Relationship between nursing home quality indicators and potentially preventable hospitalisation

Construct validity of measures of care home resident quality of life: cross-sectional analysis using data from a pilot minimum data set in England

BACKGROUND

To maintain good standards of care, evaluations of policy interventions or potential improvements to care are required. A number of quality of life (QoL) measures could be used but there is little evidence for England as to which measures would be appropriate. Using data from a pilot Minimum Data Set (MDS) for care home residents from the Developing resources And minimum dataset for Care Homes' Adoption (DACHA) study, we assessed the discriminant construct validity of QoL measures, using hypothesis testing to assess the factors associated with QoL.

METHODS

Care home records for 679 residents aged over 65 from 34 care homes were available that had been linked to health records and care home provider data. In addition to data on demographics, level of needs and impairment, proxy report measures of social care-, capability- and health-related QoL of participants were completed (ASCOT-Proxy-Resident, ICECAP-O, EQ-5D-5L Proxy 2). Discriminant construct validity was assessed through testing hypotheses developed from previous research and QoL measure constructs. Multilevel regression models were analysed to understand how QoL was influenced by personal characteristics (e.g. sex, levels of functional and cognitive ability), care home level factors (type of home, level of quality) and resident use of health services (potentially avoidable emergency hospital admissions). Multiple imputation was used to address missing data.

RESULTS

All three QoL measures had acceptable construct validity and captured different aspects of QoL, indicated by different factors explaining variation in each measure. All three measures were negatively associated with levels of cognitive impairment, whilst ICECAP-O and EQ-5D-5L Proxy 2 were negatively associated with low levels of functional ability. ASCOT-Proxy-Resident was positively associated with aspects of quality and care effectiveness at both resident- and care home-level.

CONCLUSION

The study found acceptable construct validity for ASCOT-Proxy-Resident, ICECAP-O and EQ-5D-5L Proxy 2 in care homes, with findings suggesting the three are complementary measures based on different constructs. The study has also provided evidence to support the inclusion of these QoL measures in any future MDS.

Skin Ulcer Development and Deterioration of Social Engagement among Nursing Home Residents

OBJECTIVES

Skin ulcers are a critical indicator of quality of care in nursing homes that influence residents' physical, psychological, and social health. The objective of this study is to understand the influence of developing skin ulcers on deterioration in social engagement in nursing home residents.

DESIGN

Observational retrospective cohort study with 1-year follow-up.

SETTING AND PARTICIPANTS

Nursing home residents aged ≥50 years were followed quarterly (2008/2009-2009/2010), the latest years in which the Minimum Data Set 2.0 measured social engagement.

METHODS

Cumulative incidence ratios (CIRs) and 95% CIs quantified the association between skin ulcer development and deterioration in residents' social engagement levels.

RESULTS

About 1.25% first developed new skin ulcers at the annual follow-up assessment; 1.22% developed skin ulcers at a quarterly assessment that persisted at the annual assessment, and 4.53% developed skin ulcers at a quarterly assessment that were resolved by annual assessment. Compared with residents who remained ulcer-free, those with new skin ulcer at annual assessment and persistent skin ulcers were at increased risk of experiencing a reduction in social engagement (CIR, 1.26; 95% CI, 1.11-1.44; CIR, 1.32; 95% CI, 1.16-1.50, respectively). Those with resolved skin ulcers were also at increased risk of social engagement deterioration (CIR, 1.12; 95% CI, 1.04-1.21) than those who remained ulcer-free.

CONCLUSION AND IMPLICATIONS

Residents who develop skin ulcers are at a higher risk of deteriorating social engagement. Nursing home staff should strive not only to prevent and treat skin ulcers, but also to support social engagement for those with skin ulcers.

Performance indicators on long-term care for older people in 43 high- and middle-income countries: literature review, web search and expert consultation

BACKGROUND

Long-term care (LTC) for older people is an area of focus for many health and social policies in high- and middle-income countries. Performance Indicators are used to provide national and subnational jurisdictions with insights to ensure quality of the provided LTC services for older people. Although LTC systems vary across jurisdictions, there is demand for internationally comparable indicators to support countries in monitoring LTC and facilitate mutual learning. The aim of this study was to provide an overview of indicators currently employed to monitor the performance of LTC systems and services in high- and middle- income countries and describe their key characteristics.

