Which organizational characteristics are associated with increased management of depression using antidepressants in US nursing homes?

Nursing Staff Time and Care Quality in Long-Term Care Facilities: A Systematic Review

BACKGROUND AND OBJECTIVES

In long-term care (LTC) facilities, nursing staff are important contributors to resident care and well-being. Despite this, the relationships between nursing staff coverage, care hours, and quality of resident care in LTC facilities are not well understood and have implications for policy-makers. This systematic review summarizes current evidence on the relationship between nursing staff coverage, care hours, and quality of resident care in LTC facilities.

RESEARCH DESIGN AND METHODS

A structured literature search was conducted using four bibliographic databases and gray literature sources. Abstracts were screened by two independent reviewers using Covidence software. Data from the included studies were summarized using a pretested extraction form. The studies were critically appraised, and their results were synthesized narratively.

RESULTS

The systematic searched yielded 15,842 citations, of which 54 studies (all observational) were included for synthesis. Most studies (n = 53, 98%) investigated the effect of nursing staff time on resident care. Eleven studies addressed minimum care hours and quality of care. One study examined the association between different nursing staff coverage models and resident outcomes. Overall, the quality of the included studies was poor.

DISCUSSION AND IMPLICATIONS

Because the evidence was inconsistent and of low quality, there is uncertainty about the direction and magnitude of the association between nursing staff time and type of coverage on quality of care. More rigorously designed studies are needed to test the effects of different cutoffs of care hours and different nursing coverage models on the quality of resident care in LTC facilities.

The role of regulation in the care of older people with depression living in long-term care: a systematic scoping review

BACKGROUND

This aim of this study was to explore the role of regulation on the quality of care of older people living with depression in LTC, which in this paper is a domestic environment providing 24-h care for people with complex health needs and increased vulnerability.

METHODS

We conducted a systematic scoping review. A peer reviewed search strategy was developed in consultation with a specialist librarian. Several databases were searched to identify relevant studies including: Embase (using the OVID platform); MEDLINE (using the OVID platform); Psych info (using the OVID platform); Ageline (using the EBSCO platform); and CINHAL (using the EBSCO platform). Articles were screened by three reviewers with conflicts resolved in consultation with authors. Data charting was completed by one reviewer, with a quality check performed by a second reviewer. Key themes were then derived from the included studies.

RESULTS

The search yielded 778 unique articles, of which 20 were included. Articles were grouped by themes: regulatory requirements, funding issues, and organizational issues.

CONCLUSION

The highly regulated environment of LTC poses significant challenges which can influence the quality of care of residents with depression. Despite existing evidence around prevalence and improved treatment regimens, regulation appears to have failed to capture the best practice and contemporary knowledge available. This scoping review has identified a need for further empirical research to explore these issues.

Innovation to enhance health in care homes and evaluation of tools for measuring outcomes of care: rapid evidence synthesis

Background

Flexible, integrated models of service delivery are being developed to meet the changing demands of an ageing population. To underpin the spread of innovative models of care across the NHS, summaries of the current research evidence are needed. This report focuses exclusively on care homes and reviews work in four specific areas, identified as key enablers for the NHS England vanguard programme.

Aim

To conduct a rapid synthesis of evidence relating to enhancing health in care homes across four key areas: technology, communication and engagement, workforce and evaluation.

Objectives

(1) To map the published literature on the uses, benefits and challenges of technology in care homes; flexible and innovative uses of the nursing and support workforce to benefit resident care; communication and engagement between care homes, communities and health-related organisations; and approaches to the evaluation of new models of care in care homes. (2) To conduct rapid, systematic syntheses of evidence to answer the following questions. Which technologies have a positive impact on resident health and well-being? How should care homes and the NHS communicate to enhance resident, family and staff outcomes and experiences? Which measurement tools have been validated for use in UK care homes? What is the evidence that staffing levels (i.e. ratio of registered nurses and support staff to residents or different levels of support staff) influence resident outcomes?

Data sources

Searches of MEDLINE, CINAHL, Science Citation Index, Cochrane Database of Systematic Reviews, DARE (Database of Abstracts of Reviews of Effects) and Index to Theses. Grey literature was sought via Google™ (Mountain View, CA, USA) and websites relevant to each individual search.

Design

Mapping review and rapid, systematic evidence syntheses.

Setting

Care homes with and without nursing in high-income countries.

Review methods

Published literature was mapped to a bespoke framework, and four linked rapid critical reviews of the available evidence were undertaken using systematic methods. Data were not suitable for meta-analysis, and are presented in narrative syntheses.

Results

Seven hundred and sixty-one studies were mapped across the four topic areas, and 65 studies were included in systematic rapid reviews. This work identified a paucity of large, high-quality research studies, particularly from the UK. The key findings include the following. (1) Technology: some of the most promising interventions appear to be games that promote physical activity and enhance mental health and well-being. (2) Communication and engagement: structured communication tools have been shown to enhance communication with health services and resident outcomes in US studies. No robust evidence was identified on care home engagement with communities. (3) Evaluation: 6 of the 65 measurement tools identified had been validated for use in UK care homes, two of which provide general assessments of care. The methodological quality of all six tools was assessed as poor. (4) Workforce: joint working within and beyond the care home and initiatives that focus on staff taking on new but specific care tasks appear to be associated with enhanced outcomes. Evidence for staff taking on traditional nursing tasks without qualification is limited, but promising.

Limitations

This review was restricted to English-language publications after the year 2000. The rapid methodology has facilitated a broad review in a short time period, but the possibility of omissions and errors cannot be excluded.

Conclusions

This review provides limited evidential support for some of the innovations in the NHS vanguard programme, and identifies key issues and gaps for future research and evaluation.

