Quality of Nursing Homes and Admission of Residents With Alzheimer's Disease and Related Dementias: The Potential Influence of Market Factors and State Policies

ObjectivesThis study aimed to examine the associations between nursing home (NH) quality and prevalence of newly admitted NH residents with Alzheimer's disease and related dementias (ADRD), and to assess the extent to which market-level wages for certified nursing assistants (CNAs) and state Medicaid behavioral and mental health add-on policy may influence such associations.DesignRetrospective cohort study.Setting and ParticipantsThe analytical sample included 2777 NHs with either high or low quality, located in urban areas of 41 states from 2011 to 2014.MethodsThe outcome variable was the prevalence of ADRD among newly admitted NH residents. NH quality was defined as dichotomous, based on the Nursing Home Compare (NHC) star rating system. We considered an NH with 5-star rating as having high quality and with 1-star rating as having low quality. Information on county-level CNA wages and state Medicaid behavioral and mental health add-on policies was included. Linear regression models with NH random effects and robust standard errors were estimated. A set of sensitivity analyses were performed.ResultsAfter accounting for NH-level aggregated resident characteristics and market/state-level factors, the prevalence of ADRD among newly admitted residents was 3% lower in high-quality NHs compared with low-quality NHs (P < .01). A 1-dollar increase in CNA hourly wage was associated with a 0.9–percentage point decrease in the prevalence of ADRD among newly admitted residents (P < .01). State Medicaid behavioral and mental health add-on policy was associated with a 2.5–percentage point increase in the prevalence of ADRD in high-quality NHs (P < .05), but not in low-quality NHs.Conclusions and ImplicationsOur findings suggest that high-quality NHs are less likely to admit residents with ADRD. The effect size of this relationship is modest and may be influenced by state Medicaid behavioral and mental health add-on policies. Future studies are needed to better understand reasons leading to these associations so that effective interventions can be developed to incentivize high-quality NHs to more readily serve residents with ADRD.     

Nursing Home Star Ratings and New Onset of Depression in Long-Stay Nursing Home Residents

ObjectivesTo examine the association between nursing home (NH) quality and new onset of depression and severity of depressive symptoms in a national cohort of long-stay NH residents in the United States.DesignCohort study.Setting and participants129,837 long-stay residents without indicators of depression admitted to 13,921 NHs.MethodsNH quality was measured by Nursing Home Compare star ratings (overall, health inspection, staffing, quality measures) closest to admission. Study outcomes at 90 days from the Minimum Data Set 3.0 included depression diagnosis and severity of depressive symptoms (minimal; mild; moderate; moderately severe/severe). Symptoms were measured by resident self-report Patient Health Questionnaire (PHQ-9) or a staff-report observational version (PHQ-9-OV). Logistic and multinomial logistic models with generalized estimating equations were used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs).ResultsAt 90 days postadmission, 14.1% of residents had a new diagnosis of depression, and odds did not differ across star ratings. Nearly 90% of these residents had minimal depressive symptoms, with only 8.5% reporting mild symptoms and 2.6% with moderate to severe symptoms. Using minimal depressive symptoms as the reference, residents in NHs with 5-star overall ratings were 12% less likely than those in 3-star NHs to experience mild (95% CI: 0.81-0.96) and 31% less likely to experience moderate symptoms (95% CI: 0.58-0.82). In NHs with 1-star staffing compared to 3-star, residents had 37% higher odds of moderate symptoms (95% CI: 1.14-1.64) and 57% higher odds of moderately severe to severe depressive symptoms (95% CI: 1.17-2.12). The odds of any above-minimal depressive symptoms decreased as quality measure ratings increased.Conclusions/ImplicationsLower NH quality ratings were associated with more severe depressive symptoms. Further investigation is warranted to identify potential mechanisms for a targeted intervention to improve quality and provide more equitable care.     

