Casemix for inpatient care of elderly people: rehabilitation and post-acute care. Casemix for the Elderly Inpatient Working Group

Dr Foster global frailty score: an international retrospective observational study developing and validating a risk prediction model for hospitalised older persons from administrative data sets

OBJECTIVES

This study aimed to examine the prevalence of frailty coding within the Dr Foster Global Comparators (GC) international database. We then aimed to develop and validate a risk prediction model, based on frailty syndromes, for key outcomes using the GC data set.

DESIGN

A retrospective cohort analysis of data from patients over 75 years of age from the GC international administrative data. A risk prediction model was developed from the initial analysis based on seven frailty syndrome groups and their relationship to outcome metrics. A weighting was then created for each syndrome group and summated to create the Dr Foster Global Frailty Score. Performance of the score for predictive capacity was compared with an established prognostic comorbidity model (Elixhauser) and tested on another administrative database Hospital Episode Statistics (2011-2015), for external validation.

SETTING

34 hospitals from nine countries across Europe, Australia, the UK and USA.

RESULTS

Of 6.7 million patient records in the GC database, 1.4 million (20%) were from patients aged 75 years or more. There was marked variation in coding of frailty syndromes between countries and hospitals. Frailty syndromes were coded in 2% to 24% of patient spells. Falls and fractures was the most common syndrome coded (24%). The Dr Foster Global Frailty Score was significantly associated with in-hospital mortality, 30-day non-elective readmission and long length of hospital stay. The score had significant predictive capacity beyond that of other known predictors of poor outcome in older persons, such as comorbidity and chronological age. The score's predictive capacity was higher in the elective group compared with non-elective, and may reflect improved performance in lower acuity states.

CONCLUSIONS

Frailty syndromes can be coded in international secondary care administrative data sets. The Dr Foster Global Frailty Score significantly predicts key outcomes. This methodology may be feasibly utilised for case-mix adjustment for older persons internationally.

An Overview of International Staff Time Measurement Validation Studies of the RUG-III Case-mix System

The RUG-III case-mix system is a method of grouping patients in long-term and post-acute care settings. RUG-III groups patients by relative per diem resource consumption and may be used as the basis for prospective payment systems to ensure that facility reimbursement is commensurate with patient acuity. Since RUG-III's development in 1994, more than a dozen international staff time measurement studies have been published to evaluate the utility of the case-mix system in a variety of diverse health care environments around the world. This overview of the literature summarizes the results of these RUG-III validation studies and compares the performance of the algorithm across countries, patient populations, and health care environments. Limitations of the RUG-III validation literature are discussed for the benefit of health system administrators who are considering implementing RUG-III and next-generation resource utilization group case-mix systems.

Predictors of Rehabilitation Outcomes: A Comparison of Israeli and Italian Geriatric Post-Acute Care (PAC) Facilities Using the Minimum Data Set (MDS)

OBJECTIVES

To understand the relative contribution of sociodemographic, clinical, and health care features to rehabilitation outcomes in Israel and in Italy in post-acute care (PAC) facilities.

DESIGN

Prospective cross-national study

SETTING

Two hospital geriatric PAC departments: Harzfeld Geriatric Hospital, Gedera, Israel, and Catholic University of Sacred Heart Geriatric Hospital, Rome, Italy.

PARTICIPANTS

Post-acute care patients aged 65 and older admitted consecutively for stabilization, improvement, or rehabilitation to 3 departments in Harzfeld Geriatric Hospital, Gedera, Israel from April, 1999 through February, 2002 (N = 364), and to the post-acute Geriatric Rehabilitation Unit of the "A. Gemelli" Hospital, Catholic University of Sacred Heart, Rome, Italy, between February, 1999, and April, 2002 (N = 351), for whom there were complete assessments at admission and discharge (the total number admitted in Israel was 505, and in Italy, 409).

MEASUREMENTS

Minimum Data Set for Post-Acute Care (MDS-PAC) assessments conducted within 4 days of admission and at discharge; data collected identically in both sites. Predictors of functional recovery> were identified using multivariate binary logistic regression. The dependent variable: improvement of 1 or more points in the ADL scale.

RESULTS

The staffing pattern of the PAC department in Italy had about double the physicians and physio- and occupational therapists than in Israel, but about the same number of nurses and somewhat fewer aides than in Israel. Multivariate binary logistic regression that includes country, age, sex, and marital status, found that the patients in Italy had about triple the probability of improvement in ADL function (OR 3.3, CI 2.4-4.6) (P < .001) than PAC patients in Israel. Even after health system characteristics were added to the model, ADL improvement was most significantly associated with higher cognitive ability and a diagnosis of hip fracture, as well as longer length of stay and being admitted to PAC directly from an acute hospital. For each additional point (worse cognition) in a cognitive scale, there was a 30% decrease in the probability of ADL improvement (OR 0.7, CI 0.6-0.8, P < .001). Those who had a stroke were about half as likely to show ADL improvement (OR 0.5, CI 0.3-0.7) than those without stroke, but those with a hip fracture had more than double the probability of ADL improvement (OR 2.7, CI 1.7-4.2) than those without hip fracture. Those who stayed in the PAC ward an additional block of time had a 30% higher probability of ADL improvement (P < .1), and those who were admitted directly to PAC from an acute hospital had more than 4 times the probability of ADL improvement (OR 4.1, CI 2.3-7.0, P < .001) than those who were admitted from a private home.