METHODS

A review of the literature in six scientific databases (literature review) and web searches of relevant sites across 43 selected countries (web search) was conducted. We asked country representatives from the Working Party on Health Care Quality and Outcomes of the Organization for Economic Cooperation and Development, where most of these countries are represented, to cross-validate the sources of information found (expert consultation). We then extracted and analysed the data from all obtained sources based on a predetermined set of characteristics.

RESULTS

The search of scientific databases yielded 12,960 records, from which forty papers were selected for inclusion. The scientific literature findings were complemented by 34 grey literature sources. In total, we identified performance indicators being used to monitor LTC systems and services across 29 national and subnational jurisdictions in 24 out of 43 countries. In total, 620 indicators were identified. All jurisdictions used indicators related to institutional LTC and 16 also used indicators on home care. The most frequently monitored structures, processes, and results were pressure ulcers, falls, use of restraints and pain management.

CONCLUSIONS

We identified LTC performance indicators currently being monitored in 29 jurisdictions across 24 countries. Many jurisdictions are monitoring similar structures, processes, and results. This presents an opportunity to develop internationally comparable LTC performance indicators based on existing efforts across countries.

Strategies for older people living in care homes to prevent urinary tract infection: the StOP UTI realist synthesis

Background

Urinary tract infection is the most diagnosed infection in older people. It accounts for more than 50% of antibiotic prescriptions in care homes and is a frequent reason for care home residents being hospitalised.

Objective

This realist review developed and refined programme theories for preventing and recognising urinary tract infection, exploring what works, for whom and in what circumstances.

Design

The review used realist synthesis to explore existing literature on the detection and prevention of urinary tract infection, complemented by stakeholder consultation. It applies to the UK context, although other healthcare systems may identify synergies in our findings.

Data sources

Bibliographic databases searched included MEDLINE, CINAHL, EMBASE, Cochrane Library, Web of Science Core Collection (including the Social Sciences Citation Index), Sociological Abstracts, Bibliomap and National Institute for Health and Care Research Journals Library.

Data selection and extraction

Title and abstract screening were undertaken by two researchers independently of each other. Selection and assessment were based on relevance and rigour and cross-checked by a second researcher. Data extracted from the included studies were explored for explanations about how the interventions were considered to work (or not). Evidence tables were constructed to enable identification of patterns across studies that offered insight about the features of successful interventions.

Data analysis and synthesis

Programme theories were constructed through a four-stage process involving scoping workshops, examination of relevant extant theory, analysis and synthesis of primary research, teacher-learner interviews and a cross-system stakeholder event. A process of abductive and retroductive reasoning was used to construct context-mechanism-outcome configurations to inform programme theory.

Results

The scoping review and stakeholder engagement identified three theory areas that address the prevention and recognition of urinary tract infection and show what is needed to implement best practice. Nine context-mechanism-outcome configurations provided an explanation of how interventions to prevent and recognise urinary tract infection might work in care homes. These were (1) recognition of urinary tract infection is informed by skills in clinical reasoning, (2) decision-support tools enable a whole care team approach to communication, (3) active monitoring is recognised as a legitimate care routine, (4) hydration is recognised as a care priority for all residents, (5) systems are in place to drive action that helps residents to drink more, (6) good infection prevention practice is applied to indwelling urinary catheters, (7) proactive strategies are in place to prevent recurrent urinary tract infection, (8) care home leadership and culture fosters safe fundamental care and (9) developing knowledgeable care teams.

Limitations

We adapted our approach and work to online interactions with stakeholders and as a research team because of COVID-19. This also had an impact on bringing stakeholders together at a face-to-face event at the end of the project. Studies focusing on the prevention of urinary tract infection in care home settings were predominantly from the USA and Europe where the regulatory and funding systems for the long-term care of the elderly have some differences, particularly in the USA where national reporting plays a significant role in driving improvements in care.

