Strategic orientation and nursing home response to public reporting of quality measures: an application of the miles and snow typology

OBJECTIVE: To assess whether differences in strategic orientation of nursing homes as identified by the Miles and Snow typology are associated with differences in their response to the publication of quality measures on the Nursing Home Compare website. DATA SOURCES: Administrator survey of a national 10 percent random sample (1,502 nursing homes) of all facilities included in the first publication of the Nursing Home Compare report conducted in May-June 2004; 724 responded, yielding a response rate of 48.2 percent. STUDY DESIGN: The dependent variables are dichotomous, indicating whether or not action was taken and the type of action taken. Four indicator variables were created for each of the four strategic types: Defender, Analyzer, Prospector, and Reactor. Other variables were included in the seven logistic regression models to control for factors other than strategic type that could influence nursing home response to public disclosure of their quality of care. DATA COLLECTION/EXTRACTION METHODS: Survey data were merged with data on quality measures and organizational characteristics from the first report (November 2002). PRINCIPAL FINDINGS: About 43 percent of surveyed administrators self-typed as Defenders, followed by Analyzers (33 percent), and Prospectors (19 percent). The least self-selected strategic type was the Reactor (6.6 percent). In general, results of the regression models indicate differences in response to quality measure publication by strategic type, with Prospectors and Analyzers more likely, and Reactors less likely, to respond than Defenders. CONCLUSIONS: While almost a third of administrators took no action at all, our results indicate that whether, when, and how nursing homes reacted to publication of federally reported quality measures is associated with strategic orientation.     

Prioritizing back injury risk in hospital employees: application and comparison of different injury rates

To identify high risk areas for back injury in a large teaching hospital, we calculated standard injury rates and newly developed composite statistics for nursing and non-nursing work groups. Data were extracted from the hospital's workers' compensation database. The hospital-wide total injury rate was 4.6 reports per 100 full-time equivalents (FTE); Compensation Case Rate, 1.4 cases per 100 FTE; Compensation Severity Rate, 76 days lost per 100 FTE; and the Cost Rate, $3742 per 100 FTE. The Total Injury Reports Rate for nursing varied from 14.2 per 100 FTE for Intensive Care Unit (ICU) Nursing to 3.8 per 100 FTE for Pediatric Nursing. Non-nursing areas also demonstrated increased rates for back injury. Individual statistical rates ranked areas differently in risk, whereas composite statistical measures consistently ranked ICU Nursing, Buildings and Grounds, and Orthopedics/Neurological Nursing as the top three. Patient handling was the precipitating event in the majority of nursing back injuries, indicating the need for ergonomic intervention. The use of combined statistical measures provided a more integrative measure for describing and following back injury risk over time.     

Effect of polyphloretin phosphate on the contraceptive action of a polyethylene intrauterine device in rats

A polyethylene intrauterine device (IUD) inserted in one horn of the rat uterus on Day 2 of pregnancy prevented implantation in 9 out of 12 rats in the horn with the device. When polyphloretin phosphate (PPP), a substance known to inhibit alkaline phosphatase, was administered to such rats from Day 1 till Day 5 of pregnancy, the device prevented implantation in only 3 out of 12 rats in the horn with the device. PPP also significantly reduced the raised levels of endometrial alkaline phosphatase observed in the presence of the device. A significant rise in endometrial alkaline phosphatase was seen in such animals not administered PPP. It is suggested that there is a correlation between the anti-implantation effect of an IUD and raised levels of endometrial alkaline phosphatase in rats.     

