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Armstrong MJ, Barnes LL. Under-Diagnosis of Dementia with Lewy Bodies in Individuals Racialized as Black: Hypotheses Regarding Potential Contributors. J Alzheimers Dis 2024; 97:1571-1580. [PMID: 38277299 PMCID: PMC10894581 DOI: 10.3233/jad-231177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2023] [Indexed: 01/28/2024]
Abstract
Dementia with Lewy bodies (DLB) is one of the most common degenerative dementias after Alzheimer's disease (AD) dementia. DLB is under-diagnosed across populations but may be particularly missed in older Black adults. The object of this review was to examine key features of DLB and potential associations with race in order to hypothesize why DLB may be under-diagnosed in Black adults in the U.S. In terms of dementia, symptoms associated with high rates of co-pathology (e.g., AD, vascular disease) in older Black adults may obscure the clinical picture that might suggest Lewy body pathology. Research also suggests that clinicians may be predisposed to give AD dementia diagnoses to Black adults, potentially missing contributions of Lewy body pathology. Hallucinations in Black adults may be misattributed to AD or primary psychiatric disease rather than Lewy body pathology. Research on the prevalence of REM sleep behavior in diverse populations is lacking, but REM sleep behavior disorder could be under-diagnosed in Black adults due to sleep patterns or reporting by caregivers who are not bed partners. Recognition of parkinsonism could be reduced in Black adults due to clinician biases, cultural effects on self-report, and potentially underlying differences in the frequency of parkinsonism. These considerations are superimposed on structural and systemic contributions to health (e.g., socioeconomic status, education, structural racism) and individual-level social exposures (e.g., social interactions, discrimination). Improving DLB recognition in Black adults will require research to investigate reasons for diagnostic disparities and education to increase identification of core symptoms in this population.
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Affiliation(s)
- Melissa J. Armstrong
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA
- 1Florida Alzheimer Disease Research Center, Gainesville, FL, USA
| | - Lisa L. Barnes
- Rush Alzheimer’s Disease Center, Rush University Medical Center, Chicago, IL, USA
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2
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Shireman TI, Fashaw-Walters S, Zhang T, Zullo AR, Gerlach LB, Coe AB, Daiello L, Lo D, Strominger J, Bynum JPW. Federal Nursing Home Policies on Antipsychotics had Similar Impacts by Race and Ethnicity for Residents With Dementia. J Am Med Dir Assoc 2023; 24:1283-1289.e4. [PMID: 37127131 PMCID: PMC10523862 DOI: 10.1016/j.jamda.2023.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 02/15/2023] [Accepted: 03/20/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVES Federal initiatives have been successful in reducing antipsychotic exposure in nursing home residents with dementia. We assessed if these initiatives were implemented equally across racial and ethnic minority groups. DESIGN Retrospective, cross-sectional trends study. SETTING AND PARTICIPANTS National long-stay nursing home residents with dementia from 2011 to 2017. METHODS We examined trends in psychotropic drug class exposures from the Minimum Data Set assessments for non-Hispanic Black (NHB), Hispanic, and non-Hispanic White (NHW) residents using interrupted time-series analyses with age-sex standardized quarterly outcomes and time points to denote the National Partnership (2012) and Five Star Rating changes (2015). RESULTS Initially, antipsychotic (33.0%) and sedative (6.8%) exposure was highest for Hispanic residents; antidepressant (59.8%) and anxiolytic (23.4%) exposure was highest for NHW residents; NHB residents had the lowest use of each. Antipsychotic use dropped at the time of the Partnership (β = -0.8807, P = .0023) and the slope declined further after the Partnership (β = -0.6611, P < .0001) for NHW. In comparison to NHW, the level and slope changes for NHB and Hispanics were not significantly different. The Five Star Rating change did not impact the level of antipsychotic use (β = 0.027, P = .9467), but the slope changed to indicate a slowed rate of decline (β = 0.1317, P = .4075) for NHW. As to the other psychotropic drug classes, there were few significant differences between trends seen in the racial and ethnic subgroups. The following exceptions were noted: antidepressant use decreased at a faster rate for NHB residents post-Partnership (β = -0.1485, P = .0371), and after the Five Star Rating change, NHB residents (β = -0.0428, P = .0312) and Hispanic residents (β = -0.0834, P < .0001) saw antidepressant use decrease faster than NHW. Sedative use in slope post-Partnership period (β = -0.086, P = .0275) and post-Five Star Rating (β = -0.0775, P < .0001) declined faster among Hispanic residents. CONCLUSIONS AND IMPLICATIONS We found little evidence of clinically meaningful differences in changes to 4 classes of psychotropic medication use among racial and ethnic minority nursing home residents with dementia following 2 major federal initiatives.
