV) of diagnoses taken from Medicare hospital claims and from the MDS among all new admissions from hospitals to nursing homes and the internal consistency (alpha reliability) of pairs of items within the MDS that logically should be related. We also tested the internal consistency of commonly used MDS based multi-item scales and examined the predictive validity of an MDS based severity measure viz. one year survival. Finally, we examined the correspondence of the MDS discharge record to hospitalizations and deaths seen in Medicare claims, and the completeness of MDS assessments upon skilled nursing facility (SNF) admission.

Results

Each year there were some 800,000 new admissions directly from hospital to US nursing homes and some 900,000 uninterrupted SNF stays. Comparing Medicare enrollment records and claims with MDS records revealed reasonably good correspondence that improved over time (by 2006 only 3% of deaths had no MDS discharge record, only 5% of SNF stays had no MDS, but over 20% of MDS discharges indicating hospitalization had no associated Medicare claim). The PPV and sensitivity levels of Medicare hospital diagnoses and MDS based diagnoses were between .6 and .7 for major diagnoses like CHF, hypertension, diabetes. Internal consistency, as measured by PPV, of the MDS ADL items with other MDS items measuring impairments and symptoms exceeded .9. The Activities of Daily Living (ADL) long form summary scale achieved an alpha inter-consistency level exceeding .85 and multi-item scale alpha levels of .65 were achieved for well being and mood, and .55 for behavior, levels that were sustained even after stratification by ADL and cognition. The Changes in Health, End-stage disease and Symptoms and Signs (CHESS) index, a summary measure of frailty was highly predictive of one year survival.

Conclusion

The MDS demonstrates a reasonable level of consistency both in terms of how well MDS diagnoses correspond to hospital discharge diagnoses and in terms of the internal consistency of functioning and behavioral items. The level of alpha reliability and validity demonstrated by the scales suggest that the data can be useful for research and policy analysis. However, while improving, the MDS discharge tracking record should still not be used to indicate Medicare hospitalizations or mortality. It will be important to monitor the performance of the MDS 3.0 with respect to consistency, reliability and validity now that it has replaced version 2.0, using these results as a baseline that should be exceeded.

Relationship between quality of care and negligence litigation in nursing homes

BACKGROUND

It is unclear whether high-quality health care institutions are less likely to be sued for negligence than their low-performing counterparts.

METHODS

We linked information on tort claims brought against 1465 nursing homes between 1998 and 2006 to 10 indicators of nursing home quality drawn from two U.S. national data sets: the Online Survey, Certification, and Reporting system and the Minimum Data Set Quality Measure/Indicator Report. We tested for associations between the incidence of claims and the quality measures at the facility calendar-quarter level, correcting for facility clustering and adjusting for case mix, ownership, occupancy, year, and state. Odds ratios were calculated for the effect of a change of 1 SD in each quality measure on the odds of one or more claims in each facility calendar-quarter.

RESULTS

Nursing homes with more deficiencies (odds ratio, 1.09; 95% confidence interval [CI], 1.05 to 1.13) and those with more serious deficiencies (odds ratio, 1.04; 95% CI, 1.00 to 1.08) had higher odds of being sued; this was also true for nursing homes that had more residents with weight loss (odds ratio, 1.05; 95% CI, 1.01 to 1.10) and with pressure ulcers (odds ratio, 1.09; 95% CI, 1.05 to 1.14). The odds of being sued were lower in nursing homes with more nurse's aide-hours per resident-day (odds ratio, 0.95; 95% CI, 0.91 to 0.99). However, all these effects were relatively small. For example, nursing homes with the best deficiency records (10th percentile) had a 40% annual risk of being sued, as compared with a 47% risk among nursing homes with the worst deficiency records (90th percentile).

CONCLUSIONS

The best-performing nursing homes are sued only marginally less than the worst-performing ones. Such weak discrimination may subvert the capacity of litigation to provide incentives to deliver safer care.

The implementation of the serial trial intervention for pain and challenging behaviour in advanced dementia patients (STA OP!): a clustered randomized controlled trial

Background

Pain (physical discomfort) and challenging behaviour are highly prevalent in nursing home residents with dementia: at any given time 45-80% of nursing home residents are in pain and up to 80% have challenging behaviour. In the USA Christine Kovach developed the serial trial intervention (STI) and established that this protocol leads to less discomfort and fewer behavioural symptoms in moderate to severe dementia patients. The present study will provide insight into the effects of implementation of the Dutch version of the STI-protocol (STA OP!) in comparison with a control intervention, not only on behavioural symptoms, but also on pain, depression, and quality of life. This article outlines the study protocol.

Methods/Design

The study is a cluster randomized controlled trial in 168 older people (aged >65 years) with mild or moderate dementia living in nursing homes. The clusters, Dutch nursing homes, are randomly assigned to either the intervention condition (training and implementation of the STA OP!-protocol) or the control condition (general training focusing on challenging behaviour and pain, but without the step-wise approach). Measurements take place at baseline, after 3 months (end of the STA OP! training period) and after 6 months.

Primary outcome measures are symptoms of challenging behaviour (measured with the Cohen-Mansfield Agitation Inventory (CMAI) and the Neuropsychiatric Inventory-Nursing Home version (NPI-NH)), and pain (measure with the Dutch version of the Pain Assessment Checklist for Seniors (PACSLAC-D) and the Minimum Data Set of the Resident Assessment Instrument (MDS-RAI) pain scale). Secondary outcome measures include symptoms of depression (Cornell and MDS-RAI depression scale), Quality of Live (Qualidem), changes in prescriptions of analgesics and psychotropic drugs, and the use of non-pharmacological comfort interventions (e.g. snoezelen, reminiscence therapy).

Discussion

The transfer from the American design to the Dutch design involved several changes due to the different organisation of healthcare systems. Specific strengths and limitations of the study are discussed.

Trial registration

Netherlands Trial Register (NTR): NTR1967

Private equity investment and nursing home care: is it a big deal?

Private equity investors have recently targeted nursing home chains as investment opportunities. Media attention has raised quality-of-care concerns, but little has been published in the research literature on the topic. Using a multivariate framework, we assessed how private equity purchases of nursing homes affected a range of outcomes. Although some transactions are quite recent, we found little evidence to suggest that nursing home quality worsens significantly following purchase by private equity companies. Nonetheless, recent nursing home ownership trends raise important questions about oversight and accountability, whose answers extend beyond private equity ownership.