Conclusions

Care home staff have a vital role in the prevention and recognition of urinary tract infection, which can be enabled through integration and prioritisation within the systems and routines of care homes and delivery of person-centred care. Promoting fundamental care as a means of facilitating a holistic approach to prevention and recognition of urinary tract infection helps staff to recognise how they can contribute to antimicrobial stewardship and recognition of sepsis. Challenging assumptions made by staff about the presentation of urinary tract infection is complex and requires education that facilitates 'unlearning' and questioning of low-value practices. Programmes to prevent urinary tract infection need to be co-designed and supported through active and visible leadership by care home managers with support from specialist practitioners.

Future work

We will focus on co-designing tools that facilitate implementation of our findings to ensure they fit with the care home context and address some of the challenges faced by care home leaders. This will underpin action at care home and system levels. Further research is needed to better understand the perspectives of residents and family carers, the effectiveness of non-pharmacological, pharmacological and specialist practitioner interventions and non-traditional approaches to training and educating the workforce in care home settings.

Study registration

This study is registered as PROSPERO CRD42020201782.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR130396) and is published in full in Health Technology Assessment; Vol. 28, No. 68. See the NIHR Funding and Awards website for further award information.

Interprofessional relationships and their impact on resident hospitalizations in nursing homes: A qualitative study

AIM

The aim of this study is to explore experiences and perspectives of nurses and providers (e.g., physicians, medical directors, fellows, and nurse practitioners) on reducing preventable hospitalizations of nursing home (NH) residents in relation to interprofessional relationship and hospitalization decision-making process.

BACKGROUND

Preventable NH resident hospitalization continues to be a pressing public health issue. Studies show that improved interprofessional relationship may help reduce hospitalization, yet research on communication processes and interactions among different NH staff remains limited.

METHODS

This is a qualitative descriptive study. Two focus groups were held with fourteen nurses and thirteen in-depth, qualitative interviews were conducted with providers from two Chicagoland NHs. Focus group sessions and interviews were transcribed, coded, and analyzed for common themes based on qualitative description method.

RESULTS

All study participants agreed that providers have the ultimate responsibility for hospitalization decisions. However, nurses believed they could influence those decisions, depending on provider characteristics, trust, and resident conditions. Nurses and providers differed in the way they experienced and conveyed emotions, and differed in key elements affecting hospitalization decisions such as structural or environmental factors (e.g., lacking staff and equipment at the facility, poor communication between the NH and hospitals) and interpersonal factors (e.g., characteristics of effective nurses or providers and the effective interactions between them).

CONCLUSIONS

Interpersonal factors, including perceived competence, respect, and trust, may influence NH hospitalization decisions and be targeted for reducing preventable hospitalizations of residents.

Approach to systematically examine the usefulness of quality measures in practice: Minnesota's nursing home quality indicators and scoring approach

BACKGROUND

Healthcare quality measurement systems, which use aggregated patient-level quality measures to assess organisational performance, have been introduced widely. Yet, their usefulness in practice has received scant attention. Using Minnesota nursing home quality indicators (QIs) as a case example, we demonstrate an approach for systematically evaluating QIs in practice based on: (a) parsimony and relevance, (b) usability in discriminating between facilities, (c) actionability and (d) construct validity.

METHODS

We analysed 19 risk-adjusted, facility-level QIs over the 2012-2019 period. Parsimony and relevance of QIs were evaluated using scatter plots, Pearson correlations, literature review and expert opinions. Discrimination between facilities was assessed by examining facility QI distributions and the impact of the distributions on scoring. Actionability of QIs was assessed through QI trends over time. Construct validity was assessed through exploratory factor analysis of domain structure for grouping the QIs.

RESULTS

Correlation analysis and qualitative assessment led to redefining one QI, adding one improvement-focused QI, and combining two highly correlated QIs to improve parsimony and clinical relevance. Ten of the QIs displayed normal distributions which discriminated well between the best and worst performers. The other nine QIs displayed poor discrimination; they had skewed distributions with ceiling or floor effects. We recommended scoring approaches tailored to these distributions. One QI displaying substantial improvement over time was recommended for retirement (physical restraint use). Based on factor analysis, we grouped the 18 final QIs into four domains: incontinence (4 QIs), physical functioning (4 QIs), psychosocial care (4 QIs) and care for specific conditions (6 QIs).