Relation of serum albumin concentration to death rate in nursing home men

Serum albumin was measured in 126 men (average age 70.6; range 40 to 96) of a Veterans Administration Nursing Home, and was correlated with other items in an extensive clinical data base, including death or survival during the year after the analysis. The reason for institutionalization was chronic neurologic disease or other disabling physical condition in 63 men (group A), and psychiatric disorder in 63 men (group B). In group A, the proportions of men with albumin less than 3.5, 3.5-4.0, and greater than 4.0 g/dl were 6%, 37%, and 57%, respectively. In this group, the serum albumin level was significantly (p less than 0.05) correlated with death rate, hemoglobin, hematocrit, serum cholesterol, and serum lactic dehydrogenase. The death rate in group A during the year after the albumin analysis was 25%. For the patients with albumin level less than 3.5, 3.5-4.0, and greater than 4.0 g/dl, the death rates were 50%, 43%, and 11% respectively (p less than 0.01 for comparison of the former two groups with the latter). The subgroup with albumin 3.5-4.0 g/dl represented only 37% of the men in group A, but accounted for 63% of the group's deaths. In group B, serum albumin level was not significantly correlated with any other clinical variable. Death rate during the year after the albumin analysis was only 2% in group B, and did not correlate with the albumin level. These data indicate that, in nonpsychiatric Nursing Home men, the desirable level for the serum albumin concentration is higher than 3.5 g/dl.     

Health status,staffing, and medicaid reimbursement in nursing homes: 1985 to 1995

CONTEXT: Policy changes implemented by Medicaid and Medicare in the early 1980s resulted in a functionally more dependent nursing home population. OBJECTIVES: This paper contends that (1) staffing in nursing homes has become more efficient; (2) nursing home residents are functionally more dependent;(3) Medicaid per diem reimbursement is inadequate. DATA SOURCES: Staffing data came from the National Nursing Home Facility Survey conducted by the National Center for Health Statistics (NCHS) in 1985 and 1995. Functional dependency data, defined as assistance with any of six Activities of Daily Living (ADLs), came from the NCHS National Nursing Home Current Resident Surveys in 1985 and 1995. Reimbursement rates came from the State Medicaid Reimbursement Surveys conducted by the University of California at San Francisco to which the Consumer Price Index, Hospital and Related Services Item was applied. DATA SYNTHESIS: Administration decreased by 4.4 full-time equivalents (FTEs) (80.0%) per 100 beds, whereas patient care increased by 8.2 FTEs (18.9%). Residents requiring assistance with four or more ADLs increased by 9.9%, and the mean number of ADLs per patient increased from 3.9 to 4.3. Applying the Consumer Price Index to the 1984 reimbursement rate indicated an annual deficit of 5526.00 dollars for each Medicaid patient by 1995. CONCLUSIONS: This research strongly supports its contentions but fails to demonstrate them conclusively. The data indicate that long-term care facilities have reallocated staffing to accommodate the requirements of more functionally dependent residents and that Medicaid reimbursement has failed to maintain its initial purchasing power.     

Health status and work burden of Alzheimer patients' informal caregivers: comparisons of five different care programs in the European Union

BACKGROUND: In 1998, a research study was conducted to compare existing programs in the European Union providing both care to people with senile dementia of the Alzheimer type, and support to their informal caregiver. METHOD: Five programs were selected in seven centres. Home social services (Denmark), Day centres (Germany), Expert Centres (Belgium, Spain), Group Living/Cantou (Sweden, France), Respite hospitalization (France). In each centre, 50 patients were randomly selected. The questionnaire addressed informal caregivers (or referents). It included the Nottingham Health Profile (NHP), the Zarit Scale, and it collected data on age, sex and position (spouse or child) of the informal caregiver, as well as age, level of mental deterioration and disabilities of the patient. RESULTS: (n=322 subjects) Comparatively with caregivers of Respite hospitalization patients chosen as the reference, caregivers of patients cared by Group living/Cantou and Home social services experienced a significantly lower burden. The benefit from the Expert centre program concerned emotional reactions (depression) (odds ratio=0.32; P=0.02) and work burden (Zarit) (OR=0.32; P=0.04). The main benefit for caregivers who received Day centre help was the important reduction of feelings of social isolation (OR=0.13; P=0.0003). CONCLUSIONS: The Group Living/Cantou program appeared as the most efficient way to reduce informal caregiver burden, independently from the country considered.     