Future work

Future work should provide high-quality evidence, in particular experimental studies, economic evaluations and research sensitive to the UK context.

Study registration

This study is registered as PROSPERO CRD42016052933, CRD42016052933, CRD42016052937 and CRD42016052938.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Public/private ownership and quality of care: Evidence from Danish nursing homes

The involvement of private for-profit (FP) and not-for-profit (NFP) providers in the otherwise public delivery of welfare services is gradually changing the Nordic welfare state towards a more market-oriented mode of service delivery. This article examines the relationship between ownership and quality of care in public and private FP and NFP nursing homes in Denmark. The analysis draws on original survey data and administrative registry data (quality inspection reports) for the full population of almost 1000 nursing homes in Denmark. Quality is measured in terms of structural quality, process quality and outcome quality. We find that public nursing homes have a higher structural quality (in terms of, for instance, staffing), while FP providers perform better in terms of process quality (e.g. in the form of individualised care). NFP providers perform well in terms of structural criteria such as employment of full-time staff and receive fewer critical comments in the inspection reports. However, the results depend to some extent upon the method of data collection, which underlines the benefits of using multiple data sources to examine the relationship between ownership and the quality of care.

The Variation of Statin Use Among Nursing Home Residents and Physicians: A Cross-Sectional Analysis

OBJECTIVES

To examine the variability of statin use among nursing home residents and prescribing physicians, and to assess statin use by resident frailty.

DESIGN

Population-based, cross-sectional analysis.

SETTING

All nursing home facilities (N = 631) in Ontario, Canada between April 1, 2013 and March 31, 2014.

PARTICIPANTS

All adults aged 66 years and older who received a full clinical assessment while residing in a nursing home facility and their assigned, most responsible, physician.

MEASUREMENTS

Statin use on date of clinical assessment. Resident- and physician-level characteristics ascertained through clinical assessment and health administrative data. Resident frailty was derived using a previously validated index.

RESULTS

Among 76,226 nursing home residents assigned to 1,919 physicians, 25,648 (33.6%) were statin users. There were 13,331 (30.1%) statin users among the 44,290 residents categorized as frail. In an adjusted mixed-effects logistic regression model, frail residents (adjusted odds ratio = 0.62, 95% confidence interval 0.58-0.65) were significantly less likely to be statin users compared with non-frail residents. After adjustment for resident characteristics, the intraclass correlation coefficient indicated that between-physician variability accounted for 9.1% of the residual unexplained variation in statin use (P < .001). Among the 894 physicians assigned 20 or more residents, funnel plots confirmed there were more low-outlying (17.4%) and high-outlying (12.0%) prescribers of statins than expected by chance. Physicians who were high-outlying prescribers had higher historical rates of statin prescribing.

CONCLUSIONS AND RELEVANCE

Statin prescribing was substantial within nursing homes, even among frail residents. After controlling for resident characteristics, the likelihood of statin prescribing varied significantly across physicians. Further studies are required to evaluate the risks and benefits of statin use, and discontinuation, among nursing home residents to better inform clinical practice in this setting.

Constructing a Measure of Private-pay Nursing Home Days

BACKGROUND

Nursing home (NH) care is financed through multiple sources. Although Medicaid is the predominant payer for NH care, over 20% of residents pay out-of-pocket for their care. Despite this large percentage, an accepted measure of private-pay NH occupancy has not been established and little is known about the types of facilities and the long-term care markets that cater to this population.

OBJECTIVES

To describe 2 novel measures of private-pay utilization in the NH setting, including the proportion of privately financed residents and resident days, and examine their construct validity.

DESIGN

Retrospective descriptive analysis of US NHs in 2007-2009.

MEASURES

We used Medicare claims, Medicare Enrollment records, and the Minimum Data Set to create measures of private-pay resident prevalence and proportion of privately financed NH days. We compared our estimates of private-pay utilization to payer data collected in the NH annual certification survey and evaluated the relationships of our measures with facility characteristics.

RESULTS

Our measures of private-pay resident prevalence and private-pay days are highly correlated (r=0.83, P<0.001 and r=0.83, P<0.001, respectively) with the rate of "other payer" reported in the annual certification survey. We also observed a significantly higher proportion of private-pay residents and days in higher quality facilities.

CONCLUSIONS

This new methodology provides estimates of private-pay resident prevalence and resident days. These measures were correlated with estimates using other data sources and validated against measures of facility quality. These data set the stage for additional work to examine questions related to NH payment, quality of care, and responses to changes in the long-term care market.

Is psychotropic medication use related to organisational and treatment culture in residential care

Purpose

– The purpose of this paper is to establish the relationship between organisational culture and psychotropic medication use in residential care.

Design/methodology/approach

– Cross-sectional analyses of staff and resident’s record survey in residential aged care facilities in Auckland, New Zealand (NZ). The competing values framework categorised organisational culture as clan, hierarchical, market driven or adhocracy and was completed by all staff. The treatment culture tool categorised facilities as having resident centred or traditional culture and was completed by registered nursing staff and general practitioners (GP). Functional and behavioural characteristics of residents were established by staff report and health characteristics and medications used were ascertained from the health record. Multiple regression was used to test for associations between measures of culture with psychotropic medication use (anxiolytics, sedatives, major tranquillisers).