CONCLUSIONS

We found support for the hypothesis that differences in sociodemographic and clinical factors cannot account for all differences in ADL improvement, and that the organization of care and constraints of the health system also influence functional outcomes. Policymakers should examine the policy-amenable features of the Italian and Israeli systems so that optimal ADL recovery can be encouraged. Any reduction in disability will help both patients and the health care system; slightly higher short-term PAC treatment costs may have large long-term future benefits, if they result in the reduction of ADL disability. This study is one of the first to examine outcomes of PAC in 2 countries, and can provide an initial assessment of how rehabilitation can be enhanced or limited by health policies and staffing patterns.

Assessing the Registered Nursing Care Contribution for older people in care homes: issues of reliability and validity

The present paper reports on a study designed to investigate the validity and reliability of the Registered Nursing Care Contribution (RNCC) tool for assessing the level of nursing care required by care home residents. Care plan data from 186 residents in participating care homes were assessed by multiple assessors using the RNCC tool (i.e. care home registered nurses, a nurse researcher, an external care home expert and a nurses consultant). The Minimum Data Set (MDS) rating was used as a validated comparison. The findings from the study indicated that there were disparities between the RNCC and MDS bandings, and between different raters, with the external care home expert achieving the closest agreement with the MDS. This suggests that the use of the RNCC tool varies considerably according to the assessor, which also suggests that training of users is needed to ensure consistency and reliability. However, the difference between the outcomes of using the RNCC tool and the MDS suggests that assessment of nursing need may need to be re-examined to ensure validity.

A system of patient classification in long-term psychiatric inpatients: Resource Utilization Groups T-18 (RUG T-18)

This paper shows the application of a 'case mix' system (Resources Utilization Groups T18 or RUG-T18) to a Spanish long-term inpatient psychiatric sample.

OBJECTIVE

To examine the capacity of RUG-T18 to predict patient resource use (spent time of care) in a long-term psychiatric sample.

SUBJECTS AND RESEARCH DESIGN

Data included an assessment of 163 patients' characteristics, corresponding to groups of the RUG-T18, and detailed measurement of nursing staff care over a 24-h period.

RESULTS

'Severe behavioural problems' was the most frequent RUG-T18 category. There were significant differences in the spent time of care in the different groups and high variability in the distribution of time of care within groups and in the total sample.

CONCLUSIONS

The RUG T-18 system should be improved to become a useful case mix system in long-term psychiatric inpatients. The high variance intragroups could be minimized improving the psychopathological aspects of the system.

Residential and nursing home care of elderly people with cognitive impairment: prevalence, mortality and costs

Cognitive impairment among residents has considerable resource implications for both individuals and those responsible for publicly funded care. Two linked surveys were carried out in England: (1) a longitudinal study followed 2500 admissions to publicly funded care up to 42 months after admission; and (2) a cross-sectional survey of 618 homes collected information about 11,900 residents. Information was collected about cognitive impairment using the Minimum Data Set Cognitive Performance Scale. Cognitive impairment was associated with source of funding and type of home. Although level of cognitive impairment has some effect, fees and costs were most influenced by type of home. At the same level of impairment, self-funded residents were more likely to be located in relatively low-cost settings than publicly funded residents. In independent homes fees were lower for publicly funded than for self-funded residents. Overall median length of stay of publicly funded admissions was 18 months. For the most part length of stay was not associated with level of cognitive impairment on admission. It is concluded that more information is needed about the effect of quality of care on people with cognitive impairment in different settings. If the same quality of care can be achieved in residential and nursing homes, the evidence would suggest that changes in placement policies could result in potential savings to the public purse.

Stroke rehabilitation. 4. Stroke outcome and psychosocial consequences

This self-directed learning module highlights recent research in assessment of stroke outcomes and management of the psychosocial consequences of stroke. It is a part of the chapter on stroke rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article discusses predictive factors for mortality and functional recovery; proposed case mix adjustment and prospective payment systems for stroke rehabilitation; continuum of care and utilization of acute, nursing home, outpatient and home health rehabilitation programs; reintegration and socialization after stroke; vocational rehabilitation of stroke patients; and management of the psychosocial effects of stroke on patients and families.