Nursing Home Design and COVID-19: Implications for Guidelines and Regulation

ObjectivesNursing homes (NHs) are important health care and residential environments for the growing number of frail older adults. The COVID-19 pandemic highlighted the vulnerability of NHs as they became COVID-19 hotspots. This study examines the associations of NH design with COVID-19 cases, deaths, and transmissibility and provides relevant design recommendations.DesignA cross-sectional, nationwide study was conducted after combining multiple national data sets about NHs.Setting and ParticipantsA total of 7785 NHs were included in the study, which represent 50.8% of all Medicare and/or Medicaid NH providers in the United States.MethodsZero-inflated negative binomial models were used to predict the total number of COVID-19 resident cases and deaths, separately. The basic reproduction number (R₀) was calculated for each NH to reflect the transmissibility of COVID-19 among residents within the facility, and a linear regression model was estimated to predict log(R₀ – 1). Predictors of these models included community factors and NHs’ resident characteristics, management and rating factors, and physical environmental features.ResultsIncreased percentage of private rooms, larger living area per bed, and presence of a ventilator-dependent unit are significantly associated with reductions in COVID-19 cases, deaths, and transmissibility among residents. After setting the number of actual residents as the exposure variable and controlling for staff cases and other variables, increased number of certified beds in the NH is associated with reduced resident cases and deaths. It also correlates with reduced transmissibility among residents when other risk factors, including staff cases, are controlled.Conclusions and ImplicationsArchitectural design attributes have significant impacts on COVID-19 transmissions in NHs. Considering the vulnerability of NH residents in congregated living environments, NHs will continue to be high-risk settings for infection outbreaks. To improve safety and resilience of NHs against future health disasters, facility guidelines and regulations should consider the need to increase private rooms and living areas.     

The quality of the quality indicator of pain derived from the minimum data set

OBJECTIVE: To examine facility variation in data quality of the level of pain documented in the minimum data set (MDS) as a function of level of hospice enrollment in nursing homes (NHs). DATA SOURCE: Clinical assessments on 3,469 nonhospice residents from 178 NHs were merged with On-line Survey Certification and Reporting data of 2000, Medicare Claims data of 2000 and the MDS of 2000-2002. STUDY DESIGN: Using the same assessment protocol, NH staff and study nurses independently assessed 3,469 nonhospice residents. Study nurses' assessments being gold standard, we quantified and compared quality of NH staff's pain rating across NHs with high, medium, or low hospice use. Multilevel models were built to assess the effect of NH hospice use levels on the occurrence of false positive (FP) and false negative (FN) errors in NH-rated "severe pain." PRINCIPAL FINDINGS: Of 178 NHs, 25 had medium and 41 high hospice use. NHs with higher hospice use had lower sensitivities. In multilevel analysis, we found a significant facility-level variation in the probability of FP and FN errors in facility-rated "severe pain." Resident characteristics only explained 4 and 0 percent of the facility variation in FP and FN, respectively; characteristics and locations (state) of NHs further explained 53 and 52 percent of the variance. After controlling for resident and NH characteristics, staff in NHs with medium or high hospice use were less likely to have FP or FN errors in their MDS documentation of pain than were staff in NHs with low or no hospice use. CONCLUSIONS: The examination of data quality of pooled MDS data from multiple NHs is insufficient. Multilevel analysis is needed to elucidate sources of heterogeneity in the quality of MDS data across NHs. Facility characteristics, e.g., hospice use or NH location, are systematically associated with overrated/underrated pain and may bias pain quality indicator (QI) comparisons. To ensure the integrity of QI comparison in the NH setting, the government may need to institute regular audits of MDS data quality.     