CONCLUSION

We demonstrated a systematic approach for evaluating QIs in practice by arriving at parsimonious and relevant QIs, tailored scoring to different QI distributions and a meaningful domain structure. This approach could be applied in evaluating quality measures in other health or long-term care settings.

Accuracy of Pressure Ulcer Events in US Nursing Home Ratings

BACKGROUND

The US government relies on nursing home-reported data to create quality of care measures and star ratings for Nursing Home Compare (NHC). These data are not systematically validated, and some evidence indicates NHC's patient safety measures may not be reliable.

OBJECTIVE

The objective of this study was to assess the accuracy of NHC's pressure ulcer measures, which are chief indicators of nursing home patient safety.

RESEARCH DESIGN

For Medicare fee-for-service beneficiaries who were nursing home residents between 2011 and 2017, we identified hospital admissions for pressure ulcers and linked these to the nursing home-reported data at the patient level. We then calculated the percentages of pressure ulcers that were appropriately reported by stage, long-stay versus short-stay status, and race. After developing an alternative claims-based measure of pressure ulcer events, we estimated the correlation between this indicator and NHC-reported ratings.

SUBJECTS

Medicare nursing home residents with hospitalizations for pressure ulcers.

MEASURES

Pressure ulcer reporting rates; nursing home-level claims-based measure of pressure ulcer events.

RESULTS

Reporting rates were low for both short-stay (70.2% of 173,043 stage 2-4 pressure ulcer hospitalizations) and long-stay (59.7% of 137,315 stage 2-4 pressure ulcer hospitalizations) residents. Black residents experienced more severe pressure ulcers than White residents, however, this translated into having slightly higher reporting rates because higher staged pressure ulcers were more likely to be reported. Correlations between our claims-based measure and NHC ratings were poor.

CONCLUSIONS

Pressure ulcers were substantially underreported in data used by NHC to measure patient safety. Alternative approaches are needed to improve surveillance of health care quality in nursing homes.

Quality indicators for the care of older adults with disabilities in long-term care facilities based on Maslow's hierarchy of needs

Purpose

This study aimed to develop quality indicators for the care of older adults with disabilities in long-term care facilities (LTCFs) based on Maslow’s hierarchy of needs.

Methods

The draft of the quality indicators was drawn up based on a literature review and research group discussion. The quality indicators were finalized by two rounds of expert consultation (involving 15 experts) using the Delphi method. The Analytic Hierarchy Process was applied to calculate the indicators’ weight.

Results

The response rates of the two rounds of consultation were 100% and 93%, and the expert authority coefficients were 0.86 and 0.87. After two rounds of consultation, the expert opinion coordination coefficients of the first-, second- and third-level indicators were 0.42, 0.25, and 0.96, respectively (P < 0.05), and the variation coefficient was ≤0.25. The final quality indicators for the care of older adults with disabilities in LTCFs included 7 first-level, 19 second-level, and 107 third-level indicators.

Conclusion

The quality indicators for the care of older adults with disabilities in LTCFs are reliable, scientific, comprehensive, and practical and specify the content of person-centered care needs. This can provide a reference for evaluating and improving care quality in LTCFs.

Identifying patterns of potentially preventable hospitalisations in people living with dementia

BACKGROUND

Older Australians make up 46% of all potentially preventable hospitalisations (PPHs) and people living with dementia are at significantly greater risk. While policy reforms aim to reduce PPHs, there is currently little evidence available on what drives this, especially for people living with dementia. This study examines patterns of PPHs in people living with dementia to inform service delivery and the development of evidence-based interventions.

METHODS

We used the Victorian Admitted Episodes Dataset from Victoria, Australia, to extract data for people aged 50 and over with a diagnosis of dementia between 2015 and 2016. Potentially avoidable admissions, known as ambulatory care sensitive conditions (ACSCs), were identified. The chi-square test was used to detect differences between admissions for ACSCs and non-ACSCs by demographic, geographical, and administrative factors. Predictors of ACSCs admissions were analysed using univariate and multiple logistic regression.