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Affiliation(s)
- Theresa I Shireman
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA.
| | - Shekinah Fashaw-Walters
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Tingting Zhang
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Andrew R Zullo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA; Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - Lauren B Gerlach
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Antoinette B Coe
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
| | - Lori Daiello
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Department of Neurology, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Derrick Lo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
| | - Julie Strominger
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Julie P W Bynum
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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3
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Chen AC, Grabowski DC. Nursing Homes Underreport Antipsychotic Use but Overreport Diagnoses Qualifying for Appropriate Use. Health Aff Sch 2023; 1:qxad022. [PMID: 38322323 PMCID: PMC10846688 DOI: 10.1093/haschl/qxad022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Antipsychotic drug use in U.S. nursing homes remains a priority concern, but less is understood about the characteristics associated with reporting. Using linked Medicare claims and Minimum Data Set (MDS) assessments for long-stay nursing home residents from January 2018 to December 2019, we assessed the consistency of antipsychotic drug reporting and diagnosis of conditions (schizophrenia, Tourette's syndrome, and Huntington's disease) which qualify as appropriate drug use across data sources by calculating reporting rates in facility-reported MDS and Medicare claims. The antipsychotic reporting outcome is conditional on claims reporting while the condition reporting outcomes are conditional on MDS reporting. We found underreporting (87% reporting rate) in facility-reported antipsychotic use relative to Medicare claims. In contrast, we found overreporting of the qualifying conditions with a number of facility-reported diagnoses unsupported by a corresponding claims diagnosis. Only 54.8% of schizophrenia, 46.5% of Tourette's syndrome, and 72.4% of Huntington's disease diagnoses reported in the MDS had a claims diagnosis. There was also variation in reporting odds for antipsychotic drug use by dual-eligibility status and race, with higher odds for dual-eligible and lower odds for Black residents These findings suggest CMS should continue investigating the source of reporting discrepancies in antipsychotic drug use and qualifying diagnoses.
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Affiliation(s)
| | - David C Grabowski
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health
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4
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Chappell V, Kirkham J, Seitz DP. Association Between Long-Term Care Facility Staffing Levels and Antipsychotic Use in US Long-Term Care Facilities. J Am Med Dir Assoc 2022; 23:1787-1792.e1. [PMID: 35926573 DOI: 10.1016/j.jamda.2022.06.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 05/31/2022] [Accepted: 06/25/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Inappropriate use of antipsychotics is an indicator of quality of care in long-term care (LTC) facilities. There is evidence to suggest that staffing levels in LTC may be associated with the rates of inappropriate antipsychotic use. This study sought to examine the association between staffing and antipsychotic prescribing in LTC facilities. DESIGN Cross-sectional study investigated the association between reported staffing levels and the frequency of inappropriate antipsychotic prescribing at US LTC facilities between 2016 and 2018. SETTING AND PARTICIPANTS Data from the Nursing Home Compare and LTCFocus datasets were linked, which contain information from the Minimum Data Set database on facility characteristics and staffing measures from the Payroll-Based Journal system. A final sample set of 10,436 facilities was used. METHODS Descriptive statistics were calculated for all variables of interest. An unadjusted linear correlation analysis and linear regression were performed. Potential confounders were investigated by comparison across low-vs high-staffing facilities where adjusted for in regression analyses. RESULTS The mean staff level for the facilities was identified as 3.69 (SD = 0.67) staffing hours per patient per day, and the mean antipsychotic use rate across all facilities was 15.24% (SD = 8.62%). There was a 0.75% decrease in inappropriate antipsychotic prescribing per unit increase in overall staff-to-patient ratio. When looking at staffing types, a 3.09% decrease in inappropriate antipsychotic prescribing per unit increase in licensed staff hours. More specifically, we saw a 2.25% decrease per unit increase in RN staffing hours, a 1.83% decrease per unit increase in LPN staffing hours, and nursing aide staffing hours were not associated with antipsychotic use. CONCLUSIONS AND IMPLICATIONS These findings provide support for policy-based interventions to decrease antipsychotic use in LTC facilities by improving staffing skill mix and staffing levels. The results may also inform nursing staff education and training on antipsychotic prescribing practices.
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Affiliation(s)
- Victoria Chappell
- Department of Psychiatry, Queen's University, Providence Care-Mental Health Services, Kingston, ON, Canada
| | - Julia Kirkham
- Department of Psychiatry, Hotchkiss Brain Institute, and O'Brien Institute for Public Health, Calgary, AB, Canada; Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Dallas P Seitz
- Department of Psychiatry, Queen's University, Providence Care-Mental Health Services, Kingston, ON, Canada; Department of Psychiatry, Hotchkiss Brain Institute, and O'Brien Institute for Public Health, Calgary, AB, Canada; Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
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5
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Fashaw-Walters SA, McCreedy E, Bynum JPW, Thomas KS, Shireman TI. Disproportionate increases in schizophrenia diagnoses among Black nursing home residents with ADRD. J Am Geriatr Soc 2021; 69:3623-3630. [PMID: 34590709 DOI: 10.1111/jgs.17464] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 06/04/2021] [Accepted: 06/26/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Previous research demonstrated an increase in the reporting of schizophrenia diagnoses among nursing home (NH) residents after the Centers for Medicare & Medicaid Services National Partnership to Improve Dementia Care. Given known health and healthcare disparities among Black NH residents, we examined how race and Alzheimer's and related dementia (ADRD) status influenced the rate of schizophrenia diagnoses among NH residents following the partnership. METHODS We used a quasi-experimental difference-in-differences design to study the quarterly prevalence of schizophrenia among US long-stay NH residents aged 65 years and older, by Black race and ADRD status. Using 2011-2015 Minimum Data Set 3.0 assessments, our analysis controlled for age, sex, measures of function and frailty (activities of daily living [ADL] and Changes in Health, End-stage disease and Symptoms and Signs scores) and behavioral expressions. RESULTS There were over 1.2 million older long-stay NH residents, annually. Schizophrenia diagnoses were highest among residents with ADRD. Among residents without ADRD, Black residents had higher rates of schizophrenia diagnoses compared to their nonblack counterparts prior to the partnership. Following the partnership, Black residents with ADRD had a significant increase of 1.7% in schizophrenia as compared to nonblack residents with ADRD who had a decrease of 1.7% (p = 0.007). CONCLUSIONS Following the partnership, Black NH residents with ADRD were more likely to have a schizophrenia diagnosis documented on their MDS assessments, and schizophrenia rates increased for Black NH residents with ADRD only. Further work is needed to examine the impact of "colorblind" policies such as the partnership and to determine if schizophrenia diagnoses are appropriately applied in NH practice, particularly for black Americans with ADRD.