Nursing Home Antibiotic Stewardship Policy and Antibiotics Use: 2013–2017

ObjectivesReducing inappropriate nursing home (NH) antibiotic usage by implementing stewardship programs is a national priority. Our aim is to evaluate the influence of antibiotic stewardship programs on antibiotic use rates in NHs over time.DesignRetrospective, repeated cross-sectional analysis.Setting and ParticipantsLong-term residents not receiving hospice care in freestanding NHs that participated in 1 or both surveys in 2013 and 2017.MethodsSurvey data were merged with the Minimum Data Set and the Certification and Survey Provider Enhanced Reporting data. Our outcome was a binary indicator for antibiotic use. The main predictor was the NH antibiotic stewardship policy intensity. Using multivariate linear regression models adjusting for resident and facility characteristics that differed between the 2 years, we calculated antibiotic use rates in 2013 and 2017 for all residents, those with Alzheimer's disease, and those with any infection including urinary tract infections (UTIs).ResultsOur sample included 317,003 resident assessments from 2013 and 267,537 assessments from 2017, residing in 953 and 872 NHs, respectively. NH antibiotic stewardship policy intensity increased from 2013 to 2017 (P < .01) and among all NH residents, including those with Alzheimer's disease, antibiotic use rate decreased (P < .05), with 45% of the decline attributable to strengthening stewardship programs. For most residents, policy intensity was associated with decreased usage in residents with UTI. However, among Alzheimer's disease residents with a UTI, this association did not persist.Conclusions and ImplicationsAlthough there was a decrease in antibiotic use in 2017, more time is needed to see the full impact of antibiotic stewardship policy into practice. Adjustments to programs that directly address barriers to implementation and appropriate UTI antibiotic use for residents with Alzheimer's disease are necessary to continue strengthening NH antibiotic stewardship and improve care.     

Characteristics of Nursing Homes by COVID-19 Cases Among Staff: March to August 2020

ObjectiveTo measure the association between nursing home (NH) characteristics and Coronavirus Disease 2019 (COVID-19) prevalence among NH staff.DesignRetrospective cross-sectional study.Setting and ParticipantsCenters for Disease Control and Prevention COVID-19 database for US NHs between March and August 2020, linked to NH facility characteristics (LTCFocus database) and local COVID-19 prevalence (USA Facts).MethodsWe estimated the associations between NH characteristics, local infection rates, and other regional characteristics and COVID-19 cases among NH staff (nursing staff, clinical staff, aides, and other facility personnel) measured per 100 beds, controlling for the hospital referral regions in which NHs were located to account for local infection control practices and other unobserved characteristics.ResultsOf the 11,858 NHs in our sample, 78.6% reported at least 1 staff case of COVID-19. After accounting for local COVID-19 prevalence, NHs in the highest quartile of confirmed resident cases (413.5 to 920.0 cases per 1000 residents) reported 18.9 more staff cases per 100 beds compared with NHs that had no resident cases. Large NHs (150 or more beds) reported 2.6 fewer staff cases per 100 beds compared with small NHs (<50 beds) and for-profit NHs reported 0.8 fewer staff cases per 100 beds compared with nonprofit NHs. Higher occupancy and more direct-care hours per day were associated with more staff cases (0.4 more cases per 100 beds for a 10% increase in occupancy, and 0.7 more cases per 100 beds for an increase in direct-care staffing of 1 hour per resident day, respectively). Estimates associated with resident demographics, payer mix, or regional socioeconomic characteristics were not statistically significant.Conclusions and ImplicationsThese findings highlight the urgent need to support facilities with emergency resources such as back-up staff and protocols to reduce resident density within the facility, which may help stem outbreaks.     

Variation in influenza vaccine assessment,receipt, and refusal by the concentration of Medicare Advantage enrollees in U.S. nursing homes