RESULTS

Of the 8156 hospital records, there were 3884 (48%) ACSCs admissions, of which admissions for urinary tract infections accounted for 31%, followed by diabetes complications (21%). Mean bed-days were 8.26 for non-ACSCs compared with 9.74 for ACSCs (p ≤ 0.001). There were no differences between admissions for ACSCs and non-ACSCs by sex, marital status, region (rural vs metro), and admission source (private accommodation vs residential facility). Culture and language predicted ASCS admission rates in the univariate regression analyses, with ACSC admission rates increasing by 20 and 29% if English was not the preferred language or if an interpreter was required, respectively. Results from the multiple regression analysis confirmed that language was a significant predictor of ACSC admission rates.

CONCLUSIONS

Improved primary health care may help to reduce the most common causes of PPHs for people living with dementia, particularly for those from culturally and linguistically diverse backgrounds.

Medication-related hospital admissions in aged care residents

OBJECTIVE

To determine the prevalence of medication-related hospitalisations preceded by potentially suboptimal processes of care in aged care residents.

METHOD

We conducted a retrospective analysis of administrative claims data from the Australian Government Department of Veterans' Affairs (DVA). We identified all hospital admissions for aged care residents between 1 July 2014 and 30 June 2019. The proportion of hospital admissions preceded by potentially suboptimal medication-related processes of care was determined.

RESULTS

A total of 18 874 hospitalisations were included, and 46% were preceded by potentially suboptimal medication-related care. One-quarter of fracture admissions occurred in residents at risk of fracture who were not using a medicine to prevent fracture, and 87% occurred in residents using falls-risk medicines. Thirty per cent of heart failure admissions occurred in patients who were not using an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker.

CONCLUSION

Nearly half of hospital admissions were preceded by potentially suboptimal medication-related processes of care. Interventions to improve use of medicines for aged care residents in these areas are warranted.

Nursing home performance in a trial to reduce hospitalizations: Implications for future trials

BACKGROUND

Experience in trials of implementing quality improvement (QI) programs in nursing homes (NHs) has been variable. Understanding the characteristics of NHs that demonstrate improvements during these trials is critical to improving NH care.

DESIGN

Secondary analysis of a randomized controlled trial of implementation of a QI program to reduce hospital transfers.

PARTICIPANTS

Seventy-one NHs that completed the 12-month trial INTERVENTION: Implementation included distance-learning strategies, involvement of a champion, regular submission of data on hospitalizations and root cause analyses of transfers, and training, feedback and support.

MEASUREMENTS

Primary outcomes included all-cause and potentially avoidable hospitalizations and emergency department (ED) visits per 1000 NH resident days, and the percentage of residents readmitted in 30-days. We compared multiple other variables that could influence effective program implementation in NHs in the highest versus lowest quartile of changes in the primary outcomes.

RESULTS

The 18 high-performing NHs had significant reductions in hospitalization and ED visits, whereas the 18 NHs in the low-performing group had increases. The difference in changes in each outcome varied between a reduction of 0.75 and 2.30 events relative to a NH with a census of 100; the absolute difference in 30-day readmissions was 19%. None of the variables we examined reached significance after adjustment for multiple comparisons between the groups. There was no consistent pattern of differences in nonprofit status, nursing staffing, and quality ratings.

CONCLUSION

Our experience and reviews of other NH trials suggest that key factors contributing to successful implementation QI programs in NHs remain unclear. To improve NH care, implementation trials should account for intervention fidelity and factors that have not been examined in detail, such as degree and nature of leadership support, financial and regulatory incentives, quality measures, resident and family perspectives, and the availability of onsite high-quality medical care and support of the medical director.

The Association of Nursing Home Characteristics and Quality with Adverse Events After a Hospitalization

BACKGROUND/OBJECTIVES

We previously found high rates of adverse events (AEs) for long-stay nursing home residents who return to the facility after a hospitalization. Further evidence about the association of AEs with aspects of the facilities and their quality may support quality improvement efforts directed at reducing risk.

DESIGN

Prospective cohort analysis.

SETTING AND PARTICIPANTS

32 nursing homes in the New England states. A total of 555 long-stay residents contributed 762 returns from hospitalizations.