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Affiliation(s)
- Shekinah A Fashaw-Walters
- Division of Health Policy & Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA.,Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, Rhode Island, USA.,Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Ellen McCreedy
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, Rhode Island, USA.,Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Julie P W Bynum
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA.,Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Kali S Thomas
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, Rhode Island, USA.,Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA.,Center of Innovation in Long-Term Services and Supports, U.S. Department of Veterans Affairs Medical Center, Providence, Rhode Island, USA
| | - Theresa I Shireman
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, Rhode Island, USA.,Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA
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6
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Baughman RA, Stanley B, Smith KE. Second Job Holding Among Direct Care Workers and Nurses: Implications for COVID-19 Transmission in Long-Term Care. Med Care Res Rev 2020; 79:151-160. [PMID: 33213282 DOI: 10.1177/1077558720974129] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
One reason that nursing homes are a primary source of COVID-19 infections and deaths in the United States may be that workers hold multiple jobs. We use 2010-2019 Current Population Survey data to document the rate of second jobholding among nursing and long-term care workers. On average, 6.41% of personal care and nursing aides and 6.23% of licensed practical nurses and registered nurses hold second jobs; second job holding rates are 35% and 32% higher than those of other workers, respectively. Both wages and hours in the primary job are negatively associated with the probability of holding a second job for personal care and nursing aides, while lower hours are more strongly correlated with a second job for registered nurses and licensed practical nurses. Many of these workers move across health settings from their first to second jobs, and 15% of second jobs for personal care and nursing aides are in other "essential" occupations.
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7
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Mack DS, Jesdale BM, Ulbricht CM, Forrester SN, Michener PS, Lapane KL. Racial Segregation Across U.S. Nursing Homes: A Systematic Review of Measurement and Outcomes. Gerontologist 2020; 60:e218-e231. [PMID: 31141135 DOI: 10.1093/geront/gnz056] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Nursing homes remain subjected to institutional racial segregation in the United States. However, a standardized approach to measure segregation in nursing homes does not appear to be established. A systematic review was conducted to identify all formal measurement approaches to evaluate racial segregation among nursing home facilities, and to then identify the association between segregation and quality of care in this context. RESEARCH DESIGN AND METHODS PubMed, Scopus, and Web of Science databases were searched (January 2018) for publications relating to nursing home segregation. Following the PRISMA guidelines, studies were included that formally measured racial segregation of nursing homes residents across facilities with regional-level data. RESULTS Eight studies met the inclusion criteria. Formal segregation measures included the Dissimilarity Index, Disparities Quality Index, Modified Thiel's Entropy Index, Gini coefficient, and adapted models. The most common data sources were the Minimum Data Set (MDS; resident-level), the Certification and Survey Provider Enhanced Reporting data (CASPER; facility-level), and the Area Resource File/ U.S. Census Data (regional-level). Most studies showed evidence of racial segregation among U.S. nursing home facilities and documented a negative impact of segregation on racial minorities and facility-level quality outcomes. DISCUSSION AND IMPLICATIONS The measurement of racial segregation among nursing homes is heterogeneous. While there are limitations to each methodology, this review can be used as a reference when trying to determine the best approach to measure racial segregation in future studies. Moreover, racial segregation among nursing homes remains a problem and should be further evaluated.
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Affiliation(s)
- Deborah S Mack
- Graduate School of Biomedical Sciences, University of Massachusetts Medical School, Worcester
| | - Bill M Jesdale
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester
| | - Christine M Ulbricht
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester
| | - Sarah N Forrester
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester
| | - Pryce S Michener
- Graduate School of Biomedical Sciences, University of Massachusetts Medical School, Worcester
| | - Kate L Lapane
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester
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8
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Fashaw S, Chisholm L, Mor V, Meyers DJ, Liu X, Gammonley D, Thomas K. Inappropriate Antipsychotic Use: The Impact of Nursing Home Socioeconomic and Racial Composition. J Am Geriatr Soc 2020; 68:630-636. [PMID: 31967325 DOI: 10.1111/jgs.16316] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 12/01/2019] [Accepted: 12/12/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Previous research suggests black nursing home (NH) residents are more likely to receive inappropriate antipsychotics. Our aim was to examine how NH characteristics, particularly the racial and socioeconomic composition of residents, are associated with the inappropriate use of antipsychotics. DESIGN This study used a longitudinal approach to examine national data from Long-Term Care: Facts on Care in the US (LTCFocUS.org) between 2000 and 2015. We used a multivariate linear regression model with year and state fixed effects to estimate the prevalence of inappropriate antipsychotic use at the NH level. SETTING Free-standing NHs in the United States. PARTICIPANTS The sample consisted of 12 964 NHs. MEASUREMENTS The outcome variable was inappropriate antipsychotic use at the facility level. The primary indicator variables were whether a facility had high proportions of black residents and the percentage of residents with Medicaid as their primary payer. RESULTS NHs with high and low proportions of blacks had similar rates of antipsychotic use in the unadjusted analyses. NHs with high proportions of black residents had significantly lower rates of inappropriate antipsychotic use (β = -2; P < .001) in the adjusted analyses. Facilities with high proportions of Medicaid-reliant residents had higher proportions of inappropriate use (β = .04; P < .001). CONCLUSION Findings from this study indicate a decline in the use of antipsychotics. Although findings from this study indicated facilities with higher proportions of blacks had lower inappropriate antipsychotic use, facility-level socioeconomic disparities continued to persist among NHs. Policy interventions that focus on reimbursement need to be considered to promote reductions in antipsychotic use, specifically among Medicaid-reliant NHs. J Am Geriatr Soc 68:630-636, 2020.