Findings

– In total 199 staff, 27 GP and 527 residents participated from 14 facilities. On average 8.5 medications per resident were prescribed and 42 per cent of residents received psychotropic medication. Having a diagnosis of anxiety or depression (odds ratio (OR) 3.18, 95 per cent confidence interval (CI) 1.71, 5.91), followed by persistent wandering (OR 2.53, 95 per cent CI 1.59, 4.01) and being in a dementia unit (OR 2.45, 95 per cent CI 1.17, 5.12) were most strongly associated with psychotropic use. Controlling for resident- and facility-level factors, health care assistants’ assignation of hierarchical organisational culture type was independently associated with psychotropic medication use, (OR 1.29, CI 1.08, 1.53) and a higher treatment culture score from the GP was associated with lower use of psychotropic medication (OR 0.95, CI 0.92, 0.98).

Originality/value

– Psychotropic medication use remains prevalent in residential care facilities in NZ. Interventions aimed at changing organisational culture towards a less hierarchical and more resident-centred culture may be another avenue to improve prescribing in residential aged care.

Predictors of emergency commitment for nursing home residents: the role of resident and facility characteristics

OBJECTIVES

The ability of nursing homes to manage the mental health needs of their residents is crucial to providing high quality care. An important element is preventing exacerbations of psychiatric conditions that trigger discharge from the nursing home (NH) because of an emergency commitment (EC) for an involuntary psychiatric examination. The objective of this study was to examine the relationship between resident and facility characteristics and the risk of EC for involuntary psychiatric examination among Medicaid-enrolled NH residents in Florida.

DESIGN

This retrospective cohort study employed 2.5 years (31 December 2002 through 30 June 2005) of Medicaid enrollment and fee-for-service, pharmacy, and involuntary commitment data to examine resident characteristics. NH characteristics were obtained from the Online Survey Certification and Reporting database.

SETTING

Medicaid-certified NHs in Florida (N= 584).

PARTICIPANTS

Medicaid-enrolled NH residents (N= 32,604).

RESULTS

Younger age, male gender, having dementia, having a serious mental illness (SMI), and residing in a for-profit facility were all independently associated with the greater risk of EC. Although most residents with EC were prescribed psychotropic medication, less than half received non-pharmacological behavioral health outpatient services before or after their involuntary psychiatric examination.

CONCLUSION

Our findings highlight the salience of resident and facility characteristics to prevalence rates of EC for involuntary psychiatric examinations among NH residents and underscore a need for increased education, communication, and future research on the predictive factors as well as the consequences of these adverse events.

Race, education, and the treatment of depression in nursing homes

OBJECTIVES

We investigate, among older adult nursing home residents diagnosed with depression, whether depression treatment differs by race and schooling, and whether differences by schooling differ by race. We examine whether Blacks and less educated residents are placed in facilities providing less treatment, and whether differences reflect disparities in care.

METHOD

Data from the 2006 Nursing Home Minimum Data Set for 8 states (n = 124,431), are merged with facility information from the Online Survey Certification and Reporting system. Logistic regressions examine whether resident and/or facility characteristics explain treatment differences; treatment includes antidepressants and/or psychotherapy.

RESULTS

Blacks receive less treatment (adj. OR = .79); differences by education are small. Facilities with more Medicaid enrollees, fewer high school graduates, or more Blacks provide less treatment.

DISCUSSION

We found disparities at the resident and facility level. Facilities serving a low-SES (socioeconomic status), minority clientele tend to provide less depression care, but Blacks also receive less depression treatment than Whites within nursing homes (NHs).

Antimicrobial prescribing in nursing homes in Northern Ireland: results of two point-prevalence surveys

BACKGROUND

In 2005, the European Commission recommended that all member states should establish or strengthen surveillance systems for monitoring the use of antimicrobial agents. There is no evidence in the literature of any surveillance studies having been specifically conducted in nursing homes (NHs) in Northern Ireland (NI).

OBJECTIVE

The aim of this study was to determine the prevalence of antimicrobial prescribing and its relationship with certain factors (e.g. indwelling urinary catheterization, urinary incontinence, disorientation, etc.) in NH residents in NI.

METHODS

This project was carried out in NI as part of a wider European study under the protocols of the European Surveillance of Antimicrobial Consumption group. Two point-prevalence surveys (PPSs) were conducted in 30 NHs in April and November 2009. Data were obtained from nursing notes, medication administration records and staff in relation to antimicrobial prescribing, facility and resident characteristics and were analysed descriptively.

RESULTS

The point prevalence of antimicrobial prescribing was 13.2% in April 2009 and 10.7% in November 2009, with a 10-fold difference existing between the NHs with the highest and lowest antimicrobial prescribing prevalence during both PPSs. The same NH had the highest rate of antimicrobial prescribing during both April (30.6%) and November (26.0%). The group of antimicrobials most commonly prescribed was the penicillins (April 28.6%, November 27.5%) whilst the most prevalent individual antimicrobial prescribed was trimethoprim (April 21.3%, November 24.3%). The majority of antimicrobials were prescribed for the purpose of preventing urinary tract infections (UTIs) in both April (37.8%) and in November (46.7%), with 5% of all participating residents being prescribed an antimicrobial for this reason. Some (20%) antimicrobials were prescribed at inappropriate doses, particularly those which were used for the purpose of preventing UTIs. Indwelling urinary catheterization and wounds were significant risk factors for antimicrobial use in April [odds ratio {OR} (95% CI) 2.0 (1.1, 3.5) and 1.8 (1.1, 3.0), respectively] but not in November 2009 [OR (95% CI) 1.6 (0.8, 3.2) and 1.2 (0.7, 2.2), respectively]. Other resident factors, e.g. disorientation, immobility and incontinence, were not associated with antimicrobial use. Furthermore, none of the NH characteristics investigated (e.g. number of beds, hospitalization episodes, number of general practitioners, etc.) were found to be associated with antimicrobial use in either April or November 2009.