Medicaid bed-hold policy and Medicare skilled nursing facility rehospitalizations

OBJECTIVE

To analyze the effect of states' Medicaid bed-hold policies on the 30-day rehospitalization of Medicare postacute skilled nursing facility (SNF) residents.

DATA SOURCES

Minimum data set assessments were merged with Medicare claims and eligibility files for all first-time SNF admissions (N = 3,322,088) over the period 2000 through 2005; states' Medicaid bed-hold policies were obtained via survey.

STUDY DESIGN

Regression specification incorporating facility fixed effects to examine changes in Medicaid bed-hold policies on the likelihood of a 30-day SNF rehospitalization.

PRINCIPAL FINDINGS

Using a continuous measure of bed-hold generosity, state Medicaid bed-hold was positively related to Medicare SNF rehospitalization. Specifically, the introduction of a bed-hold policy with average generosity increases Medicare rehospitalizations by 1.8 percent, representing roughly 12,000 SNF rehospitalizations at a cost to Medicare of approximately U.S.$100 million over our study period.

CONCLUSIONS

Although facilities do not receive a Medicaid bed-hold payment for Medicare SNF stays, we found that the adoption of more generous policies led to greater SNF rehospitalizations. This type of spillover is largely ignored in current discussions of Medicare payment reforms such as bundled payment. Neither Medicare nor Medicaid has an incentive to internalize the risks and benefits of its actions as they affect the other.

A RUG-III Case-Mix System for Home Care

Le système de classification de la composition de la clientèle des maisons de soins infirmiers, Resource Utilization Groups Version III (RUG-III), a été éprouvé et raffiné pour les bénéficiaires de soins de longue durée à domicile. Lapos;échantillonnage étudié regroupe 804 personnes recevant des soins à domicile par l'entremise du Michigan Care Management Program ou du Home and Community Based Waiver for the Elderly and Disabled. On a catégorisé les clients et établi des modèles de RUG-III à partir du Minimum Data Set for Home Care (MDS-HC). On a établi un modèle raffiné de soins à domicile, RUG-III/HC, en incorporant les activités instrumentales de la vie quotidienne (AIVQ) à la classification RUG-EH des établissements de soins. Le modèle explique 33,7 pour cent de la variance des coûts quotidiens, à partir de la variable dépendante du coût pondéré des soins structurés ou non. L'utilisation des ressources à l'égard des différents groupes est relativement homogène. Le CMI (case-mix index) du temps pondéré des soins structurés ou non couvre une échelle de 8. Il faudra songer à effectuer des analyses plus poussées du coût de l'inclusion des soins non structurés à l'égard des patients recevant des soins à domicile de longue durée.

Measuring Health Outcomes for Older People Using the Sage Database

Cet article cherche à établir le potentiel d'évaluation des programmes d'une base de données sur les soins de longue durée dans la communauté. Les données proviennent d'un projet-pilote sur la qualité et la clientèle du Health Care Financing Administration, incluant tous les établissements couverts par Medicare/ Medicaid de cinq états américains entre 1992 et 1994. À l'aide du Minimum Data Set, 70 000 résidents de plus de 65 ans souffrant d'insuffisance cardiaque globale ont été identifiés. L'analyse préliminaire de la pharmacothérapie de l'insuffisance cardiaque globale et de ses effets sur le déclin des fonctions physiques est présentée. L'état des fonctions physiques, mesuré par le taux de déclin des activités instrumentales de la vie quotidienne des patients qui suivent une thérapie combinée s'améliore par rapport à ceux qui prennent seulement de la digoxine ou des inhibiteurs de l'enzyme convertissant l'angiotensine. La disponibilité d'un ensemble de donnees sur la population fournit done une méthode d'évaluation des politiques et des pratiques courantes.

Stress, Social Engagement and Psychological Well-Being in Institutional Settings: Evidence Based on the Minimum Data Set 2.0

Alors qu'il existe une importante documentation sur la relation entre le stress, le soutien social et le bien-etrê chez les aîné(e)s vivant dans la communauté, peu d'études ont examiné la population des institutions. Cette étude a utilisé les données d'enquêtes pilotes du MDS 2.0 de trois hôpitaux ainsi que d'autres enquêtes reliées au bien-être psychologique. On a constaté que les patients les plus engagés socialement avaient tendance à afficher des niveaux plus élevés de bien-être et cette tendance était encore plus frappante chez ceux qui jouissaient d'un meilleur état de santé. La douleur était un prédicteur important de la réduction du bien-être. Étant donné que le MDS 2.0 fournit une approche complète à l'identification des problèmes sociaux, psychologiques et physiques et à leur réponse chez les aîné(e)s vivant en institution, il peut entraîner des effets importants sur le bien-être si on l'utilise à l'appui de la prise de décision et des interventions cliniques.

Cross-National Comparisons of Antidepressant Use Among Institutionalized Older Persons Based on the Minimum Data Set (MDS)

On a examiné l'usage des antidépresseurs dans des échantillons provenant d'établissements de soins de longue durée de Toronto (Canada), Sapporo et Naie (Japon), Reykjavik (Islande) et Prague (République tchéque). C'est seulement en Islande que la majorité des résidents souffrant de dépression recevaient des antidépresseurs. Le taux de dépression et l'usage des antidépresseurs sont généralement faibles au Japon. On a constaté un écart important entre le diagnostic de dépression et le comportement dépressif en République tchèque. Dans tous les pays examinés, environ la moitié des utilisateurs d'antidépresseurs ne présentent pas de symptômes évidents de dépression. Dans certains pays, l'usage des antidépresseurs était moins élevé chez les résidentes, chez les aîné(e)s plus âgés ou plus handicapés. La dépression est clairement sous-diagnostiqué en République tchèque mais les faibles taux de dépression au Japon sont plus difficiles à interpréter. Étant donné l'opinion largement répandue voulant que la dépressione passe souvent inaperçue et soit done mal soignée, les résultats de l'étude laissent entendre que l'on pourrait améliorer les mesures prises dans les cas de dépression grâce à des outils comme le MDS.