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Affiliation(s)
- Shekinah Fashaw
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, Rhode Island.,Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island
| | - Latarsha Chisholm
- Department of Health Management & Informatics, College of Community Innovation and Education, University of Central Florida, Orlando, Florida
| | - Vincent Mor
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, Rhode Island.,Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island.,Center of Innovation in Long-Term Services and Supports, U.S. Department of Veterans Affairs Medical Center, Providence, Rhode Island
| | - David J Meyers
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, Rhode Island.,Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island
| | - Xinliang Liu
- Department of Health Management & Informatics, College of Community Innovation and Education, University of Central Florida, Orlando, Florida
| | - Denise Gammonley
- School of Social Work, College of Health Professions and Sciences, University of Central Florida, Orlando, Florida
| | - Kali Thomas
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, Rhode Island.,Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island.,Center of Innovation in Long-Term Services and Supports, U.S. Department of Veterans Affairs Medical Center, Providence, Rhode Island
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9
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Resnick B, Kolanowski A, Van Haitsma K, Galik E, Boltz M, Ellis J, Behrens L, Eshraghi K, Zhu S. Current Psychotropic Medication Use and Contributing Factors Among Nursing Home Residents With Cognitive Impairment. Clin Nurs Res 2019; 30:59-69. [PMID: 30943786 DOI: 10.1177/1054773819838678] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study described current use and predictors of psychotropics among residents with moderate to severe cognitive impairment. This was a secondary data analysis using baseline data from the first 341 residents in an ongoing trial. Predictive measures included age, gender, race, depressive symptoms, agitation, resistiveness to care, depression, cognition, pain, comorbidities, facility factors, and state. Overall 63% (n = 211) received at least one psychotropic medication, 16% (n = 52) an anti-seizure medication, 23% (n = 77) an anxiolytic, 30% (n = 99) an antidepressant, 2% (n = 8) a sedative hypnotic, 28% (n = 93) an antipsychotic medication, and 9% (n = 29) an opioid. Testing of models explained 9% to 15% of psychotropic medication use. There were high rates of psychotropic medication use and a limited association between demographic factors, behavioral symptoms, and psychotropic medication use. Continued research is needed to explore the impact of deprescribing, person-centered behavioral interventions, and beliefs of providers on psychotropic medication use.
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Affiliation(s)
| | - Ann Kolanowski
- Pennsylvania State University College of Nursing, University Park, USA
| | | | | | - Marie Boltz
- Pennsylvania State University College of Nursing, University Park, USA
| | - Jeanette Ellis
- University of Maryland School of Nursing, Baltimore, USA
| | - Liza Behrens
- Pennsylvania State University College of Nursing, University Park, USA
| | - Karen Eshraghi
- Pennsylvania State University College of Nursing, University Park, USA
| | - Shijun Zhu
- University of Maryland School of Nursing, Baltimore, USA
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10
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Green AR. Time for Nursing Homes to Recognize and Address Disparities in Care. Jt Comm J Qual Patient Saf 2017; 43:551-553. [DOI: 10.1016/j.jcjq.2017.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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11
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Hefele JG, Ritter GA, Bishop CE, Acevedo A, Ramos C, Nsiah-Jefferson LA, Katz G. Examining Racial and Ethnic Differences in Nursing Home Quality. Jt Comm J Qual Patient Saf 2017; 43:554-564. [PMID: 29056175 DOI: 10.1016/j.jcjq.2017.06.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 06/08/2017] [Accepted: 06/08/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND Identifying racial/ethnic differences in quality is central to identifying, monitoring, and reducing disparities. Although disparities across all individual nursing home residents and disparities associated with between-nursing home differences have been established, little is known about the degree to which quality of care varies by race//ethnicity within nursing homes. A study was conducted to measure within-facility differences for a range of publicly reported nursing home quality measures. METHODS Resident assessment data on approximately 15,000 nursing homes and approximately 3 million residents (2009) were used to assess eight commonly used and publicly reported long-stay quality measures: the proportion of residents with weight loss, with high-risk and low-risk pressure ulcers, with incontinence, with depressive symptoms, in restraints daily, and who experienced a urinary tract infection or functional decline. Each measure was stratified by resident race/ethnicity (non-Hispanic white, non-Hispanic black, and Hispanic), and within-facility differences were examined. RESULTS Small but significant differences in care on average were found, often in an unexpected direction; in many cases, white residents were experiencing poorer outcomes than black and Hispanic residents in the same facility. However, a broad range of differences in care by race/ethnicity within nursing homes was also found. CONCLUSION The results suggest that care is delivered equally across all racial/ethnic groups in the same nursing home, on average. The results support the call for publicly reporting stratified nursing home quality measures and suggest that nursing home providers should attempt to identify racial/ethnic within-facility differences in care.