BackgroundMore older adults enrolled in Medicare Advantage (MA) are entering nursing homes (NHs), and MA concentration could affect vaccination rates through shifts in resident characteristics and/or payer-related influences on preventive services use. We investigated whether rates of influenza vaccination and refusal differ across NHs with varying concentrations of MA-enrolled residents.MethodsWe analyzed 2014–2015 Medicare enrollment data and Minimum Data Set clinical assessments linked to NH-level characteristics, star ratings, and county-level MA penetration rates. The independent variable was the percentage of residents enrolled in MA at admission and categorized into three equally-sized groups. We examined three NH-level outcomes including the percentages of residents assessed and appropriately considered for influenza vaccination, received influenza vaccination, and refused influenza vaccination.ResultsThere were 936,513 long-stay residents in 12,384 NHs. Categories for the prevalence of MA enrollment in NHs were low (0% to 3.3%; n = 4131 NHs), moderate (3.4% to 18.6%; n = 4127 NHs) and high (>18.6%; n = 4126 NHs). Overall, 81.3% of long-stay residents received influenza vaccination and 14.3% refused the vaccine when offered. Adjusting for covariates, influenza vaccination rates among long-stay residents were higher in NHs with moderate (1.70 percentage points [pp], 95% confidence limits [CL]: 1.15 pp, 2.24 pp), or high (3.05 pp, 95% CL: 2.45 pp, 3.66 pp) MA versus the lowest prevalence of MA. Influenza vaccine refusal was lower in NHs with moderate (-3.10 pp, 95% CL: ?3.53 pp, ?2.68 pp), or high (-4.63 pp, 95% CL: ?5.11 pp, ?4.15 pp) MA compared with NHs with the lowest prevalence of MA.ConclusionA higher concentration of long-stay NH residents enrolled in MA was associated with greater influenza vaccine receipt and lower vaccine refusal. As MA becomes a larger share of the Medicare program, and more MA beneficiaries enter NHs, decisionmakers need to consider how managed care can be leveraged to improve the delivery of preventive services like influenza vaccinations in NH settings.     

Multimorbidity type,hospitalizations and emergency department visits among nursing home residents: A preliminary study

Background

The burden of multimorbidity in institutionalized elderly is poorly investigated. We examined the associations of the type of multimorbidity (i.e., physical, mental or both) with the number of hospitalizations and emergency department (ED) visits in nursing home (NH) residents.

Methods

This is a cross-sectional study among NH residents. Information on residents’ health, number of hospitalizations in the last 12 months and hospital department of admission (having been seen in ED vs. non) was recorded by NH staff of 175 French NHs (data was collected in 2011). Participants were screened for the presence of several mental (e.g., dementia) and physical conditions (e.g., diabetes).

Results

Data on hospitalization was available for 6076 NH residents. Compared to having no diseases, the concomitant presence of ≥ 2 physical conditions was the multimorbidity type more strongly associated with both the number of hospitalizations (incidence rate ratio (IRR) =1.93; 95% confidence interval (CI) =1.57 ? 2.37) and ED visits (odds ratio (OR)= 1.79; 95% CI=1.24 ? 2.58). The presence of a mental condition appeared to moderate the associations between physical conditions and hospitalizations, since the estimate effects were lower among people who had both physical and mental conditions, compared to those with only physical conditions. For example, compared to people with ≥ 2 physical conditions, those with multiple physical and mental conditions had lower IRR (IRR = 0.84; 95% CI=0.75 ? 0.95) for the number of hospitalizations.

Conclusions

Mental diseases in very old and multimorbid NH residents probably moderate the associations between physical diseases and hospitalizations. To what extent this represents either a mirror of better clinical practice in NHs or the under-recognition from the NH staff of symptoms leading to justifiable hospitalizations remains unclear.     

New Toolkit to Measure Quality of Person-Centered Care: Development and Pilot Evaluation With Nursing Home Communities