CONCLUSIONS

This study has identified a high overall rate of antimicrobial use in NHs in NI, with variability evident both within and between homes. More research is needed to understand which factors influence antimicrobial use and to determine the appropriateness of antimicrobial prescribing in this population in general and more specifically in the management of recurrent UTIs.

Antidepressant prescribing patterns in the nursing home: second-generation issues revisited

INTRODUCTION

The object of this study was to provide an updated evaluation of the quality of antidepressant management and prescribing patterns in nursing homes in the context of organizational and resident factors.

DESIGN

Pearson correlation and chi-square analyses were conducted using information gathered from random nursing home charts.

SETTING

Nursing home facilities in and around the Louisville, KY, metropolitan area (n = 10).

PARTICIPANTS

Chart reviews were randomly chosen for 20% of long term care resident records in participating homes (n = 209).

MEASUREMENTS

Demographic information, documentation of depression diagnoses, and antidepressant prescribing patterns were evaluated using the Quality of Depression Management and Antidepressant Prescribing rating scale and information found in the Minimum Data Set 2.0.

RESULTS

Of the sample, 59.8% was prescribed antidepressants at the time of the chart review; 205 chart reviews indicated the absence or presence of a depression diagnosis. For those with documented depression diagnoses (n = 126), nearly one-quarter were not prescribed antidepressants. Of 79 chart reviews indicating no depression diagnosis, nearly a third were receiving an antidepressant. Documentation related to changes in dosing, the presence or absence of side effects, or reasons for continuation were suboptimal.

CONCLUSION

Discrepancy between antidepressant prescribing and the presence/absence of depression diagnoses continue to exist for nursing home residents. The quality of antidepressant documentation in nursing home charts continues to be inadequate. Future research should aim to explore possible solutions to these discrepancies and deficiencies in documentation.

Treatment decisions on antidepressants in nursing homes: a qualitative study

OBJECTIVE

To explore decision-making on treatment with antidepressants among doctors and nurses in nursing homes.

DESIGN AND SUBJECTS

A qualitative study based on interviews with three focus groups comprising eight physicians engaged full time, eight physicians engaged part time, and eight registered nurses, respectively. The interview guide comprised questions on initiating, evaluating, and withdrawing treatment with antidepressants. The interviews were audio-recorded, transcribed, and analysed by systematic text condensation.

RESULTS

The first theme was the diagnostic process. The informants expressed difficulty in differentiating between depression and sorrow resulting from loss in old age. Further, the doctors reported that they relied on nurses' observations and rarely carried out systematic diagnostic work and follow-up of patients with depression. The second theme was treatment. Antidepressants were usually the only type of treatment provided, and patients were kept on medication even though staff felt uncertain whether this was effective. The third theme was who really determines the treatment. Registered nurses reported that unskilled and auxiliary nursing staff requested drug treatment, and doctors felt some pressure from the nurses to prescribe antidepressants.

CONCLUSIONS

This study suggests that the quality of diagnosis and treatment for depression in nursing homes needs to be improved in Norway. Doctors should be more available and take responsibility and leadership in medical decisions.

Prevalence and predictors of antidepressant prescribing in nursing home residents in the United States

BACKGROUND

Late-life depression is a common psychiatric disorder associated with increased morbidity and mortality. Depression is often under-detected and undertreated in elderly nursing home residents.

OBJECTIVES

The aim of this study was to examine the prevalence of antidepressant drug use and to identify the factors associated with its use among elderly nursing home residents.

METHODS

The study involved the analysis of a nationally representative sample of prescription and resident files from the 2004 National Nursing Home Survey (NNHS). The study sample included all elderly nursing home residents ≥65 years of age. The analysis focused on prescribing from any antidepressant class, including selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), serotonin modulators, serotonin-norepinephrine reuptake inhibitors (SNRIs), monoamine oxidase inhibitors (MAOIs), and others. Descriptive weighted analysis was performed to examine antidepressant use prevalence patterns in elderly nursing home residents. Multiple logistic regression analysis within the conceptual framework of Anderson's behavioral model was used to examine the predisposing, enabling, and need characteristics associated with antidepressant use.

RESULTS

According to the 2004 NNHS, overall prevalence of antidepressant use among elderly nursing home residents was 46.22% (95% CI, 45.16-47.27). Most antidepressant users were ≥85 years of age (49.7%), female (75.7%), non-Hispanic (96.4%), and white (91.1%). The most prescribed class of antidepressants was SSRIs (31.09%; 95% CI, 30.12-32.07), followed by serotonin modulators (4.65%; 95% CI, 4.22-5.09), SNRIs (2.78%; 95% CI, 2.45-3.12), TCAs (2.34%; 95% CI, 2.03-2.65), and MAOIs (0.01%; 95% CI, 0.00-0.03). Citalopram (12.92%; 95% CI, 12.21-13.63) was the most prescribed individual antidepressant, followed by mirtazapine (10.19%; 95% CI, 9.55-10.84). Among the predisposing characteristics, age, race, and marital status were significantly associated with antidepressant use. The odds of receiving an antidepressant were lower for those aged ≥85 years and those who were unmarried elderly residents, when compared with their counterparts; whites were more likely to receive an antidepressant than nonwhites. Enabling factors such as Medicaid and bed capacity significantly predicted antidepressant use. Having Medicaid was positively associated with antidepressant prescription, whereas an increase in the total number of beds decreased the probability of an antidepressant prescription. Among need characteristics, the likelihood of antidepressant prescription use decreased with increased dependence in decision-making ability and out-of-bed mobility. The presence of depressed mood indicators and a history of falls/fractures increased the likelihood of antidepressant prescription use. The odds of receiving an antidepressant increased with diagnosis of depression but decreased with diagnosis of anxiety.