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12
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Cioltan H, Alshehri S, Howe C, Lee J, Fain M, Eng H, Schachter K, Mohler J. Variation in use of antipsychotic medications in nursing homes in the United States: A systematic review. BMC Geriatr 2017; 17:32. [PMID: 28122506 PMCID: PMC5267409 DOI: 10.1186/s12877-017-0428-1] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Accepted: 01/19/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The use of antipsychotic medications (APMs) in nursing home residents in the U.S. is an increasingly prominent issue and has been associated with increased risk of hospitalization, cardiovascular events, hip fractures, and mortality, among other adverse health events. The Food and Drug Administration has placed a black box warning on these drugs, specifying that they are not meant for residents with dementia, and has asked providers to review their treatment plans. The purpose of this systematic PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses)-based review was to summarize original research studies on facility level characteristics contributing to the use of antipsychotics in nursing homes across the United States, in order to investigate the variation of use. METHODS We searched Ovid Medline, Embase, Cochrane Library, Web of Science, CINAHL, PsycInfo, and Sociological Abstracts. Articles were selected according to the following criteria: (1) Population of interest: older adults (≥60 years of age) residing in nursing homes (not home-based or inpatient hospital settings) in the U.S. (2) Receiving APMs, typical and/or atypical. Specifically excluded were studies of psychotropic medications such as antidepressants, benzodiazepines, anxiolytics, hypnotics, mood stabilizers, and stimulants. All study designs were considered, though reviews, editorials, letters to the editor and opinion pieces were excluded. An expert consultant panel was consulted to categorize facility characteristics into domains and determine possible etiologies of APM use based upon each characteristic. RESULTS Nineteen observational studies, both quantitative and qualitative, published from 2000 to 2015, met full inclusion criteria and were included in this review. APM use varied based on multiple facility characteristics across several domains: 1) physical, 2) staffing, 3) occupancy, 4) market, and 5) quality. CONCLUSIONS Variation in use of APMs in U.S. nursing homes based upon facility characteristics exemplifies the need for a more systematic protocol guiding the use of these medications, along with heightened regulatory policies and enforcement.
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Affiliation(s)
- Hannah Cioltan
- College of Public Health, University of Arizona, Tucson, Arizona, USA.
- Arizona Center on Aging, College of Medicine, University of Arizona, Tucson, Arizona, USA.
| | - Samah Alshehri
- College of Pharmacy, University of Arizona, Tucson, Arizona, USA
| | - Carol Howe
- University of Arizona Health Sciences Library, Tucson, USA
| | - Jeannie Lee
- Arizona Center on Aging, College of Medicine, University of Arizona, Tucson, Arizona, USA
- College of Pharmacy, University of Arizona, Tucson, Arizona, USA
| | - Mindy Fain
- Arizona Center on Aging, College of Medicine, University of Arizona, Tucson, Arizona, USA
- Division of Geriatrics, General Internal Medicine and Palliative Medicine, College of Medicine, University of Arizona, Tucson, Arizona, USA
| | - Howard Eng
- College of Public Health, University of Arizona, Tucson, Arizona, USA
- College of Pharmacy, University of Arizona, Tucson, Arizona, USA
| | - Kenneth Schachter
- College of Public Health, University of Arizona, Tucson, Arizona, USA
| | - Jane Mohler
- College of Public Health, University of Arizona, Tucson, Arizona, USA
- Arizona Center on Aging, College of Medicine, University of Arizona, Tucson, Arizona, USA
- College of Pharmacy, University of Arizona, Tucson, Arizona, USA
- Division of Geriatrics, General Internal Medicine and Palliative Medicine, College of Medicine, University of Arizona, Tucson, Arizona, USA
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13
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Bliss DZ, Gurvich OV, Eberly LE, Savik K, Harms S, Wyman JF, Mueller C, Virnig B, Wiltzen K. Racial disparities in primary prevention of incontinence among older adults at nursing home admission. Neurourol Urodyn 2016; 36:1124-1130. [PMID: 27376926 DOI: 10.1002/nau.23065] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 06/11/2016] [Indexed: 11/08/2022]
Abstract
AIMS Maintaining continence of nursing home (NH) residents promotes dignity and well-being and may reduce morbidity and healthcare treatment costs. To determine the prevalence of older continent adults who received primary prevention of incontinence at NH admission, assess whether there were racial or ethnic disparities in incontinence prevention, and describe factors associated with any disparities. METHODS The design was an observational cross-sectional study of a nation-wide cohort of older adults free of incontinence at NH admission (n = 42,693). Four US datasets describing NH and NH resident characteristics, practitioner orders for NH treatment/care, and socioeconomic and sociodemographic status of the community surrounding the NHs were analyzed. Disparities were analyzed for four minority groups identified on the minimum data set using the Peters-Belson method and covariates at multiple levels. RESULTS Twelve percent of NH admissions received incontinence prevention. There was a significant disparity (2%) in incontinence prevention for Blacks (P < 0.05): Fewer Black admissions (8.6%) were observed to receive incontinence prevention than was expected had they been part of the White group (10.6%). The percentage of White admissions receiving incontinence prevention was 10.6%. Significant factors associated with disparity in receiving incontinence prevention were having greater deficits in ADL function and cognition and more comorbidities. No disparity disadvantaging the other minority groups was found. CONCLUSIONS Greater efforts for instituting incontinence prevention at the time of NH admission are needed. Eliminating racial disparities in incontinence prevention seems an attainable goal. Appropriate staff training, organizational commitment, and monitoring progress toward equitable outcomes can help achieve this goal. Neurourol. Urodynam. 36:1124-1130, 2017. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Donna Z Bliss