The impact of social networks on knowledge transfer in long-term care facilities: Protocol for a study

BACKGROUND

Social networks are theorized as significant influences in the innovation adoption and behavior change processes. Our understanding of how social networks operate within healthcare settings is limited. As a result, our ability to design optimal interventions that employ social networks as a method of fostering planned behavior change is also limited. Through this proposed project, we expect to contribute new knowledge about factors influencing uptake of knowledge translation interventions.

OBJECTIVES

Our specific aims include: To collect social network data among staff in two long-term care (LTC) facilities; to characterize social networks in these units; and to describe how social networks influence uptake and use of feedback reports.

METHODS AND DESIGN

In this prospective study, we will collect data on social networks in nursing units in two LTC facilities, and use social network analysis techniques to characterize and describe the networks. These data will be combined with data from a funded project to explore the impact of social networks on uptake and use of feedback reports. In this parent study, feedback reports using standardized resident assessment data are distributed on a monthly basis. Surveys are administered to assess report uptake. In the proposed project, we will collect data on social networks, analyzing the data using graphical and quantitative techniques. We will combine the social network data with survey data to assess the influence of social networks on uptake of feedback reports.

DISCUSSION

This study will contribute to understanding mechanisms for knowledge sharing among staff on units to permit more efficient and effective intervention design. A growing number of studies in the social network literature suggest that social networks can be studied not only as influences on knowledge translation, but also as possible mechanisms for fostering knowledge translation. This study will contribute to building theory to design such interventions.

The Resident Assessment Instrument-Minimum Data Set 2.0 quality indicators: a systematic review

Background

The Resident Assessment Instrument-Minimum Data Set (RAI-MDS) 2.0 is designed to collect the minimum amount of data to guide care planning and monitoring for residents in long-term care settings. These data have been used to compute indicators of care quality. Use of the quality indicators to inform quality improvement initiatives is contingent upon the validity and reliability of the indicators. The purpose of this review was to systematically examine published and grey research reports in order to assess the state of the science regarding the validity and reliability of the RAI-MDS 2.0 Quality Indicators (QIs).

Methods

We systematically reviewed the evidence for the validity and reliability of the RAI-MDS 2.0 QIs. A comprehensive literature search identified relevant original research published, in English, prior to December 2008. Fourteen articles and one report examining the validity and/or reliability of the RAI-MDS 2.0 QIs were included.

Results

The studies fell into two broad categories, those that examined individual quality indicators and those that examined multiple indicators. All studies were conducted in the United States and included from one to a total of 209 facilities. The number of residents included in the studies ranged from 109 to 5758. One study conducted under research conditions examined 38 chronic care QIs, of which strong evidence for the validity of 12 of the QIs was found. In response to these findings, the 12 QIs were recommended for public reporting purposes. However, a number of observational studies (n = 13), conducted in "real world" conditions, have tested the validity and/or reliability of individual QIs, with mixed results. Ten QIs have been studied in this manner, including falls, depression, depression without treatment, urinary incontinence, urinary tract infections, weight loss, bedfast, restraint, pressure ulcer, and pain. These studies have revealed the potential for systematic bias in reporting, with under-reporting of some indicators and over-reporting of others.

Conclusion

Evidence for the reliability and validity of the RAI-MDS QIs remains inconclusive. The QIs provide a useful tool for quality monitoring and to inform quality improvement programs and initiatives. However, caution should be exercised when interpreting the QI results and other sources of evidence of the quality of care processes should be considered in conjunction with QI results.

Rated cognition in nursing home residents with multiple sclerosis: cross-sectional and longitudinal analyses

PURPOSE

To examine cognitive change in nursing home residents with multiple sclerosis (MS) over the first year of a nursing home stay and to predict cognition functioning in these residents at admission and the 1-year annual assessment.

METHOD

In the first part of this study, the cognitive functioning of nursing home residents with MS (n = 1890) and without MS (n = 22,985) were compared. In the second part, demographic and other variables were used to predict cognition at the admission and 1-year annual assessment for MS residents.

RESULTS

Nursing home residents with MS had better cognitive functioning than residents without MS at admission and 1 year later. Regression analyses demonstrated that higher education and pain predicted higher Minimum Data Set Cognition Scale (MDS-Cog) at admission and at 1 year later, but poorer activities of daily living predicted worse MDS-Cog at admission and 1 year later. For the longitudinal analysis, MDS-Cog at the admission assessment was an independent predictor of MDS-Cog scores at the 1-year annual assessment.

CONCLUSIONS

Nursing home residents with MS have significantly better cognitive functioning than non-MS residents and, over the first year of a nursing home stay, higher education and pain, but lower activities of daily living, predict poorer cognitive functioning.

Antipsychotic use and the risk of hip fracture among older adults afflicted with dementia

OBJECTIVE

To quantify the association between use of antipsychotic (AP) medications and the risk of hip fracture among older adults residing in a nursing home (NH) and afflicted with dementia.

DESIGN

Nested case-control study.

SETTING

NHs in California, Florida, Illinois, New York, and Ohio in 2001-2002 (N=586).

PARTICIPANTS

The source population consisted of long-stay Medicaid-eligible residents living in NHs with at least 20 beds, who were 65 years of age or older and had a diagnosis of dementia but were not receiving hospice care, were not comatose, bedfast, paralyzed, or in a wheelchair, and had no record of a previous hip fracture (N=69,027). There were 764 cases of hip fracture identified; up to 5 controls, matched to cases on NH and quarter of Minimum Data Set (MDS) assessment, were randomly selected from the source population (N=3582).

MEASUREMENTS

Cases of hip fracture were identified and medication use was ascertained from Medicaid claims data. Resident-level characteristics, including dementia severity, were obtained from resident MDS assessments.

RESULTS

Current use of APs conveyed a small increased risk of hip fracture (adjusted odds ratio=1.26; 95% confidence interval: 1.05 -1.52). When analyzed separately, users of conventional antipsychotics had a slightly higher risk of hip fracture than residents on atypical agents. Long-term use of APs conferred a greater risk of hip fracture than short-term use.

CONCLUSION

APs appear to increase the risk of hip fracture among older adults with dementia residing in an NH. Hip fractures may be a contributory mechanism to the increased risk mortality observed among AP users.