CONCLUSION

Nearly half of elderly nursing home residents received antidepressants. In addition to need factors, predisposing and enabling factors played an important role in influencing the use of antidepressants in elderly nursing home residents.

Exploring variation in rates of polypharmacy across long term care homes

OBJECTIVE

Use of multiple, concurrent drug therapies, often referred to as polypharmacy, is a concern in the long term care (LTC) setting, where frail older adults are particularly at risk for adverse events. We quantified the scope of this practice by exploring variation in the use of nine or more drug therapies across LTC homes.

DESIGN

Cross-sectional analysis of LTC home census data.

SETTING

All LTC homes in Ontario, Canada.

PARTICIPANTS

A total of 64,394 LTC residents aged 66 years and older residing in 589 LTC homes in the fall of 2005.

MEASUREMENTS

Facility-level rates of polypharmacy were compared with rates of use of Beers criteria and antipsychotic drug therapies. Multivariate logistic regression models were used to assess predictors of polypharmacy across residents and LTC homes.

RESULTS

Nine or more drug therapies were dispensed concurrently to 10,007 (15.5%) of LTC home residents. Compared with those dispensed fewer drugs, residents receiving 9 or more drug therapies were more likely to have multiple comorbidities. There was threefold variation in polypharmacy rates across homes (26.2% versus 7.9%) and facility-level rates of polypharmacy were modestly correlated with rates of use of Beers criteria drugs (r = 0.27, P < .001) and antipsychotic drug therapies (r = 0.16, P < .001). Controlling for resident factors, those living in LTC homes with high polypharmacy rates were more likely to receive 9 or more drug therapies (odds ratio 1.9, 95% confidence interval 1.7-2.0).

CONCLUSION

Residents in Ontario LTC homes commonly received nine or more concurrent drug therapies, particularly residents with multiple chronic conditions. The threefold variation in rate across homes suggests a role for this measure in guiding drug review at the facility level.

Prescribing for older people in nursing homes: strategies to improve prescribing and medicines use in nursing homes

Interventions to improve prescribing in the nursing home environment are many and varied. The critical literature review presented in Paper 1 (Parsons et al., 2011, International Journal of Older People Nursing 6, 45-54) in this series discussed the main issues repeatedly identified as problematic, and this paper summarises the main approaches which have been used to attempt to improve prescribing. These include national legislation which demands documented justification for the prescribing of medicines, medication review, approaches to reducing medication errors, improving communication across care boundaries and assessment teams and alternative service models. It is difficult to make global recommendations as some of these approaches are country specific or have been delivered in different ways, involving different professionals. However, a series of prompt questions have been provided which may assist nursing home staff in deciding whether prescribing is optimal in a resident or if an intervention is required which may lead to an overall improvement in outcomes.

Correlations of nursing home characteristics with prescription of osteoporosis medications

BACKGROUND

Osteoporosis is highly prevalent in the nursing home (NH) populations but medications that increase bone mineral density are used infrequently. Prior research finds few patient characteristics predict treatment. NH characteristics have been associated with prescription of some medications. We examined associations of NH-level characteristics with osteoporosis treatment in elderly patients admitted to a NH after a fracture.

METHOD

We conducted a cohort study of patients with hip, wrist and humeral fractures admitted to a NH in NJ. They were followed for 12 months from 1999 to 2004. Possible NH-level predictors of receiving osteoporosis treatment were assessed in mixed multivariable models to account for clustering within individual NHs.

RESULTS

Of the 2838 post-fracture patients identified from 180 NHs, 156 (5.5%) were prescribed an osteoporosis medication. There was wide variation in treatment between individual NHs (0-40%), which was substantially reduced after adjusting for patient case mix. Several patient characteristics did associate with osteoporosis treatment-female gender (odds ratio (OR) 2.56, 95% confidence interval (CI) 1.42, 4.61), younger age per year (OR 0.98, 95%CI 0.96, 0.99), white race (OR 2.37, 95%CI 1.23, 4.56) and prior history of fracture (OR 4.41, 95%CI 1.04, 18.73). However no NH characteristics significantly associate with treatment (profit status, NH chain member, occupancy rate, and bed size).

CONCLUSION

NH characteristics did not predict pharmacological treatment of osteoporosis. Further studies of osteoporosis prescribing in NHs need to consider other types of variables as possible correlates of prescribing.

Evidence behind The Green House and similar models of nursing home care

The Green House and similar models of nursing home care offer a solution to the institutional nature of nursing homes. In The Green House model, small houses are home to 6–12 residents in which care is given as much attention as treatment and is provided by a consistent, self-directed team of staff who are responsible for all care, including preparing meals in a centrally located open kitchen. Residents have private rooms and bathrooms that open onto a central living area. Although a nurse is available 24 h a day and the clinical care team is nearby and visits the home to provide care, the sense is that one is receiving care in a family-type setting. While these homes are expanding rapidly and seem to embody a better culture of nursing home care, their future growth may depend on the evidence that supports or refutes the quality of care that they provide.

End-of-life care in nursing homes: the importance of CNA staff communication

OBJECTIVE

Staff communication has been shown to influence overall nursing home (NH) performance. However, no empirical studies have focused specifically on the impact of CNA communication on end-of-life (EOL) care processes. This study examines the relationship between CNA communication and nursing home performance in EOL care processes.

DESIGN

Secondary data analysis of 2 NH surveys conducted in 2006-2007.

SETTING

One hundred seven nursing homes in New York State.

PARTICIPANTS

Participants were 2636 CNAs and 107 directors of nursing (DON).

MEASUREMENTS

The measures of EOL care processes-EOL assessment and care delivery (5-point Likert scale scores)-were obtained from survey responses provided by 107 DONs. The measure of CNA communication was derived from survey responses obtained from 2636 CNAs. Other independent variables included staff education, hospice use intensity, staffing ratio, staff-resident ethnic overlap index, facility religious affiliation, and ownership.