BackgroundIncreasingly, nursing home (NH) providers are adopting a person-centered care (PCC) philosophy; yet, they currently lack methods to measure their progress toward this goal. Few PCC tools meet criteria for ease of use and feasibility in NHs. The purpose of this article is to report on the development of the concept and measurement of preference congruence among NH residents (phase 1), its refinement into a set of quality indicators by Advancing Excellence in America's Nursing Homes (phase 2), and its pilot evaluation in a sample of 12 early adopting NHs prior to national rollout (phase 3). The recommended toolkit for providers to use to measure PCC consists of (1) interview materials for 16 personal care and activity preferences from Minimum Data Set 3.0, plus follow-up questions that ask residents how satisfied they are with fulfillment of important preferences; and (2) an easy to use Excel spreadsheet that calculates graphic displays of quality measures of preference congruence and care conference attendance for an individual, household or NH. Twelve NHs interviewed residents (N = 146) using the toolkit; 10 also completed a follow-up survey and 9 took part in an interview evaluating their experience.ResultsNH staff gave strong positive ratings to the toolkit. All would recommend it to other NHs. Staff reported that the toolkit helped them identify opportunities to improve PCC (100%), and found that the Excel tool was comprehensive (100%), easy to use (90%), and provided high quality information (100%). Providers anticipated using the toolkit to strengthen staff training as well as to enhance care planning, programming and quality improvement.ConclusionsThe no-cost PCC toolkit provides a new means to measure the quality of PCC delivery. As of February 2014, over 700 nursing homes have selected the Advancing Excellence in America's Nursing Homes PCC goal as a focus for quality improvement. The toolkit enables providers to incorporate quality improvement by moving beyond anecdote, and advancing more systematically toward honoring resident preferences.     

High Prevalence of Multidrug-Resistant Organism Colonization in 28 Nursing Homes: An “Iceberg Effect”

ObjectiveDetermine the prevalence of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus spp. (VRE), extended-spectrum beta-lactamase producing organisms (ESBLs), and carbapenem-resistant Enterobacteriaceae (CRE) among residents and in the environment of nursing homes (NHs).DesignPoint prevalence sampling of residents and environmental sampling of high-touch objects in resident rooms and common areas.SettingTwenty-eight NHs in Southern California from 2016 to 2017.ParticipantsNH participants in Project PROTECT, a cluster-randomized trial of enhanced bathing and decolonization vs routine care.MethodsFifty residents were randomly sampled per NH. Twenty objects were sampled, including 5 common room objects plus 5 objects in each of 3 rooms (ambulatory, total care, and dementia care residents).ResultsA total of 2797 swabs were obtained from 1400 residents in 28 NHs. Median prevalence of multidrug-resistant organism (MDRO) carriage per NH was 50% (range: 24%-70%). Median prevalence of specific MDROs were as follows: MRSA, 36% (range: 20%-54%); ESBL, 16% (range: 2%-34%); VRE, 5% (range: 0%-30%); and CRE, 0% (range: 0%-8%). A median of 45% of residents (range: 24%-67%) harbored an MDRO without a known MDRO history. Environmental MDRO contamination was found in 74% of resident rooms and 93% of common areas.Conclusions and ImplicationsIn more than half of the NHs, more than 50% of residents were colonized with MDROs of clinical and public health significance, most commonly MRSA and ESBL. Additionally, the vast majority of resident rooms and common areas were MDRO contaminated. The unknown submerged portion of the iceberg of MDRO carriers in NHs may warrant changes to infection prevention and control practices, particularly high-fidelity adoption of universal strategies such as hand hygiene, environmental cleaning, and decolonization.     

Thirty-Year Trends in Nursing Home Composition and Quality Since the Passage of the Omnibus Reconciliation Act

ObjectiveIn 1987, the Omnibus Reconciliation Act (OBRA) called for a dramatic overhaul of the nursing home (NH) quality assurance system. This study examines trends in facility, resident, and quality characteristics since passage of that legislation.MethodsWe conducted univariate analyses of national data on US NHs from 3 sources: (1) the 1985 National Nursing Home Survey (NNHS), (2) the 1992-2015 Online Survey Certification and Reporting (OSCAR) Data, and (3) LTCfocUS data for 2000-2015. We examined changes in NH characteristics, resident composition, and quality.Setting and participantsUS NH facilities and residents between 1985 and 2015.ResultsThe proportion of NHs that are Medicare and Medicaid certified, members of chains, and operating not-for-profit has increased over the past 30 years. There have also been reductions in occupancy and increases in the share of residents who are racial or ethnic minorities, admitted for post-acute care, in need of physical assistance with daily activities, primarily supported by Medicare, and diagnosed with a psychiatric condition such as schizophrenia. With regard to NH quality, direct care staffing levels have increased. The proportion of residents physically restrained has decreased dramatically, coupled with changes in inappropriate antipsychotic (chemical restraint) use.Conclusions and implicationsTogether with changes in the long-term care market, the NHs of today look very different from NHs 30 years ago. The 30th anniversary of OBRA provides a unique opportunity to reflect, consider what we have learned, and think about the future of this and other sectors of long-term care.     