- University of Minnesota School of Nursing, Minneapolis, Minnesota
| | - Olga V Gurvich
- University of Minnesota School of Nursing, Minneapolis, Minnesota
| | | | - Kay Savik
- University of Minnesota School of Nursing, Minneapolis, Minnesota
| | - Susan Harms
- University of Minnesota School of Nursing, Minneapolis, Minnesota.,College of Pharmacy, Minneapolis, Minnesota
| | - Jean F Wyman
- University of Minnesota School of Nursing, Minneapolis, Minnesota
| | | | - Beth Virnig
- Division of Health Services Research and Policy of School of Public Health, Minneapolis, Minnesota
| | - Kjerstie Wiltzen
- University of Minnesota School of Nursing, Minneapolis, Minnesota
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14
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Bliss DZ, Gurvich OV, Savik K, Eberly LE, Harms S, Wyman JF, Mueller C, Garrard J, Virnig B. Analysis of Racial and Ethnic Disparities as Possible Risk Factors for Development of Incontinence by Nursing Home Residents. Res Nurs Health 2015; 38:449-61. [PMID: 26340375 DOI: 10.1002/nur.21680] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2015] [Indexed: 11/10/2022]
Abstract
Incontinence is a common health problem among nursing home (NH) residents. Differences between black and white NH residents in incontinence prevalence have been reported. Although reducing health disparities is a principal objective of the national health care agenda, little is known about disparities in incidence of new incontinence in NHs. The purpose of this study was to assess whether there were racial/ethnic disparities in the time to development of incontinence in adults over age 65 who had been continent on NH admission. If no racial or ethnic disparities in time to incontinence were found, other predictors of time to incontinence would be explored. Three national databases were sources of data on 42,693 adults over 65 admitted to 446 for-profit NHs in a national chain. Multi-level predictors of time to any type of incontinence were analyzed, using Cox proportional hazards regression for white Non-Hispanic NH admissions and the Peters-Belson method for minority NH admissions: American Indians/Alaskan Natives, Asians/Pacific Islanders, Black non-Hispanics, and Hispanics. No racial/ethnic disparities in time to incontinence were found. Approximately 30% of all racial/ethnic groups had developed incontinence by 6 months. Those who developed incontinence sooner were older and had greater deficits in activities of daily living (ADL) and cognition. Results were consistent with past evidence and suggest that interventions to maintain continence from the time of admission should be applied across racial/ethnic groups.
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Affiliation(s)
- Donna Z Bliss
- School of Nursing, University of Minnesota, 5-140 Weaver-Densford Hall, 308 Harvard Street, Minneapolis, MN, 55455
| | - Olga V Gurvich
- School of Nursing, University of Minnesota, Minneapolis, MN
| | - Kay Savik
- School of Nursing, University of Minnesota, Minneapolis, MN
| | - Lynn E Eberly
- School of Public Health, University of Minnesota, Minneapolis, MN
| | - Susan Harms
- School of Nursing and Public Health, University of Minnesota, Minneapolis, MN
| | - Jean F Wyman
- School of Nursing, University of Minnesota, Minneapolis, MN
| | | | - Judith Garrard
- School of Nursing and Public Health, University of Minnesota, Minneapolis, MN
| | - Beth Virnig
- School of Nursing and Public Health, University of Minnesota, Minneapolis, MN
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15
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Abstract
Staffing level requirements for nursing homes exist at state and federal levels in the United States. While quality of care measures may include antipsychotic (AP) prescribing, the appropriate use of APs as chemical restraints in nursing homes continues to be debated. Although the two variables appear to be related, improved research methods and availability of accurate staffing data will be needed to understand causal relationships regarding AP use for facility dwelling patients.
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Affiliation(s)
- T Joseph Mattingly
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA.
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16
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Archibald ME, Rankin CP. Community context and healthcare quality: the impact of community resources on licensing and accreditation of substance abuse treatment agencies. J Behav Health Serv Res 2013; 40:442-56. [PMID: 23666273 DOI: 10.1007/s11414-013-9340-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
This study examines variation in healthcare quality among substance abuse treatment agencies. Using an organizations framework, the authors predict that resource advantages benefit certain types of healthcare organizations, especially those located in affluent communities. As a result, levels of licensing and accreditation of substance abuse treatment agencies will differ across United States counties. The authors model these resources at both the organizational and community levels in an effort to understand the variability of licensing and accreditation between agencies and their local contexts. In multivariate models, the findings confirm that organizational characteristics such as private ownership (compared to public ownership), managed care contracts, inpatient and residential programs (compared to outpatient settings), as well as socioeconomic, racial/ethnic, and healthcare system advantage promote higher levels of licensing and accreditation. Public ownership and outpatient settings, as well as socioeconomic, racial/ethnic, and healthcare system disadvantage, are associated with lower levels of licensing and accreditation.