METHODS

The reliability and validity of the measures of EOL care processes and CNA communication were tested in the current study sample. Multivariate linear regression models with probability weights were used. The analysis was conducted at the facility level.

RESULTS

We found better CNA communication to be significantly associated with better EOL assessment (P = .043) and care delivery (P = .098). Two potentially modifiable factors-staff education and hospice use intensity-were associated with NHs' performance in EOL care processes. Facilities with greater ethnic overlap between staff and residents demonstrated better EOL assessment (P = .051) and care delivery scores (P = .029).

CONCLUSION

Better CNA communication was associated with better performance in EOL care processes. Our findings provide specific insights for NH leaders striving to improve EOL care processes and ultimately the quality of care for dying residents.

The quality of warfarin prescribing and monitoring in Veterans Affairs nursing homes

OBJECTIVES

To describe the quality of warfarin prescribing and monitoring in Veterans Affairs (VA) nursing homes and to assess the factors associated with maintaining a therapeutic international normalized ratio (INR).

DESIGN

Retrospective cohort.

SETTING

Five VA nursing homes.

PARTICIPANTS

All veterans who received warfarin between January 1 and June 30, 2008, at the nursing homes.

MEASUREMENTS

Using medical records, the percentage of person-time spent in the target INR range, the proportion of patients with INRs in the therapeutic range on 50% or more of their person-days, and the frequency of INR monitoring were estimated. Multivariable logistic regression was used to identify factors associated with maintaining a therapeutic INR 50% or more of the time.

RESULTS

Over 6 months, 160 patients received 10,380 person-days of warfarin. INRs were in the therapeutic range for 55% of the person-days, and 99% of the INR tests were repeated within 4 weeks of the previous result. On an individual level, 49% of patients had INRs in the target range for 50% or more of their person-days. Achieving this outcome was more likely in patients with prevalent warfarin use than with new use (adjusted odds ratio (AOR)=2.86, 95% confidence interval (CI)=1.06-7.72). Conversely, patients with a history of a stroke (AOR=0.38, 95% CI =0.18-0.80) were less likely to have therapeutic INRs for 50% or more of their days.

CONCLUSION

Warfarin appears to be prescribed and monitored effectively in VA nursing home patients. Future studies should focus on increasing time in therapeutic range in patients with poor INR control.

Antidepressant prescribing in US nursing homes between 1996 and 2006 and its relationship to staffing patterns and use of other psychotropic medications

BACKGROUND

Few studies have examined factors associated with antidepressant prescribing in older nursing home residents.

OBJECTIVE

The primary objective was to describe the change in antidepressant prescribing for nursing home residents between 1996 and 2006. An additional objective was to examine the association between any change in antidepressant prescribing and staffing patterns or coprescribing of other psychotropic medications in the same cohort.

DESIGN

Longitudinal.

SETTINGS

Settings were 12,556 US nursing homes in 1996 and 2006.

DATA SOURCES

Online Survey Certification and Reporting (OSCAR) data and the Area Resource File (ARF).

MEASUREMENTS

Increasing prescribing of antidepressants analyzed using multivariable multinomial generalized estimating equations (GEE).

RESULTS

Antidepressant prescribing significantly increased (P < .05) from 21.9% in 1996 to 47.5% in 2006. After controlling for resident, organizational, and market factors, increased antidepressant prescribing was associated with more time spent by physician extenders (adjusted odds ratio [AOR] 2.21; 95% confidence interval [CI] 1.96-2.51), registered nurses (AOR 1.06, 95% CI 1.02-1.10), or nurse aides (AOR 1.08; 95%CI 1.04-1.12) in a facility, as well as the coprescribing of sedative/hypnotics (AOR 1.12; 95% CI 1.08-1.16). Factors found to be protective of increasing antidepressant prescribing (ie, decrease antidepressant prescribing) included having medical directors and physicians spend more time in the facility (AOR 0.60; 95% CI 0.53-0.69 and AOR 0.62; 95% CI 0.54-0.71, respectively), or coprescribing of antianxiety or antipsychotic agents (AOR 0.70; 95% CI 0.68-0.72 and AOR 0.74; 95% CI 0.72-0.77, respectively).

CONCLUSIONS

Prescribing of antidepressants has increased dramatically in the past decade in older nursing home residents and seems to be associated with certain staffing characteristics and the coprescribing of psychotropic medications. Further research is needed to determine if antidepressants are appropriately prescribed, and if overuse is determined, develop interventions to improve the quality of prescribing of these medications in older nursing home residents.

Quality of mental health care for nursing home residents: a literature review

Because of the high proportion of nursing home residents with a mental illness other than dementia, the quality of mental health care in nursing homes is a major clinical and policy issue. The authors apply Donabedian's framework for assessing quality of care based on the triad of structure, process, and outcome-based measures in reviewing the literature on the quality of mental health care in nursing homes. Quality measures used within the literature include mental health consultations and hospitalizations, inappropriate use of medications, and mental health survey deficiencies. Factors related to the resident's welfare (nurse staffing), provider norms (locality), and financial factors (payer mix) were associated with the quality of mental health care. Although future research is necessary, the extant literature suggests that persons with mental illness are frequently admitted to nursing homes and their care is often of poor quality and related to a series of resident and facility factors.