Nursing Home and Market Factors and Risk-Adjusted Hospitalization Rates Among Urban,Micropolitan, and Rural Nursing Homes

ObjectivesHospitalizations are common among long-stay nursing home (NH) residents, but the role of rurality in hospitalization is understudied. This study examines the relationships between rurality, NH, and market characteristics and NH quarterly risk-adjusted hospitalization rates of long-stay residents over 10 quarters (2011 Q2-2013 Q3).DesignThe longitudinal associations of NH and market factors and hospitalization rates were modeled separately on urban, micropolitan, and rural NHs using generalized estimating equation models and a fully interacted model of all NH and market characteristics with micropolitan and rural indicators to test significance of differences compared with urban NHs.Setting and ParticipantsIn total, 14,600 unique NHs.MeasuresRisk-adjusted hospitalization rates were calculated from 2011 to 2013 national Medicare claims and NH Minimum Data Set 3.0. Rurality was defined based on the 2010 Rural Urban Commuting Area codes. NH and market characteristics were extracted from Certification and Survey Provider Enhanced Reporting and Area Health Resources File.ResultsOver the study period, risk-adjusted hospitalization rates averaged 9.8% (standard deviation = 8.2%). No difference was found in the overall hospitalization rates of long-stay NH residents among urban, micropolitan, and rural NHs. Generalized estimating equation models show that urban NHs with higher percentages of Medicare and Medicaid residents and any nurse practitioner/physician assistant were associated with lower rates, but these associations were insignificant in rural settings. Higher registered nurse to total nurses ratio was only associated with lower hospitalization rates in urban settings. Higher median household income was associated with lower hospitalization rates in micropolitan and rural NHs.Conclusions/ImplicationsRurality is not associated with hospitalization rates of long-stay residents, but NH and market factors (eg, payer distribution, staffing, and population income) may affect hospitalization differently in micropolitan/rural NHs than urban NHs. Future intervention on hospitalization should target factors unique to micropolitan/rural NHs which adopt strategies appropriate to their setting.     

Potentially Harmful Medication Prescribing by the Degree of Physician Specialization in Nursing Home Practice: An Observational Study

ObjectivesThe use of anticholinergics, antipsychotics, benzodiazepines, and other potentially harmful medications (PHMs) is associated with particularly poor outcomes in nursing home (NH) residents with Alzheimer's disease and related dementias (ADRD). Our objective was to compare PHM prescribing by NH physicians and advanced practitioners who focus their practice on NH residents (NH specialists) vs non-NH specialists.DesignRetrospective cohort study.Setting and ParticipantsWe included a 20% random sample of Medicare beneficiaries with ADRD who resided in 12,278 US NHs in 2017. Long-stay NH residents with ADRD were identified using MDS, Medicare Parts A and B claims. Residents <65 years old or without continuous Part D coverage were excluded.MethodsPhysicians in generalist specialties and advanced practitioners with ≥90% of Part B claims for NH care were considered NH specialists. Residents were assigned to NH specialists vs non-NH specialists based on plurality of Part D claims submitted for that resident. Any PHM use (defined using the Beers Criteria) and the proportion of NH days on a PHM were modeled using generalized estimating equations. Models included resident demographics, clinical characteristics, cognitive and functional status, behavioral assessments, and facility characteristics.ResultsOf the 54,713 residents in the sample, 27.9% were managed by an NH specialist and 72.1% by a non-NH specialist. There was no statistically significant difference in any PHM use [odds ratio (OR) 0.97, 95% CI 0.93-1.02, P = .23]. There were lower odds of prolonged PHM use (OR 0.87, 95% CI 0.81-0.94, P < .001, for PHM use on >75% vs >0%-<25% of NH days) for NH specialists vs non-NH specialists.Conclusions and ImplicationsAlthough the use of PHMs among NH residents with ADRD managed by NH specialists was not lower, they were less likely to receive PHMs over longer periods of time. Future work should evaluate the underlying causes of these differences to inform interventions to improve prescribing for NH residents.     