Peterborough Hospital at Home: an evaluation

An evaluation of the Peterborough Hospital at Home scheme was undertaken to examine the complementary roles of Hospital at Home, hospital ward and the District Nursing Service. The evaluation involved two surveys; the first was a retrospective study of records of patients admitted to one of the three care settings during 1983. The second survey was a prospective study of Hospital at Home patients in 1985 with the index diagnoses of malignant neoplasms, cerebrovascular accidents and post-operative patients discharged early from hospital. In 1985, 284 patients were admitted to Hospital at Home, and of these the largest group (73 patients) were terminally ill cancer patients. Hospital at Home provided care for more severely ill patients than those normally looked after by the District Nursing Service, and comparable in severity and outcome to those in hospital. There was an emphasis on terminal care by Hospital at Home which would make it appear to be an enhancement to the usual domiciliary nursing services available, as, for the majority of the cancer patients cared for by Hospital at Home, admission to hospital would probably not be sought.     

It takes a village: a multidisciplinary model for the acute illness aftercare of individuals experiencing homelessness

Homeless individuals are often uninsured and are more likely than the housed to utilize acute health care services and experience longer hospitalizations. Currently in the United States, there are fragmented services available for the aftercare of these patients to ensure continuum of care, promote healing, and avoid re-entry into the acute care system. The Fourth Street Clinic Respite Program was created to address these issues. Patients are referred to the program from local hospitals and other service providers. Based on the acuity of illness and need for nursing care, patients are admitted to one of four programs: (1) Shelter-based Day Bed Program, (2) Temporary Emergency Housing (Motel) Program, (3) Tuberculosis Housing Program, or (4) Nursing Home Program. Aftercare patients receive medical, social, and behavioral health services and are discharged to local shelters when stable. The aftercare program provides a safe refuge for recovery from acute illnesses for those experiencing homelessness.     

Beyond patient dependency: family characteristics and access of elderly patients to home care services following hospital discharge

Access to Skilled Nursing and Home Health Aid services among elderly patients (N = 580) and their family caregivers post hospital discharge was examined using logistic regression. A majority of the sample (65%) were referred for Skilled Nursing services while only 28% were referred for Home Health Aid services. Caregiving situations in which the spouse was the primary caregiver were less than half as likely to be referred for either service when compared to non-spouses. As expected, ADL limitations were a significant predictor of referral for both services. Women patients with the same ADL limitation as men were only about a fourth as likely to be referred for Home Health Aid services as men. Findings are discussed in terms of access to care and the need for policy to consider more than patient limitations in the referral criteria.     

The "Nursing Home Compare" Measure of Urinary/Fecal Incontinence: Cross-Sectional Variation, Stability over Time, and the Impact of Case Mix

Objectives. To assess the impact of facility case mix on cross-sectional variations and short-term stability of the "Nursing Home Compare" incontinence quality measure (QM) and to determine whether multivariate risk adjustment can minimize such impacts.
Study Design. Retrospective analyses of the 2005 national minimum data set (MDS) that included approximately 600,000 long-term care residents in over 10,000 facilities in each quarterly sample. Mixed logistic regression was used to construct the risk-adjusted QM (nonshrinkage estimator). Facility-level ordinary least-squares models and adjusted R ² were used to estimate the impact of case mix on cross-sectional and short-term longitudinal variations of currently published and risk-adjusted QMs.
Principal Findings. At least 50 percent of the cross-sectional variation and 25 percent of the short-term longitudinal variation of the published QM are explained by facility case mix. In contrast, the cross-sectional and short-term longitudinal variations of the risk-adjusted QM are much less susceptible to case-mix variations (adjusted R ²<0.10), even for facilities with more extreme or more unstable outcome.
Conclusions. Current "Nursing Home Compare" incontinence QM reflects considerable case-mix variations across facilities and over time, and therefore it may be biased. This issue can be largely addressed by multivariate risk adjustment using risk factors available in the MDS.     

Nursing education: interface between the curriculum guidelines and content of primary health attention

This study aimed to analyze the Political and Pedagogical Projects (PPP) of three nursing courses older Ceará, showing how the National Curriculum Guidelines for Nursing are expressed in them, and the changes occurring in nursing as a profession in Brazil. This is a documentary research, in which he noted the influence of the National Curriculum Guidelines for Nursing in training professionals to work in Primary Care. From the study it was concluded that the PPP analysis are concerned with the training focused on the but two of the universities concerned have a curriculum more focused on the principles of primary care and only one of them brings the proposal of the whole curriculum, an aspect that contributes to discussions in education when considering the professional training for Single Health System.     