Neglecting the importance of the decision making and care regimes of personal support workers: a critique of standardization of care planning through the RAI/MDS

PURPOSE

The Resident Assessment Instrument-Minimum Data Set (RAI/MDS) is an interdisciplinary standardized process that informs care plan development in nursing homes. This standardized process has failed to consistently result in individualized care planning, which may suggest problems with content and planning integrity. We examined the decision making and care practices of personal support workers (PSWs) in relation to the RAI/MDS standardized process.

DESIGN AND METHODS

This qualitative study utilized focus groups and semi-structured interviews with PSWs (n = 26) and supervisors (n = 9) in two nursing homes in central Canada.

RESULTS

PSWs evidenced unique occupational contributions to assessment via proximal familiarity and biographical information as well as to individualizing care by empathetically linking their own bodily experiences and forging bonds of fictive kinship with residents. These contributions were neither captured by RAI/MDS categories nor relayed to the interdisciplinary team. Causal factors for PSW exclusion included computerized records, low status, and poor interprofessional collaboration. Intraprofessional collaboration by PSWs aimed to compensate for exclusion and to individualize care.

IMPLICATIONS

Exclusive institutional reliance on the RAI/MDS undermines quality care because it fails to capture residents' preferences and excludes input by PSWs. Recommendations include incorporating PSW knowledge in care planning and documentation and examining PSWs' nascent occupational identity and their role as interprofessional brokers in long-term care.

Comparing the functional independence measure and the interRAI/MDS for use in the functional assessment of older adults: a review of the literature

BACKGROUND

The rehabilitation of older persons is often complicated by increased frailty and medical complexity - these in turn present challenges for the development of health information systems. Objective investigation and comparison of the effectiveness of geriatric rehabilitation services requires information systems that are comprehensive, reliable, valid, and sensitive to clinically relevant changes in older persons. The Functional Independence Measure is widely used in rehabilitation settings - in Canada this is used as the central component of the National Rehabilitation Reporting System of the Canadian Institute of Health Information. An alternative system has been developed by the interRAI consortium. We conducted a literature review to compare the development and measurement properties of these two systems.

METHODS

English language literature published between 1983 (initial development of the FIM) and 2008 was searched using Medline and CINAHL databases, and the reference lists of retrieved articles. Relevant articles were summarized and charted using the criteria proposed by Streiner. Additionally, attention was paid to the ability of the two systems to address issues particularly relevant to older rehabilitation clients, such as medical complexity, comorbidity, and responsiveness to small but clinically meaningful improvements.

RESULTS

In total, 66 articles were found that met the inclusion criteria. The majority of FIM articles studied inpatient rehabilitation settings; while the majority of interRAI/MDS articles focused on nursing home settings. There is evidence supporting the reliability of both instruments. There were few articles that investigated the construct validity of the interRAI/MDS.

CONCLUSION

Additional psychometric research is needed on both the FIM and MDS, especially with regard to their use in different settings and with different client groups.

Person-environment interactions contributing to nursing home resident falls

Although approximately 50% of nursing home residents fall annually, the surrounding circumstances remain inadequately understood. This study explored nursing staff perspectives of person, environment, and interactive circumstances surrounding nursing home falls. Focus groups were conducted at two nursing homes in the mid-Atlantic region with the highest and lowest fall rates among corporate facilities. Two focus groups were conducted per facility: one with licensed nurses and one with geriatric nursing assistants. Thematic and content analysis revealed three themes and 11 categories. Three categories under the Person theme were Change in Residents' Health Status, Decline in Residents' Abilities, and Residents' Behaviors and Personality Characteristics. There were five Nursing Home Environment categories: Design Safety, Limited Space, Obstacles, Equipment Misuse and Malfunction, and Staff and Organization of Care. Three Interactions Leading to Falls categories were identified: Reasons for Falls, Time of Falls, and High-Risk Activities. Findings highlight interactions between person and environment factors as significant contributors to resident falls.

Instruments for measuring fall risk in older adults living in long-term care facilities: an integrative review

Lack of consistency in the literature regarding the use of fall risk assessment in long-term care settings and the uniqueness of the environment demand a critical analysis of fall risk instruments specific to older adults living in long-term care facilities. This integrative review of the existing literature on instruments used to measure fall risk in residents living in long-term care facilities revealed a total of 16 fall risk assessment tools from 13 studies. Of the 13 studies, only 8 reported sensitivity, specificity, and interrater reliability values of the tools. Only the Morse Fall Scale and Mobility Fall Chart demonstrated high predictive values in their initial developmental studies. This review can help clinicians make informed choices about tools to predict falls in their settings and establish appropriate preventive interventions.

Depression is the strongest independent risk factor for poor social engagement among Chinese elderly veteran assisted-living residents

BACKGROUND

Social engagement prolongs the lifespan and preserves cognition in the elderly. However, most studies concerning social engagement have been conducted in Western countries; few have been performed in the Chinese population. This study attempted to identify the risk factors for poor social engagement among elderly veterans in Taiwan.

METHODS

A total of 597 male veterans were enrolled, with a mean age of 80.8 +/- 5.0 years. This cross-sectional study employed the Resident Assessment Instrument (RAI) Minimum Data Set (MDS), the Geriatric Depression Scale-Short Form (GDS-SF), and the Mini-Mental State Examination (MMSE). Multivariate logistic regression analysis was done to investigate significant independent risk factors for poor social engagement, which were identified using the MDS Index of Social Engagement (ISE).

RESULTS

Mean ISE score was 1.5 +/- 1.3 (range, 0-5); 52% of subjects had poor levels of social engagement (ISE < 2; 312/597). Regression analyses suggested that depression (OR, 6.6; 95% CI, 2.7-16.1; p < 0.001), illiteracy (OR, 2.2; 95% CI, 1.3-3.8; p = 0.003), the presence of unsettled relationships (OR, 3.6; 95% CI, 1.5-8.7; p = 0.004), and cognitive impairment (OR, 2.0; 95% CI, 1.1-3.9; p = 0.03) were significant independent risk factors for poor social engagement, after controlling for age, marital status, level of daily living activity and degree of sensory impairment.

CONCLUSION

Poor social engagement is common among Chinese assisted-living veteran home residents. Depression is the greatest risk factor of poor social engagement in this population.