METHODS

We measured the association between AEs developing in the 45 days following discharge back to long-term care and characteristics of the nursing homes including bed size, ownership, 5-star quality ratings, registered nurse and nursing assistant hours, and the individual Centers for Medicare & Medicaid Services (CMS) quality indicators. We constructed Cox proportional hazards models controlling for individual resident characteristics that were previously found associated with AEs.

RESULTS

We found no association of AEs with most nursing home characteristics, including 5-star quality ratings and the composite quality score. Associations with individual quality indicators were inconsistent and frequently not monotonic. Several individual quality indicators were associated with AEs; the highest tertile of percentage of residents with depression (4%-25%) had a hazard ratio (HR) of 1.65 [95% confidence interval (CI) 1.16, 2.35] and the highest tertile of the percentage taking antipsychotic medications (18%-35%) had an HR of 1.58 (CI 1.13, 2.21). The percentage of residents needing increased assistance with activities of daily living was statistically significant but not monotonic; the middle tertile (13% to <20%) had an HR of 1.69 (CI 1.16, 2.47).

CONCLUSIONS AND IMPLICATIONS

AEs occurring during transitions between nursing homes and hospitals are not explained by the characteristics of the facilities or summary quality scores. Development of risk reduction approaches requires assessment of processes and quality beyond the current quality measures.

Measuring safety in older adult care homes: a scoping review of the international literature

BACKGROUND

Safety is a key concern in older adult care homes. However, it is a less developed concept in older adult care homes than in healthcare settings. As part of study of the collection and application of safety data in the care home sector in England, a scoping review of the international literature was conducted.

OBJECTIVES

The aim of the review was to identify measures that could be used as indicators of safety for quality monitoring and improvement in older adult residential or nursing care homes.

SOURCES OF EVIDENCE

Systematic searches for journal articles published in English language from 1 January 1970, without restriction to the study location or country, were conducted in Web of Science, Scopus and PubMed on 28 July 2019.

ELIGIBILITY CRITERIA

Inclusion criteria were: peer-reviewed journal articles; qualitative or quantitative studies of older adult nursing and/or residential care homes; and related to any aspect of safety in care homes, including the safety of healthcare provision in the care home. A total of 45 articles were included after review of the title/abstract or full text against the inclusion criteria.

CHARTING METHODS

Key information was extracted and charted. These findings were then mapped to the Safety Measurement and Monitoring Framework in healthcare (SMMF), adapted by the research team to reflect the care home context, to determine the coverage of different aspects of safety, as well as potential gaps.

RESULTS AND CONCLUSIONS

Systematic searches for journal articles published in English language from 1 January 1970, without restriction to the study location or country, were conducted in Web of Science, Scopus and PubMed on 28 July 2019. Inclusion criteria were: peer-reviewed journal articles; qualitative or quantitative studies of older adult nursing and/or residential care homes; and related to any aspect of safety in care homes, including the safety of healthcare provision in the care home.A total of 45 articles were included after review of the title/abstract or full text against the inclusion criteria. Key information was extracted and charted. These findings were then mapped to the Safety Measurement and Monitoring Framework in healthcare (SMMF), adapted by the research team to reflect the care home context, to determine the coverage of different aspects of safety, as well as potential gaps.The findings indicate that there are a range of available safety measures used for quality monitoring and improvement in older adult care homes. These cover all five domains of safety in the SMMF. However, there are potential gaps. These include user experience, psychological harm related to the care home environment, abusive or neglectful care practice and the processes for integrated learning. Some of these gaps may relate to challenges and feasibility of measurement in the care home context.

Nobody ever questions-Polypharmacy in care homes: A mixed methods evaluation of a multidisciplinary medicines optimisation initiative

BACKGROUND

Nurse-led monitoring of patients for signs and symptoms associated with documented 'undesirable effects' of medicines has potential to prevent avoidable harm, and optimise prescribing.

INTERVENTION

The Adverse Drug Reaction Profile for polypharmacy (ADRe-p) identifies and documents putative adverse effects of medicines commonly prescribed in primary care. Nurses address some problems, before passing ADRe-p to pharmacists and prescribers for review, in conjunction with prescriptions.