The cost of hospital readmissions: evidence from the VA

This paper is an examination of hospital 30-day readmission costs using data from 119 acute care hospitals operated by the U.S. Veterans Administration (VA) in fiscal year 2011. We applied a two-part model that linked readmission probability to readmission cost to obtain patient level estimates of expected readmission cost for VA patients overall, and for patients discharged for three prevalent conditions with relatively high readmission rates. Our focus was on the variable component of direct patient cost. Overall, managers could expect to save $2140 for the average 30-day readmission avoided. For heart attack, heart failure, and pneumonia patients, expected readmission cost estimates were $3432, $2488 and $2278. Patient risk of illness was the dominant driver of readmission cost in all cases. The VA experience has implications for private sector hospitals that treat a high proportion of chronically ill and/or low income patients, or that are contemplating adopting bundled payment mechanisms.     

Health status and work burden of Alzheimer patients’ informal caregivers: Comparisons of five different care programs in the European Union

Background: In 1998, a research study was conducted to compare existing programs in the European Union providing both care to people with senile dementia of the Alzheimer type, and support to their informal caregiver. Method: Five programs were selected in seven centres. Home social services (Denmark), Day centres (Germany), Expert Centres (Belgium, Spain), Group Living/Cantou (Sweden, France), Respite hospitalization (France). In each centre, 50 patients were randomly selected. The questionnaire addressed informal caregivers (or referents). It included the Nottingham Health Profile (NHP), the Zarit Scale, and it collected data on age, sex and position (spouse or child) of the informal caregiver, as well as age, level of mental deterioration and disabilities of the patient. Results: (n=322 subjects) Comparatively with caregivers of Respite hospitalization patients chosen as the reference, caregivers of patients cared by Group living/Cantou and Home social services experienced a significantly lower burden. The benefit from the Expert centre program concerned emotional reactions (depression) (odds RATIO=0.32; P=0.02) and work burden (Zarit) (OR=0.32; P=0.04). The main benefit for caregivers who received Day centre help was the important reduction of feelings of social isolation (OR=0.13; P=0.0003). Conclusions: The Group Living/Cantou program appeared as the most efficient way to reduce informal caregiver burden, independently from the country considered.     

Fractures in the men of a Veterans Administration Nursing Home: relation to 1,25-dihydroxyvitamin D

One hundred fifty-three men, age 48-96, 86% white, had resided in this Nursing Home for an average of 6.3 years (range 1.3-36) as of August 1984. At that time, we reviewed their medical charts to record the numbers and sites of fractures which had been diagnosed during the preceding 1 to 5 years of Nursing Home residence, the duration of this period depending on the duration of institutionalization. In addition, a clinical database was compiled comprising 70 attributes, including diagnoses, drugs, plasma (serum) chemistries, and measures of hematologic, nutritional, and functional status. Fractures during the studied period of Nursing Home residence had occurred in 24 of 153 men; six residents had experienced two or more fractures. Fracture rates in hip, spine, and wrist were 2564, 366, and 549 per 100,000 patient years, respectively. The total fracture rate, hip fracture rate, and limb fracture rate were five to 11 times higher than in the age-matched general population of white men in the United States; in Rochester, MN; in Dundee, England; in Oxford, England; or in Finland. Univariate statistical analysis showed that the rates for hip fracture or for fracture at any site were significantly associated with 13 attributes: directly with age, plasma somatomedin C, blood urea N, serum creatinine, serum uric acid, serum 25-hydroxyvitamin D (25-OH-D), degree of functional impairment, and chronic urinary tract infection, and inversely with serum 1,25-dihydroxyvitamin D [1,25-(OH)2-D], serum albumin, hematocrit, and hemoglobin. There was not a significant correlation with the number of falls/month which occurred during the 7 months after August 1984. After the effect of age was partialed out, somatomedin C, 25-OH-D, 1,25-(OH)2-D, and the diagnosis of urinary tract infection were still significantly related to the occurrence of fractures. The fact that Nursing Home fracture cases had significantly higher blood urea nitrogen and 25-OH-D, and significantly lower 1,25-(OH)2-D, than their non-fracture counterparts suggests that impaired renal production of the latter vitamin D metabolite contributed to the excessive rate of fractures.     