Study protocol for the translating research in elder care (TREC): building context - an organizational monitoring program in long-term care project (project one)

Background

While there is a growing awareness of the importance of organizational context (or the work environment/setting) to successful knowledge translation, and successful knowledge translation to better patient, provider (staff), and system outcomes, little empirical evidence supports these assumptions. Further, little is known about the factors that enhance knowledge translation and better outcomes in residential long-term care facilities, where care has been shown to be suboptimal. The project described in this protocol is one of the two main projects of the larger five-year Translating Research in Elder Care (TREC) program.

Aims

The purpose of this project is to establish the magnitude of the effect of organizational context on knowledge translation, and subsequently on resident, staff (unregulated, regulated, and managerial) and system outcomes in long-term care facilities in the three Canadian Prairie Provinces (Alberta, Saskatchewan, Manitoba).

Methods/Design

This study protocol describes the details of a multi-level – including provinces, regions, facilities, units within facilities, and individuals who receive care (residents) or work (staff) in facilities – and longitudinal (five-year) research project. A stratified random sample of 36 residential long-term care facilities (30 urban and 6 rural) from the Canadian Prairie Provinces will comprise the sample. Caregivers and care managers within these facilities will be asked to complete the TREC survey – a suite of survey instruments designed to assess organizational context and related factors hypothesized to be important to successful knowledge translation and to achieving better resident, staff, and system outcomes. Facility and unit level data will be collected using standardized data collection forms, and resident outcomes using the Resident Assessment Instrument-Minimum Data Set version 2.0 instrument. A variety of analytic techniques will be employed including descriptive analyses, psychometric analyses, multi-level modeling, and mixed-method analyses.

Discussion

Three key challenging areas associated with conducting this project are discussed: sampling, participant recruitment, and sample retention; survey administration (with unregulated caregivers); and the provision of a stable set of study definitions to guide the project.

Reliability estimates of clinical measures between Minimum Data Set and Online Survey Certification and Reporting data of US nursing homes

BACKGROUND

Evidence-based quality improvement in nursing homes relies heavily on administrative data. Minimum Data Set (MDS) and Online Survey Certification and Reporting (OSCAR) are the 2 largest sources of national nursing home administrative data. Although clinical measures in each of the data systems have frequently and independently been used to measure nursing home performance, no study has systematically examined their relative reliability.

OBJECTIVES

This study estimates the reliability of clinical measures between MDS and OSCAR data and discusses the utility of these databases in research.

RESEARCH DESIGN

We analyzed 4 waves of national MDS and OSCAR data (1999-2002). A comparable group of 24 clinical indicators from both datasets was selected for the reliability test. Spearman rank-order correlation analyses were used to measure the test-retest reliability relationships.

RESULTS

Across the 4 years, the majority of coefficients of clinical measures exhibit good reliability. There are 17 clinical measures (71% of the total measures) with correlation coefficients greater than 0.4, the minimally acceptable reliability threshold according to Morris. The highest correlation coefficients were associated with tube feeding at 0.883.

CONCLUSIONS

Our findings indicate that the target clinical measures in OSCAR and MDS are generally consistent and reliable. However, researchers should use OSCAR self-reported clinical measures to measure nursing home outcomes in place of corresponding MDS clinical measures with caution because some indicators in the administrative data are more reliable than others.

Relationship between interRAI HC and the ICF: opportunity for operationalizing the ICF

Background

The International Classification of Functioning, Disability and Health (ICF) is embraced as a framework to conceptualize human functioning and disability. Health professionals choose measures to represent the domains of the framework. The ICF coding classification is an administrative system but multiple studies have linked diverse clinical assessments to ICF codes. InterRAI-HC (home care) is an assessment designed to assist planning of care for patients receiving home care. Examining the relationship between the ICF and the interRAI HC is of particular interest because the interRAI assessments are widely used in clinical practice and research, are computerized, and uploaded to databases that serve multiple purposes including public reporting of quality in Canada and internationally. The objective of this study was to examine the relationship between the interRAI HC (home care) assessment and the ICF. Specifically, the goal was to determine the proportion of interRAI HC items that can be linked to each of the major domains of the ICF (Body Function, Body Structure, Activities and Participation, and the Environmental Factors), the chapters and the specific ICF codes.

Methods

Three coders who were familiar with both the home care assessment and the ICF independently assigned ICF codes to inter-RAI HC items. Subsequently, a series of teleconference meetings were held to reach consensus on the primary code and much later consensus was used to finalize codes for additional items added to the interRAI HC.

Results

Following exclusion of administrative and diagnostic sections, 175 interRAI items were examined for potential assignment of codes. Of these 52 were assigned codes related to body function, 43 to activities and participation, 34 to environment, 1 to body structure, 17 to not coded, and 26 to not defined. Considering all 3-digit ICF codes, interRAI items addressed 43.2% of Body Function and 50.6% of Activities and Participation codes.

Conclusion

The conceptual overlap in content, offers an excellent opportunity to operationalize the ICF domains and the codes particularly in the areas of Body Function and Activities and Participation. Use of measures such as the interRAI assessments with common elements across settings facilitates standardized reporting for organizations, regions and nations.

The nursing home minimum data set for vision and its association with visual acuity and contrast sensitivity

OBJECTIVES

To evaluate the association between the Minimum Data Set's (MDS) Vision Patterns section and near and distance visual acuity and contrast sensitivity in nursing home residents.

DESIGN

Cross-sectional study.

SETTING

Seventeen nursing homes in the Birmingham, Alabama, area.

PARTICIPANTS

Three hundred seventy-one nursing home residents aged 55 and older with Mini-Mental State Examination scores of 13 or greater.

MEASUREMENTS

The MDS 2.0 assessment for vision from the date closest to acuity and contrast sensitivity assessment were obtained from the resident's medical record. Acuity and contrast sensitivity were measured using the ETDRS chart and Pelli-Robson chart, respectively.

RESULTS

The MDS rating of visual status was associated with distance and near visual acuity and contrast sensitivity. The MDS performed poorly in distinguishing residents with mild visual impairment from those with moderate visual impairment. For residents who were rated on the MDS as having adequate vision, 45.9% had distance acuity worse than 20/40 in the better eye, 72.8% had near acuity worse than 20/40 in the better eye, and 85.8% had contrast sensitivity less than 1.50.