Staffing characteristics, turnover rates, and quality of resident care in nursing facilities

Despite substantial spending and considerable regulatory oversight, the quality of care provided to residents in the nation's nursing facilities is inadequate, and strategies to address this problem are needed. Staffing characteristics are important predictors of quality in nursing facilities, and the relationship between staffing and various quality measures fluctuates across studies and in analyses that account for the effects of market, resident, and organizational characteristics. However and even with such variations, it is has generally been concluded that higher staffing levels, less turnover, and higher retention rates are associated with an array of improved resident and facility outcomes. This article synthesizes literature, including published reports, expert opinion, and peer reviewed studies, on staffing levels, turnover, and quality of care in nursing homes. The findings were used to develop three staffing interventions that need to be further evaluated in an effort to improve the quality of care in nursing facilities.

Social work student interest in nursing home employment: a North American study

Nursing homes (NHs) are a primary setting for gerontological social work; yet, little is known about social workers' career interest relative to this setting. This article reports the findings of an online survey of social work students (177 U.S. and 91 Canadian) that sought to identify personal characteristics and beliefs that influence NH employment intentions. Students who were enrolled in bachelors programs, lacked previous practice experience, and had already had a NH field placement or wanted this experience were more likely to express employment intent. The implications of these findings for social work education and research are discussed.

The association of individual and facility characteristics with psychiatric hospitalization among nursing home residents

OBJECTIVE

To examine resident and facility characteristics associated with psychiatric hospitalizations (PH) for Medicaid enrolled nursing home (NH) residents.

METHODS

Participants were all Medicaid enrolled NH residents (n = 32,604) from all Medicaid certified nursing homes in Florida (n = 584) with complete data. We used individual demographic and diagnostic characteristics, as well as facility characteristics, to explore risk of psychiatric hospitalization in this dataset.

RESULTS

Using generalized estimating equations, we found that younger age, male gender, poor physical health, serious mental illness, dementia, and drug use disorder were associated with risk of psychiatric hospitalization. Most notably, residents under 65 were more than three times more likely to undergo psychiatric hospitalization and dementia was associated with a three-fold increase in the risk of psychiatric hospitalization. Predictors of PH differed somewhat for younger and older residents. Among facility characteristics, greater facility size, low proportion of those paying via Medicare and high proportion of residents with serious mental illness were associated with increased risk of psychiatric hospitalization, whereas, low proportion of residents paying via Medicaid, high proportion of residents paying via Medicare, and low proportion of resident with serious mental illness were associated with reduced risk.

CONCLUSIONS

Both resident and facility characteristics impact risk for psychiatric hospitalization. Attention to identified predictors may reduce risk and improve outcomes for nursing home residents.

Does the presence of a dementia special care unit improve nursing home quality?

OBJECTIVE

This study quantifies the effect of a new dementia special care unit (D-SCU) on the provision of care to all residents in a nursing home (NH).

METHOD

The authors use data from the On-line Survey Certification and Reporting system to identify free-standing NHs that first reported a D-SCU between 1996 and 2003 (N = 1,519). Fixed-effects models estimate the effect of a new D-SCU on the prevalence of each outcome (physical restraints, feeding tubes, and psychotropic medications) while controlling for secular trends.

RESULTS

For all NHs, the use of physical restraints declined, the use of antipsychotics increased, and other measures remained relatively constant. The introduction of a D-SCU was not associated with changes in trends for any measure.

DISCUSSION

Differences in care processes between NHs with and without D-SCUs are the result of differences in their underlying approach to care, not the result of care practice diffusion from the D-SCU.

Nursing Home Caregiver Staffing Levels and Quality of Care

In this research, the author reviewed 70 studies that had examined the relationship between staffing levels and quality in nursing homes (covering the years 1991 to 2006). The results of the review including all of this literature show that approximately 40% of the quality indicators examined show an association with nursing home staffing levels. Nevertheless, this finding is further interpreted in the context of the limitations of many of these prior studies. The author discusses the limitations of poor quality staffing data, small sample size, quality indicators used, methodological concerns, and underspecified models inherent to many prior studies. The author finds no study representing a “gold standard” exists in this area. Still, the few studies that seem methodologically most robust would seem to indicate that an association between nursing home staffing levels and quality exists. However, the author concludes that studies in this area need to be further enhanced.

Long-term care market competition and nursing home dementia special care units

BACKGROUND

The proliferation of noninstitutional long-term care (LTC) alternatives, particularly assisted living (AL), raises questions about how the nursing home (NH) industry is affected. Dementia special care units (SCUs), which provided NHs a competitive edge in the past, are of interest because they have traditionally served residents who now have other options.

OBJECTIVES

To quantify the effect of LTC competition on the odds of SCU presence in a NH; among those NHs with an SCU, to quantify the effect of competition on overall acuity.

RESEARCH DESIGN

Cross-sectional with LTC market defined as the NH's county.

SUBJECTS

Nine hundred forty-two NHs, 88 with an SCU, in 122 Texas counties during 2004.

MEASURES

LTC competition was measured by a NH's share of beds, the presence of another NH SCU, the presence of AL, the presence of dementia care in AL, and the presence of home health in the market. The outcomes were the presence of an SCU in a NH and the average level of resident acuity on those SCUs.

RESULTS

Competition from another NH-based SCU was associated with the presence of an SCU in a NH [adjusted odds ratio, 3.3; 95% confidence interval (CI), 1.6-6.6] but there were no associations with other measures. Within NH-based SCUs, mean acuity was higher when there was AL in the market (beta, 1.6; 95% CI, 0.4-2.7), but there was no additional effect of AL dementia beds (beta, 1.6; 95% CI, 0.2-3.0).

CONCLUSIONS

A NH's investment in specialized dementia care is influenced by the behavior of nearby NHs but not yet by other forms of LTC; however, the profile of residents served by SCUs is affected by AL competition.