Fractures in the men of a Veterans Administration Nursing Home: relation to 1,25-dihydroxyvitamin D.

One hundred fifty-three men, age 48-96, 86% white, had resided in this Nursing Home for an average of 6.3 years (range 1.3-36) as of August 1984. At that time, we reviewed their medical charts to record the numbers and sites of fractures which had been diagnosed during the preceding 1 to 5 years of Nursing Home residence, the duration of this period depending on the duration of institutionalization. In addition, a clinical database was compiled comprising 70 attributes, including diagnoses, drugs, plasma (serum) chemistries, and measures of hematologic, nutritional, and functional status. Fractures during the studied period of Nursing Home residence had occurred in 24 of 153 men; six residents had experienced two or more fractures. Fracture rates in hip, spine, and wrist were 2564, 366, and 549 per 100,000 patient years, respectively. The total fracture rate, hip fracture rate, and limb fracture rate were five to 11 times higher than in the age-matched general population of white men in the United States; in Rochester, MN; in Dundee, England; in Oxford, England; or in Finland. Univariate statistical analysis showed that the rates for hip fracture or for fracture at any site were significantly associated with 13 attributes: directly with age, plasma somatomedin C, blood urea N, serum creatinine, serum uric acid, serum 25-hydroxyvitamin D (25-OH-D), degree of functional impairment, and chronic urinary tract infection, and inversely with serum 1,25-dihydroxyvitamin D [1,25-(OH)2-D], serum albumin, hematocrit, and hemoglobin. There was not a significant correlation with the number of falls/month which occurred during the 7 months after August 1984. After the effect of age was partialed out, somatomedin C, 25-OH-D, 1,25-(OH)2-D, and the diagnosis of urinary tract infection were still significantly related to the occurrence of fractures. The fact that Nursing Home fracture cases had significantly higher blood urea nitrogen and 25-OH-D, and significantly lower 1,25-(OH)2-D, than their non-fracture counterparts suggests that impaired renal production of the latter vitamin D metabolite contributed to the excessive rate of fractures.     

Infectious diseases and mortality among US nursing home residents.

Data collected in the 1985 National Nursing Home Survey were analyzed to identify risk factors for infections and mortality and to explore their relationship in US nursing homes. An infection was recorded in 166,609 (14%) discharges. Risk of pneumonia was found to be higher among bedbound patients (54.5 vs 13.1 per 100 discharges); urinary tract and other infections were most frequent among residents with indwelling catheters (6.6 vs 1.0 per 100 discharges). Residents with pneumonia were more likely than those with other infections to die (35% vs 28%), or be discharged to hospitals if alive (94% vs 66%). Thus, immobility and catheterization were associated with infections in US nursing homes, and pneumonia was found to contribute to mortality.     

Improving Quality Assessment through Multilevel Modeling: The Case of Nursing Home Compare

Objective. To demonstrate how multilevel modeling and empirical Bayes (EB) estimates can improve Medicare's Nursing Home Compare quality measures (QMs).
Data Sources/Study Setting. Secondary data from July 1 to September 30, 2004. Facility-level QMs were estimated from minimum data set (MDS) assessments for approximately 31,000 Minnesota nursing home residents in 393 facilities.
Study Design. Prevalence and incidence rates for 12 nursing facility QMs (e.g., use of physical restraints, pressure sores, and weight loss) were estimated with EB methods and risk adjustment using a hierarchical general linear model. Three sets of rates were developed: Nursing Home Compare's current method, unadjusted EB rates, and risk-adjusted EB rates. Bayesian 90 percent credibility intervals (CIs) were constructed around EB rates, and these were used to flag facilities for potential quality of care problems.
Data Collection/Extraction Methods. MDS assessments were performed by nursing facility staff, transmitted electronically to the Minnesota Department of Health, and provided to the investigators.
Principal Findings. Facility rates and rankings for the 12 QMs differed substantially using the multilevel models compared with current methods. The EB estimated rates shrank considerably toward the population mean. Risk adjustment had a large impact on some QM rates and a more modest impact on others. When EB CIs were used to flag problem facilities, there was wide variation across QMs in the percentage of facilities flagged.
Conclusions. Multilevel modeling should be applied to Nursing Home Compare and more widely in other health care quality assessment systems.     