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17
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Kang-Yi CD, Mandell DS, Mui AC, Castle NG. Interaction effect of Medicaid census and nursing home characteristics on quality of psychosocial care for residents. Health Care Manage Rev 2011; 36:47-57. [PMID: 21157230 DOI: 10.1097/HMR.0b013e3181f8a864] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Numerous studies have identified disparities in nursing home quality of care. Although previous studies have found the overlap among Medicaid census, nursing home characteristics, and negative quality of care outcomes, few studies have examined how the psychosocial well-being of nursing home residents is associated with Medicaid census and other nursing home characteristics. PURPOSE The purpose of this study was to elucidate the intertwined relationships between Medicaid census and other important nursing home factors and its impact on psychosocial care for residents. This study examined the interactive effects of (1) nursing home ownership status and Medicaid census, (2) staffing level and Medicaid census, and (3) resident ethnic mix and Medicaid census on psychosocial well-being outcomes. METHODOLOGY The sample, derived from a combined data set of New York State nursing homes' Online Survey Certification and Reporting System and Minimum Data Set, included 565 nursing homes in rural and urban areas of the state. FINDINGS Medicaid census had no main effect on psychosocial well-being outcomes of nursing home care but had a significant interactive effect with other nursing home characteristics. High Medicaid census was associated with lower level of psychosocial symptom detection in nonprofit nursing homes and nursing homes with a higher proportion of ethnic minority residents. PRACTICE IMPLICATIONS Nursing staff training on better psychosocial well-being care, in particular, better psychosocial assessment, is important. To obtain the training resources, nursing homes with high Medicaid census can collaborate with other nursing homes or social service agencies. Considering that nursing homes with a high proportion of ethnic minority residents have lower level of detection rate for psychosocial well-being issues, culturally competent care should be a component of quality improvement plans.
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18
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Siegel MJ, Lucas JA, Akincigil A, Gaboda D, Hoover DR, Kalay E, Crystal S. Race, education, and the treatment of depression in nursing homes. J Aging Health 2012; 24:752-78. [PMID: 22330731 DOI: 10.1177/0898264311435548] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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).
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Affiliation(s)
- Michele J Siegel
- Medical Center, Traumatic Stress Studies Division, Department of Psychiatry, Mount Sinai School of Medicine, Bronx, NY 10029-6574, USA.
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19
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Strully KW. Health care segregation and race disparities in infectious disease: the case of nursing homes and seasonal influenza vaccinations. J Health Soc Behav 2011; 52:510-526. [PMID: 22144734 PMCID: PMC3711693 DOI: 10.1177/0022146511423544] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Examining nursing home segregation and race disparities in influenza vaccinations, this study demonstrates that segregation may increase both susceptibility and exposure to seasonal flu for black Americans. Evidence based on the 2004 U.S. National Nursing Home Survey shows that individuals in nursing homes with high percentages of black residents have less personal immunity to flu because they are less likely to have been vaccinated against the disease; they may also be more likely to be exposed to flu because more of their coresidents are also unvaccinated. This implies that segregation may generate dual disease hazards for contagious conditions. Segregation appears to limit black Americans' access to personal preventive measures against infection, while spatially concentrating those people who are most likely to become contagious.
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Affiliation(s)
- Kate W Strully
- Department of Sociology, University at Albany, State University of New York, Albany, NY 12222, USA.
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20
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De Bellis A, Mosel K, Curren D, Prendergast J, Harrington A, Muir-Cochrane E. Education on physical restraint reduction in dementia care: a review of the literature. Dementia (London) 2011; 12:93-110. [PMID: 24336665 DOI: 10.1177/1471301211421858] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Dementia is a priority area for all countries as populations age and dementia prevalence increases. The use of physical restraint is a possible clinical practice for persons with dementia across settings when behaviours indicate a perceived need. Indeed, this may be the first choice in practice, occurring in part because of lack of education, safety concerns, perceived costs and staffing issues. This article reviews the literature on the issues surrounding, and use of, physical restraint for people with dementia, highlighting the rationales for use and the benefits and barriers to physical restraint. Recommendations include the importance of education and policy to reduce or eliminate physical restraint of persons with dementia to overcome identified barriers at the individual, cultural and organizational levels. An educational programme from the literature review is proposed specific to the reduction or elimination of physical restraint.