Hospitalization of Nursing Home Residents With Cognitive Impairments: The Influence of Organizational Features and State Policies

PURPOSE

The purpose of this study was to quantify the effect of specific nursing home features and state Medicaid policies on the risk of hospitalization among cognitively impaired nursing home residents.

DESIGN AND METHODS

We used multilevel logistic regression to estimate the odds of hospitalization among long-stay (>90 days) nursing home residents against the odds of remaining in the nursing home over a 5-month period, controlling for covariates at the resident, nursing home, and county level. We stratified analyses by resident diagnosis of dementia.

RESULTS

Of 359,474 cognitively impaired residents, 49% had a diagnosis of dementia. Of those, 16% were hospitalized. The probability of hospitalization was negatively associated with the presence of a dementia special care unit (adjusted odds ratio [AOR] = 0.90, 95% confidence interval [CI] = 0.86-0.94) and with a high prevalence of dementia in the nursing home (AOR = 0.96, 95% CI = 0.88-1.03). Higher Medicaid payment rates were associated with reduced likelihood of hospitalization (AOR = 0.95, 95% CI = 0.90-1.00), whereas any bed-hold policy substantially increased that likelihood (AOR = 1.44, 95% CI = 1.12-1.86). We observed similar results for residents without a dementia diagnosis.

IMPLICATIONS

Directed management of chronic conditions, as indicated by facilities' investment in special care units, reduces the risk of hospitalization, but the effect of bed-hold policies illustrates how fragmentation in the financing system impedes these efforts.

Does incorporating medications in the surveyors' interpretive guidelines reduce the use of potentially inappropriate medications in nursing homes?

OBJECTIVES

To quantify the association between including specific medications deemed potentially inappropriate in the surveyors' interpretive guidelines for nursing homes and the prevalence of use.

DESIGN

Quasi-experimental.

SETTING

One thousand one hundred forty-one nursing homes in four U.S. states.

PARTICIPANTS

Residents living in one of the included nursing homes in operation during 1997 (before Beers; n=130,250) and 2000 (after Beers; n=164,889).

INTERVENTION

Inclusion of specific medications deemed potentially inappropriate in the surveyors' interpretive guidelines for nursing homes.

MEASUREMENTS

Logistic regression models adjusting for clustering effects of residents residing in homes provided estimates of the relationship between the survey process and use of any medications targeted as potentially inappropriate as part of the survey process, as well as those deemed inappropriate but not included.

RESULTS

The use of any potentially inappropriate medication decreased from 42.5% in 1997 to 39.8% in 2000. After adjustment for resident characteristics, residents were less likely to receive any potentially inappropriate medication (odds ratio (OR)=0.85, 95% confidence interval (95% CI)=0.84-0.87), those considered high-severity drugs (those with a high likelihood of a clinically significant adverse event) (OR=0.67, 95% CI=0.65-0.69), or Beers' medications not included in the surveyors' guidelines (OR=0.76, 95% CI=0.74-0.79) in 2000 than in 1997 after the changes to the drug regulations and interpretive guidelines.

CONCLUSION

Targeting specific drugs in the surveyor's interpretive guidelines as a method to reduce potentially inappropriate medication use may not produce desired gains in medication-use quality improvement. Alternative strategies for nursing homes should be evaluated.

Does Organisational Culture Influence Prescribing in Care Homes for Older People?

Prescribing in care homes for older people has been the focus of much research and debate because of inappropriate drug choice and poor monitoring practices. In the US, this has led to the implementation of punitive and adversarial regulation that has sought to improve the quality of prescribing in this healthcare setting. This approach is unique to the US and has not been replicated elsewhere. The literature has revealed that there are limitations as to how much can be achieved with regulation that is externally imposed (an 'external factor'). Other influences, which may be categorised as 'internal factors' operating within the care home (e.g. patient, physician and care-home characteristics), also affect prescribing. However, these internal and external factors do not appear to affect prescribing uniformly, and poor prescribing practices in care homes continue to be observed. One intangible factor that has received little attention in this area of healthcare is that of organisational culture. This factor has been linked to quality and performance within other health organisations. Consideration of organisational culture within care-home settings may help to understand what drives prescribing decisions in this particularly vulnerable patient group and thus provide new directions for future strategies to promote quality care.

Use of Medication Technicians in US Nursing Homes: Part of the Problem or Part of the Solution?

OBJECTIVES

To determine the relation between organizational characteristics and medication technician (MT) use and quantify the impact of MTs on increasing the likelihood of using medications, employing the example of antiosteoporosis medications.

DESIGN

Cross-sectional study.

SETTING

The setting included 6344 Medicare/Medicaid certified nursing homes in 23 states.

PARTICIPANTS

Residents older than 65 years of age.

MEASUREMENTS

On-line Survey and Certification of Automated Records (OSCAR) provided facility characteristics information including structural, resource, and staffing levels. The Minimum Data Set (MDS) provided information regarding use of antiosteoporosis medications and resident factors. Adjusted estimates of MT use on antiosteoporosis medication use were derived using logistic regression with generalized estimating equations.

RESULTS

MT use varied by state (6.7% in Alaska vs 85% in Kansas). Homes with greater nursing staffing levels per 100 beds (CNA, RN, LPN) were less likely to use MTs, while larger homes, homes using physician extenders, and contracting pharmacy services were more likely to use MTs. Homes with MTs were more likely to have medication error rates of at least 5% (10.1% vs 7.3%) than homes without MTs. After adjustment for resident and facility factors, residents in MT facilities were not more likely to receive antiosteoporosis treatment relative to those in homes without MTs.

CONCLUSION

These data call into question the use of MTs in nursing homes. Use of MTs may lead to more errors, yet not increase use of medications that are labor intensive to administer.