Toward a model for improved targeting of aged at risk of institutionalization.

A national sample of institutionalized and noninstitutionalized aged was created by merging the 1977 National Nursing Home Survey and its counterpart, the National Health Interview Survey for the same year. A weighted logistic regression analysis was conducted to identify factors that might be useful in calculating home- and community-based long-term care clients' risk of institutionalization. A model containing patient characteristics, nursing home bed supply, and a climate variable correctly classified 98.2 percent of cases residing in nursing homes or the community. Physical dependency, mental disorder and degenerative disease, lack of spouse, being white, poverty, old age, unoccupied nursing home beds, and climate all appear to be determinants of institutional residency among the aged.     

Barriers to providing osteoporosis care in skilled nursing facilities: perceptions of medical directors and directors of nursing

OBJECTIVES: The objectives of this study were to identify the barriers to osteoporosis clinical practice guideline use perceived by Medical Directors (MED DIR) and Directors of Nursing (DON) in skilled nursing facilities; and to describe differences in the perceptions of MED DIRs and DONs. DESIGN: The authors conducted a cross-sectional national survey. PARTICIPANTS: This study consisted of a random national sample of MED DIRs (n=1300) and DONs (n=1300) belonging to the American Medical Directors Association or the National Association of Directors of Nursing Administration in Long-term Care. MEASUREMENTS: A 24-item survey using a five-point Likert scale was developed. The survey measured agreement to questions in four domains (provider factors, guideline characteristics, patient factors, environmental factors) and 10 content areas (problem acknowledgment, patient/family concern, patient/family compliance, testing availability, safety, reimbursement, regulatory oversight, staff knowledge/time/ability, belief in guidelines, and malpractice liability). Response distributions to each item were plotted and differences between MED DIRs and DONs were tested. RESULTS: Survey response rates were 40% for MED DIRs and 48% for DONs. Respondents strongly agreed that fractures are a problem in their facilities and that osteoporosis guidelines are useful and cost-beneficial (mean responses > or = 4.0). A large proportion of respondents (at least 40% of the sample) identified multiple patient comorbidities, reimbursement issues, length of stay, and regulatory oversight as barriers to providing osteoporosis care. Respondents did not believe that patient and family acceptance, testing availability, staff time, staff self-efficacy, or concerns about bisphosphonate safety were barriers to osteoporosis care. DONs were more likely than MED DIRs to believe that patients and families are concerned about fractures, whereas MED DIRs were more likely to endorse length of stay, staffing issues, and regulatory oversight as influencing treatment decisions. Years of practice and facility size, but not formal geriatrics training, significantly influenced responses. CONCLUSION: Perceived barriers to implementing osteoporosis guidelines differ between facilities and between MED DIRs and DONs. Identification of these barriers could facilitate quality improvement initiatives and improve the quality of osteoporosis care.     

Prognostic significance of serum cholesterol in nursing home men

Serum cholesterol was measured in 129 men (average age 70.6; range 41-96) of a Veterans Administration Nursing Home, and was correlated with other items in an extensive clinical data base. Serum cholesterol was less than 150 mg/dl in 13% of the subjects, and was less than 160 mg/dl in 18%. Cholesterol greater than 280 mg/dl occurred in 8%. Serum cholesterol varied directly (p less than 0.02) with: body weight, serum albumin, serum total protein, serum sodium, ability to walk, and ability to feed oneself; and indirectly (p less than 0.02) with death rate, degree of functional dependence, and serum SGOT and LDH. Nursing home men with cholesterol less than 150 mg/dl had a death rate of 63% during the 14 months after the cholesterol analysis, compared to a death rate of 9% in men with cholesterol greater than 150 mg/dl (p less than 0.05). Death rate during the year after the analysis was 52% if cholesterol was below 160 mg/dl, compared to 7% if it was above this threshold (p less than 0.05).