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21
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Ryvicker M. Staff–resident interaction in the nursing home: An ethnographic study of socio-economic disparities and community contexts. J Aging Stud 2011; 25:295-304. [DOI: 10.1016/j.jaging.2010.11.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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22
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Bardenheier B, Shefer A, Ahmed F, Remsburg R, Rowland Hogue CJ, Gravenstein S. Do vaccination strategies implemented by nursing homes narrow the racial gap in receipt of influenza vaccination in the United States? J Am Geriatr Soc 2011; 59:687-93. [PMID: 21438863 PMCID: PMC4544855 DOI: 10.1111/j.1532-5415.2011.03332.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To determine whether the racial inequity between African Americans and Caucasians in receipt of influenza vaccine is narrower in residents of nursing homes with facility-wide vaccination strategies than in residents of facilities without vaccination strategies. DESIGN Secondary data analysis using the National Nursing Home Survey 2004, a nationally representative survey. SETTING One thousand one hundred seventy-four participating nursing homes sampled systematically with probability proportional to bed size. PARTICIPANTS Thirteen thousand five hundred seven randomly sampled residents of nursing homes between August and December 2004. MEASUREMENTS Receipt of influenza vaccine within the last year. Logistic regression was used to examine the relationship between facility-level influenza immunization strategy and racial inequity in receipt of vaccination, adjusted for characteristics at the resident, facility, state, and regional levels. RESULTS Overall in the United States, vaccination coverage was higher for Caucasian and African-American residents; the racial vaccination gaps were smaller (<6 percentage points) and nonsignificant in residents of homes with standing orders for influenza vaccinations (P=.14), verbal consent allowed for vaccinations(P=.39), and routine review of facility-wide vaccination rates (P=.61) than for residents of homes without these strategies. The racial vaccination gap in residents of homes without these strategies were two to three times as high (P=.009, P=.002, and P=.002, respectively). CONCLUSION The presence of several immunization strategies in nursing homes is associated with higher vaccination coverage for Caucasian and African-American residents, narrowing the national vaccination racial gap.
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Affiliation(s)
- Barbara Bardenheier
- Immunization Services Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
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23
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Abstract
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.
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Affiliation(s)
- Eric Collier
- Department of Social and Behavioral Sciences, School of Nursing, University of California-San Francisco, 3333 California Street, San Francisco, CA 94118, USA.
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24
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Abstract
BACKGROUND Hierarchical modeling (HM) is a statistical technique that has gained in popularity in health care research. It has been used for analysis of secondary data, performance profiles or benchmarking studies, and in prospective trials. The technique is used in situations in which traditional regression analysis might lead to incorrect conclusions. Specifically, data drawn from nested settings such as hospital units or hospice providers may be correlated, thus violating an assumption required for ordinary least squares regression. OBJECTIVE This article provides a description of HM, reviews two recent articles in palliative care that have used the technique, and presents an illustrative case study to further illuminate the potential of the method. CONCLUSION When used appropriately, HM allows researchers to specify and test hypotheses that would not otherwise be possible, and avoid incorrect conclusions from nested data.
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Affiliation(s)
- Howard B Degenholtz
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, USA.
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25
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Knudsen HK, Roman PM. Racial and Ethnic Composition as a Correlate of Medication Availability within Addiction Treatment Organizations. ACTA ACUST UNITED AC 2009; 42:133-151. [PMID: 20414366 DOI: 10.1080/00380237.2009.10571347] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Most analyses of racial and ethnic disparities in healthcare focus on individuals rather than organizations. Healthcare organizations may be one mechanism that produces disparities if the representation of minorities within organizations' patient populations is associated with differential patterns of service delivery. This research considers whether the racial and ethnic composition of addiction treatment centers' caseloads is associated with the likelihood that organizations offer any prescription medications to treat addiction, psychiatric conditions, or pain. Data were collected from 288 publicly-funded substance abuse treatment centers in the US. Logistic regression was used to estimate models of medication availability. The percentage of racial and ethnic minority patients was negatively associated with the odds of medication availability, even after controlling for organizational characteristics and patients' diagnostic characteristics. Future research should continue to investigate how healthcare organizations may produce inequalities in access to high-quality care.
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Abstract
A growing body of evidence documents pervasive racial, ethnic, and class disparities in long-term care in the United States. At the same time, major quality improvement initiatives are being implemented that rely on market-based incentives, many of which may have the unintended consequence of exacerbating disparities. We review existing evidence on disparities in the use and quality of long-term care services, analyze current market-based policy initiatives in terms of their potential to ameliorate or exacerbate these disparities, and suggest policies and policy modifications that may help decrease disparities. We find that racial disparities in the use of formal long-term care have decreased over time. Disparities in quality of care are more consistently documented and appear to be related to racial and socioeconomic segregation of long-term care facilities as opposed to within-provider discrimination. Market-based incentives policies should explicitly incorporate the goal of mitigating the potential unintended consequence of increased disparities.
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Gruneir A, Miller SC, Feng Z, Intrator O, Mor V. Relationship between state medicaid policies, nursing home racial composition, and the risk of hospitalization for black and white residents. Health Serv Res 2008; 43:869-81. [PMID: 18454772 DOI: 10.1111/j.1475-6773.2007.00806.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To examine racial differences in the risk of hospitalization for nursing home (NH) residents. DATA SOURCES National NH Minimum Data Set, Medicare claims, and Online Survey Certification and Reporting data from 2000 were merged with independently collected Medicaid policy data. STUDY DESIGN One hundred and fifty day follow-up of 516,082 long-stay residents. PRINCIPLE FINDINGS 18.5 percent of white and 24.1 percent of black residents were hospitalized. Residents in NHs with high concentrations of blacks had 20 percent higher odds (95 percent confidence interval [CI]=1.15-1.25) of hospitalization than residents in NHs with no blacks. Ten-dollar increments in Medicaid rates reduced the odds of hospitalization by 4 percent (95 percent CI=0.93-1.00) for white residents and 22 percent (95 percent CI=0.69-0.87) for black residents. CONCLUSIONS Our findings illustrate the effect of contextual forces on racial disparities in NH care.
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Affiliation(s)
- Andrea Gruneir
- Kunin-Lunenfeld Applied Research Unit, Baycrest Centre for Geriatric Care, Toronto, ON M6A 2E1, Canada
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