OBJECTIVES

We investigated changes in: the number and nature of residents' problems as recorded on ADRe-p; prescription regimens; medicines optimisation: and healthcare costs. We explored aetiologies of problems identified and stakeholders' perspectives.

SETTING AND PARTICIPANTS

In three UK care homes, 19 residents completed the study, December 2018 to May 2019. Two service users, three pharmacists, six nurses gave interviews.

METHODS

This mixed-method process evaluation integrated data from residents' ADRe-ps and medicines charts, at the study's start and 5-10 weeks later.

RESULTS

We recruited three of 27 homes approached and 26 of 45 eligible residents; 19 completed ADRe-p at least twice. Clinical gains were identified for 17/19 residents (mean number of symptoms 3 SD 1.67, range 0-7). Examples included management of: pain (six residents), seizures (three), dyspnoea (one), diarrhoea (laxatives reduced, two), falls (two of five able to stand). One or more medicine was de-prescribed or dose reduced for 12/19 residents. ADRe administration and review cost ~£30 in staff time. ADRe-p helped carers and nurses bring residents' problems to the attention of prescribers.

IMPLICATIONS

ADRe-p relieved unnecessary suffering. It supported carers and nurses by providing a tool to engage with pharmacists and prescribers, and was the only observable strategy for multidisciplinary team working around medicines optimisation. ADRe-p improved care by: a) regular systematic checks and problem documentation; b) information transfer from care home staff to prescribers and pharmacists; c) recording changes.

REGISTRATION

NLM Identifier NCT03955133; ClinicalTrials.gov.

Staff nurses' evaluation of care process quality and patient outcomes in long-term care hospitals: A cross-sectional questionnaire survey

AIM

Despite the large and growing body of research on quality care evaluation and improvements in long-term care facilities, issues regarding the quality of care provided prevail worldwide. Further and more diverse research related to this topic is urgently required. To that end, this study examines the association between the subjective care process evaluations of nurses and selected patient outcomes in Japanese long-term care hospitals.

METHOD

To conduct a cross-sectional survey, we approached 2,000 long-term care hospitals in Japan, of which 263 (13.2%) completed and returned the questionnaires. We recruited ward managers and all full/part-time nurses in one ward from each hospital. We questioned managers about six patient outcome indicators: prevalence of physical restraint, urinary tract infections, indwelling catheter use, monthly incidence of new pressure ulcers, falls and recreational activities. We examined the nurses' care process evaluations using nine questions pertaining to daily caregiving activities developed from previous qualitative research. We examined the association between the ward averages of the nurses' evaluations and selected patient outcomes using the generalised linear model with a negative binomial distribution, with the exception of recreational activities for which we used a Poisson distribution, controlling for ward size and patient case mix.

RESULTS

We analysed the responses with complete data for outcome indicators from 199 (10.0%) managers and 2,508 nurses. Some patient outcome indicators were significantly associated with the nurses' care process evaluations, namely, urinary tract infections (B = -1.28, p < .001), indwelling catheter use (B = -0.57, p < .049), pressure ulcers (B = -1.20, p < .001) and recreational activities (B = 1.48, p < .001). These results suggest that better patient outcomes were associated with higher care process evaluations.

CONCLUSION

The nurses' evaluations and certain patient outcome indicators were associated. When considering potential quality improvement programmes, focusing on these evaluations will be beneficial.

Two Decades of Nursing Home Compare: What Have We Learned?

Approximately two decades ago, federally mandated public reporting began for U.S. nursing homes through a system now known as Nursing Home Compare. The goals were to provide information to enable consumers to choose higher quality nursing homes and to incent providers to improve the quality of care delivered. We conduct a systematic review of the literature on responses to Nursing Home Compare and its effectiveness in meeting these goals. We find evidence of modest but meaningful response by both consumers and providers. However, we also find evidence that some improvement in scores does not reflect true quality improvement, that disparities by race and income have increased, that risk-adjustment of the measures is likely inadequate, and that several key domains of quality are not represented. Our results support moderate success of Nursing Home Compare in achieving intended goals but also reveal the need for continued refinement.