CONCLUSION

The MDS 2.0 assessment for vision in nursing home residents is positively associated with visual acuity and contrast sensitivity but does not adequately distinguish between individuals with mild and moderate visual impairment and classifies many as having adequate vision who have visual impairment. The validity of the MDS 2.0 as a mechanism for triggering comprehensive eye care for nursing home residents is questionable.

Survival prediction in nursing home residents using the Minimum Data Set subscales: ADL Self-Performance Hierarchy, Cognitive Performance and the Changes in Health, End-stage disease and Symptoms and Signs scales

BACKGROUND

With the intention to aid planning for elderly focused public health and residential care needs in rapidly aging societies, a simple model using only age, gender and three Minimum Data Set (MDS) subscales (MDS-ADL Self-Performance Hierarchy, MDS-Cognitive Performance and the MDS-Changes in Health, End-stage disease and Symptoms and Signs scales) was used to estimate long-term survival of older people moving into nursing homes.

METHODS

A total of 1820 nursing home residents were assessed by the MDS 2.0 and their mortality status 5 years later was used to develop a survival prediction model.

RESULT

In December 2006, 54.2% of subjects were dead. Older age at nursing home admission (HR = 1.036 per 1-year increment, 95% CI 1.028-1.045), men (HR = 1.895, 95% CI 1.651-2.175), higher impairment level according to the MDS-ADL (HR = 1.135 per 1-unit increment, 95% CI 1.099-1.173) and MDS-CPS (HR = 1.077 per 1-unit increment, 95% CI 1.033-1.123), and more frail on the MDS-CHESS (HR = 1.150 per 1-unit increment, 95% CI 1.042-1.268), were all independent predictors of shorter survival after nursing home admission in multivariate analysis. Survival function was derived from the fitted Cox regression model. Survival time of nursing home residents with different combinations of risk factors were estimated through the survival function.

CONCLUSION

The MDS-ADL, MDS-CPS and MDS-CHESS scales, in addition to age and gender, provide prognostic information in terms of survival time after institutionalization. The model may be useful for health care and residential care planning in an ageing community.

Reliability of the interRAI suite of assessment instruments: a 12-country study of an integrated health information system

Background

A multi-domain suite of instruments has been developed by the interRAI research collaborative to support assessment and care planning in mental health, aged care and disability services. Each assessment instrument comprises items common to other instruments and specialized items exclusive to that instrument. This study examined the reliability of the items from five instruments supporting home care, long term care, mental health, palliative care and post-acute care.

Methods

Paired assessments on 783 individuals across 12 nations were completed within 72 hours of each other by trained assessors who were blinded to the others' assessment. Reliability was tested using weighted kappa coefficients.

Results

The overall kappa mean value for 161 items which are common to 2 or more instruments was 0.75. The kappa mean value for specialized items varied among instruments from 0.63 to 0.73. Over 60% of items scored greater than 0.70.

Conclusion

The vast majority of items exceeded standard cut-offs for acceptable reliability, with only modest variation among instruments. The overall performance of these instruments showed that the interRAI suite has substantial reliability according to conventional cut-offs for interpreting the kappa statistic. The results indicate that interRAI items retain reliability when used across care settings, paving the way for cross domain application of the instruments as part of an integrated health information system.

Not so black and white: nursing home concentration of Hispanics associated with prevalence of pressure ulcers

OBJECTIVE

To examine the association between the nursing home (NH) concentration of Hispanics and prevalence of pressure ulcer.

DESIGN

Secondary data analysis using data from the national repository of the 2000 Minimum Data Set (MDS) and On-Line Survey Certification and Reporting (OSCAR) data. We used a multivariate logistic model, with the Huber-White correction to account for clustering of persons within a nursing facility, to examine the association of Hispanic NH concentration with the prevalence of pressure ulcers, after adjusting for resident level characteristics.

SETTING

Five states with a high population of Mexican-Americans (California, New Mexico, Arizona, Colorado, and Texas).

PARTICIPANTS

A total of 74,343 persons (9.26% black, 11.28% Hispanic, 79.46% non-Hispanic white) in a NH located in 1 of these 5 states during the last quarter of 2000.

MEASUREMENTS

The prevalence of Stage II-IV pressure ulcers was examined in the last quarter of 2000. Stage II-IV pressure ulcers, resident demographics, and medical illness data were documented by nursing staff on the MDS.

RESULTS

Hispanics and non-Hispanic blacks had a higher prevalence of pressure ulcers than non-Hispanic whites (7.60%, 9.71% and 12.10%, respectively). A facility's concentration of Hispanic residents was associated with prevalent pressure ulcers after adjustment for resident characteristics.

CONCLUSIONS

Residents in nursing homes in which there is a higher concentration of Hispanic residents are more likely to have a pressure ulcer.

A review of evidence on the reliability and validity of Minimum Data Set data

This paper reviews the reliability and validity of the Minimum Data Set (MDS) assessment, which is being used increasingly in Canadian nursing homes and continuing care facilities. The central issues that surround the development and implementation of a standardized assessment such as the MDS are presented, including implications for health care managers in how to approach data quality concerns. With other sectors such as home care and inpatient psychiatry using MDS for national reporting, these issues have importance in and beyond residential care management.

Associated factors of falls in nursing home residents in Hong Kong and the role of restraints: a cross-sectional survey using the Resident Assessment Instrument (RAI) 2.0

BACKGROUND AND AIMS

To identify factors associated with falls in non-bedridden nursing home residents in Hong Kong, and to examine whether restraints are protective against falls.

METHODS

Cross-sectional survey of 1710 nursing home residents, examining factors associated with falls and use of restraints, as documented in the RAI questionnaire.

RESULTS

Vision impairment is highly associated with falls (OR 1.75, 95% CI 1.29-2.34), whereas older age (OR 1.03, 95% CI 1.01-1.05), dementia (OR 1.46, 95% CI 1.05-2.04), and intake of psychotropics (OR 1.52, 95% CI 1.06-2.17) were moderately associated. Women were less likely to fall (OR 0.65, 95% CI 0.48-0.90). Walking with aids and taking more medications were not associated with falls in this population. Restraints were used in 68%. The use of any type of restraint was marginally associated with fewer falls (OR 0.73, 95% CI 0.53-1.00).