Factors Associated With Antimicrobial Use in Nursing Home Residents With Advanced Dementia

ObjectivesWidespread antimicrobial misuse among nursing home (NH) residents with advanced dementia raises concerns regarding the emergence of multidrug-resistant organisms and avoidable treatment burden in this vulnerable population. The objective of this report was to identify facility and resident level characteristics associated with receipt of antimicrobials in this population.DesignCross-sectional analysis of baseline data from the Trial to Reduce Antimicrobial use in Nursing home residents with Alzheimer's disease and other Dementias (TRAIN-AD).Setting and ParticipantsTwenty-eight Boston area NHs, 430 long stay NH residents with advanced dementia.MeasuresThe outcome was the proportion of residents who received any antimicrobials during the 2 months prior to the start of TRAIN-AD determined by chart review. Multivariable logistic regression was used to identify resident and facility characteristics associated with this outcome.ResultsA total of 13.7% of NH residents with advanced dementia received antimicrobials in the 2 months prior to the start of TRAIN-AD. Residents in facilities with the following characteristics were significantly more likely to receive antimicrobials: having a full time nurse practitioner/physician assistant on staff [adjusted odds ratio (aOR) 3.02; 95% confidence interval (CI), 1.54, 5.94], fewer existing infectious disease practices (eg, antimicrobial stewardship programs, established algorithms for infection management) (aOR, 2.35; 95% CI 1.14, 4.84), and having fewer residents with severely cognitively impaired residents (aOR 1.96; 95% CI 1.12, 3.40). No resident characteristics were independently associated with receipt of antimicrobials.Conclusions and ImplicationsFacility-level characteristics are associated with the receipt of antimicrobials among residents with advanced dementia. Implementation of more intense infectious disease practices and targeting the prescribing practices of nurse practitioners/physician assistants may be critical targets for interventions aimed at reducing antimicrobial use in this population.     

The Benefits of Culture Change in Nursing Homes—Obtaining Nationally Representative Evidence

ObjectiveDespite face validity and regulatory support, empirical evidence of the benefit of culture change practices in nursing homes (NHs) has been inconclusive. We used rigorous methods and large resident-level cohorts to determine whether NH increases in culture change practice adoption in the domains of environment, staff empowerment, and resident-centered care are associated with improved resident-level quality outcomes.DesignWe linked national panel 2009-2011 and 2016-2017 survey data to Minimum Data Set assessment data to test the impact of increases in each of the culture change domains on resident quality outcomes.Setting and ParticipantsThe sample included 1584 nationally representative US NHs that responded to both surveys, and more than 188,000 long-stay residents cared for in the pre- and/or postsurvey periods.MethodsWe used multivariable logistic regression with robust standard errors and a difference-in-differences methodology. Controlling for the endogeneity between increases in culture change adoption and NH characteristics that are also related to quality outcomes, we tested whether pre-post quality outcome differences (ie, improvements in outcomes) were greater for residents in NHs with culture change increases vs in those without such increases.ResultsNH performance on most quality indicators improved, but improvement was not significantly different by whether NHs increased or did not increase their culture change domain practices.Conclusions and ImplicationsThis study found that increases in an NH’s culture change domain practices were not significantly associated with improved resident-level quality. It describes a number of potential limitations that may have contributed to the null findings.