CONCLUSIONS

Men, those with impaired vision, dementia or taking psychotropic drugs were more likely to fall. Restraints are very commonly used in Hong Kong nursing homes. Although their use was associated with fewer falls, their effect on preventing falls could not be established in this cross-sectional study.

[Stroke patients in need of long-term nursing home care. Who are they? What are their problems? Which care do they receive?]

BACKGROUND AND OBJECTIVE

Many patients who suffer from an acute stroke, will need long-term nursing home care. We are poorly informed about the demographic and clinical characteristics and about the care problems and received care of these patients. This study aims to provide a first description of these characteristics in this group of patients.

METHODS

Data on demographic and health-related characteristics, social participation and received care were collected with the Minimum Data Set of the Resident Assessment Instrument, from january 2004-march 2007, in patients who needed long-term nursing home care. Data were collected in eight nursing homes at admission and six months after admission.

RESULTS

Many patients were functionally impaired, suffered from depressive symptoms and pain, and were cognitively impaired. In addition, decisional capacity was frequently diminished. The majority of patients were residing at somatic wards, even when severe cognitive impairment was present, such as dementia. Several forms of restraints were frequently used, also at somatic wards. About 40% of the patients, mostly residing at somatic wards, received paramedical treatment. Social engagement was low and was correlated with functional impairment.

CONCLUSIONS

Stroke patients who need long-term nursing home care suffer from problems in several domains. The high prevalence of cognitive impairment in stroke patients residing at somatic wards, combined with the ample use of restraints on these wards, raises questions about the appropriateness of the currently delivered care to these patients, considering the problems they have.

Ownership conversions and nursing home performance

OBJECTIVE

To examine the effects of ownership conversions on nursing home performance.

DATA SOURCE

Online Survey, Certification, and Reporting system data from 1993 to 2004, and the Minimum Data Set (MDS) facility reports from 1998 to 2004.

STUDY DESIGN

Regression specification incorporating facility fixed effects, with terms to identify trends in the pre- and postconversion periods.

PRINCIPAL FINDINGS

The annual rate of nursing home conversions almost tripled between 1994 and 2004. Our regression results indicate converting facilities are generally different throughout the pre/postconversion years, suggesting little causal effect of ownership conversions on nursing home performance. Before and after conversion, nursing homes converting from nonprofit to for-profit status generally exhibit deterioration in their performance, while nursing homes converting from for-profit to nonprofit status generally exhibit improvement.

CONCLUSIONS

Policy makers have expressed concern regarding the implications of ownership conversions for nursing home performance. Our results imply that regulators and policy makers should not only monitor the outcomes of nursing home conversions, but also the targets of these conversions.

Implementation of the resident assessment instrument/minimum data set in the nursing home as organization: implications for quality improvement in RN clinical assessment

The Resident Assessment Instrument/Minimum Data Set (RAI/MDS) used in nursing homes (NHs) participating in the Federal Medicare and Medicaid programs is a state-of-the-art, computerized clinical assessment instrument. RAI/MDS-derived data are essential, used for NH reimbursement, quality measurement, regulatory quality monitoring activities, and clinical care planning. Completing or coordinating the RAI/MDS, which may be conceived of as implementation, is a federally mandated responsibility of the RN involving clinical assessment, a core professional competency of any RN. How the RAI/MDS is implemented in each NH provides evidence of how each NH as an organization understands both the RAI/MDS process and its organizational level responsibility for promotion of RN competence in clinical assessment. Research literature related to RAI/MDS development, testing, and accuracy is used to identify what is known about organizational level implementation of the RAI/MDS. Evidence-based suggestions to enhance RN competence in RAI/MDS clinical assessments, given existing organizational barriers, are provided.

Pain in the nursing home: assessment and treatment on different types of care wards

The assessment and management of pain in nursing homes have been shown to be suboptimal, but no study has evaluated differences in clinical setting within these homes. The prevalence and management of pain on different care wards (psychogeriatric, somatic, and rehabilitation) was studied on 562 newly admitted Dutch nursing home residents. Pain was measured according to the Nottingham Health Profile (perceived pain) and the Minimum Data Set pain observation items (frequency and intensity). Pain frequency differed significantly across the different ward types: on psychogeriatric wards (n=247), it was 27.1%; on somatic wards (n=181), 53.9%; and on rehabilitation wards (n=129), 57.8%. Being admitted on a psychogeriatric ward was significantly related to less pain compared to being admitted on a somatic ward, even when adjusted for possible confounders such as age, gender, cognitive status, activities of daily living, pain-related disorders, and depression (odds ratio [OR] 0.38 [95% confidence interval (CI)=0.23-0.62]). Patients on psychogeriatric wards who had pain received less pain medication, adjusted for frequency and intensity of pain (OR 0.37 [95% CI=0.23-0.59]), compared to patients on somatic wards. We conclude that admission to a psychogeriatric care ward, independent of cognition, is associated with lower pain prevalence, and also with lower levels of pain treatment.

Cost and Quality

BACKGROUND

Although both quality and cost are important concerns for long term care (LTC) facility management and policy, the relationship between cost and quality is poorly understood. Such knowledge is necessary to guide facility management and policy action.

OBJECTIVE

We sought to determine the net effect of quality on cost in LTC hospital settings.

STUDY SAMPLE

A 4-year panel dataset from April 1997 through March 2002 comprising observations from 99 LTC hospitals were included in this analysis.

METHODS

We examined the relationship between direct resident costs and 7 indicators of quality for long-stay residents. We used panel data methods to control for unobserved facility-level characteristics.

RESULTS

We found that increases in restraint use and incident pressure/skin ulcers were associated with lower per diem costs, whereas incontinence prevalence was associated with higher per diem costs.

CONCLUSIONS

Our results point to different implications regarding cost and quality for different quality indicators. Although facilities have a strong internal business case to improve quality in incontinence, policy-makers may need to provide financial incentives to encourage reductions in restraint use and incident skin ulcers so as to defray potential higher costs associated with improving quality in these areas.

Hospitalization of nursing home residents: the effects of states' Medicaid payment and bed-hold policies

OBJECTIVE

Hospitalizations of nursing home residents are costly and expose residents to iatrogenic disease and social and psychological harm. Economic constraints imposed by payers of care, predominantly Medicaid policies, are hypothesized to impact hospitalizations.

DATA SOURCES/STUDY SETTING

Federally mandated resident assessments were merged with Medicare claims and eligibility files to determine hospitalizations and death within 150 days of baseline assessment. Nursing home and market characteristics were obtained from the Online Survey Certification and Reporting, and the Area Resource File, respectively. States' average daily Medicaid nursing home payments and bed-hold policies were obtained independently.

STUDY DESIGN

Prospective cohort study of 570,614 older (> or =65-year-old), non-MCO (Medicare Managed Care), long-stay (> or =90 days) residents in 8,997 urban, freestanding nursing homes assessed between April and June 2000, using multilevel models to test the impact of state policies on hospitalizations controlling for resident, nursing home, and market characteristics.

PRINCIPAL FINDINGS

Overall, 99,379 (17.4 percent) residents were hospitalized with rates varying from 8.4 percent in Utah to 24.9 percent in Louisiana. Higher Medicaid per diem was associated with lower odds of hospitalizations (5 percent lower for each $10 above average $103.5, confidence intervals [CI] 0.91-0.99). Hospitalization odds were higher by 36 percent in states with bed-hold policies (CI: 1.12-1.63).

CONCLUSIONS

State Medicaid bed-hold policy and per-diem payment have important implications for nursing home hospitalizations, which are predominantly financed by Medicare. This study emphasizes the importance of properly aligning state Medicaid and federal Medicare policies in regards to the subsidy of acute, maintenance, and preventive care in the nursing home setting.

Use of osteoporosis medications in older nursing facility residents

INTRODUCTION

Epidemiologic studies demonstrated that 70% to 85% of nursing home residents have osteoporosis. Few studies report comprehensive information about treatment of osteoporosis in nursing facilities.

OBJECTIVE

To determine the prevalence of osteoporosis treatment and identify resident characteristics associated with the use of antiresorptive medications or supplements indicated to treat osteoporosis in nursing homes.

METHODS

The study design was cross-sectional. The Systematic Assessment of Geriatric Drug Use via Epidemiology database provided the data. From this database, 186,221 residents were identified as newly admitted to nursing facilities in Kansas, Maine, Missouri, Ohio, and South Dakota between 1998 and 2000. The outcome measure was the use of antiresorptive medications (alendronate, risedronate, calcitonin, estrogen, raloxifene) or supplements (calcium with vitamin D) indicated for treatment of osteoporosis. The independent variables included demographic, health status, and fracture risk factors.

RESULTS

Of the overall sample, 9.1% received antiresorptive medications and/or supplements indicated for osteoporosis treatment. The most commonly used treatment was the combination of calcium and vitamin D (5.0%). Calcitonin (2.5%) use exceeded that of any other antiresorptive. Multivariable logistic regression analyses revealed that a diagnosis of osteoporosis and female gender were strongly associated with being more likely to receive an osteoporosis treatment (OR 6.34 with 95% CI 6.11-6.64 and OR 2.67 with 95% CI 2.53-2.83 respectively). The number of medications residents received was also strongly associated with receiving osteoporosis treatment. Being black and having 4 or more active diagnoses were strongly associated with lower odds of receiving treatment (OR 0.63 with 95% CI 0.57-0.68 and OR 0.71 with 95% CI 0.68-0.74 for 4 to 6 diagnoses).

DISCUSSION

Newly admitted nursing facility residents infrequently received an indicated osteoporosis treatment, including calcium with vitamin D, despite the expected high prevalence of osteoporosis in this setting. Few demographic, health status, and fracture risk factors were strongly associated with receiving indicated treatment.

Terminal trajectories of functional decline in the long-term care setting

BACKGROUND

Little is known about the terminal trajectories of functional decline among long-term care (LTC) residents dying with different diseases.

METHODS

A retrospective cohort study was performed on 747 individuals aged 65 or older who died between January 1994 and December 2004 in a 675-bed LTC facility in Massachusetts. Three study groups were created: advanced dementia, n = 314 (42%); terminal cancer, n = 63 (8%); and organ failure (congestive heart failure and chronic obstructive pulmonary disease), n = 370 (50%). Quarterly scores of 7 activities of daily living (ADLs) during the last year of life derived from the Minimum Data Set were compared among the three groups. Each activity was rated from 0 to 4 (higher scores indicate more dependence; total range, 0-28).

RESULTS

The mean age of all individuals at death was 91 +/- 6 (standard deviation) years. Functional decline was greatest during the last 3 months of life, but this decline was most precipitous in the terminal cancer and organ failure groups compared to the advanced dementia group. The mean change in ADL scores during the last year of life differed among the three groups (p <.001), with the greatest decline in the terminal cancer group (from initial score 13 to final score 25), followed by the organ failure group (13 to 22), and finally, the advanced dementia group (24 to 27).

CONCLUSIONS

The terminal trajectories of functional decline among LTC residents vary by underlying diseases. An understanding of these trajectories may be useful to clinicians and families caring for LTC residents near the end of life.

Use of antiepileptic medications in nursing homes

The University of Minnesota Epilepsy Research and Education Program published two studies evaluating the use of antiepileptic drugs (AEDs) among nursing home (NH) elderly. The studies used a large, nongovernmental data set for studying this population. This chapter is a summary of those two studies. In the first study, a 1-day point prevalence study, 10.5% of the NH residents had one or more AED orders, a prevalence 10 times greater than that found in the community. In a multivariate analysis of factors associated with AED treatment, seizure indication was the most important factor, and age was inversely related to AED use. Phenytoin was the most commonly used AED, followed by carbamazepine, phenobarbital, and valproic acid. The most frequently used combination was phenytoin and phenobarbital. In the second study, evaluating NH admission data, 8% of newly admitted residents were already receiving one or more AEDs when they entered the NH. Factors associated with AED use in this group included epilepsy/seizure disorder, age, cognitive performance, and manic depression (bipolar disease). Among residents recently admitted who were not using an AED at entry, 3% were initiated on an AED within 3 months of admission. Among the factors associated with the initiation of AEDs during this period, the strongest association was with epilepsy/seizure disorder. Manic depression (bipolar disease) was also significantly associated with initiation of an AED after admission. In this group, there was an inverse relationship between age and initiation of an AED.