Deriving a risk-adjustment model for pressure ulcer development using the Minimum Data Set

OBJECTIVE: To use the Minimum Data Set (MDS) to derive a risk-adjustment model for pressure ulcer development that may be used in assessing the quality of nursing home care. DESIGN: Perspective observational study using MDS data from 1997. SETTING: A large, for-profit, nursing home chain. PARTICIPANTS: Our unit of analysis was 39,649 observations made on 14,607 nursing home residents who were without a stage 2 or larger pressure ulcer on an index assessment. MEASUREMENTS: Pressure ulcer status was determined at an outcome assessment approximately 90 days after an index assessment. Potential predictors of pressure ulcer development were examined for bivariate associations, contributing to the development of a multivariate logistic regression model. RESULTS: A stage 2 or larger pressure ulcer developed in 2.3% of the observations. Seventeen resident characteristics were found to be associated with pressure ulcer development. These included dependence in mobility and transferring, diabetes mellitus, peripheral vascular disease, urinary incontinence, lower body mass index, and end-stage disease. A risk-adjustment model based on these characteristics was well calibrated and able to discriminate among residents with different levels of risk for ulcer development (model c-statistic = 0.73). CONCLUSION: A clinically credible risk-adjustment model with good performance properties can be developed using the MDS. This model may be useful in profiling nursing homes on their rate of pressure ulcer development.     

Validation of Minimum Data Set for Nursing Home in Hong Kong Chinese Elders

Abstract

The objective of this study was to validate the Chinese version of the Minimum Data Set-Resident Assessment Instrument (MDS-RAI) in Hong Kong Chinese elders. The respondents were 83 people aged 65 years or older who lived at a care and attention home in Hong Kong. Firstly, test-retest reliabilities of four Resident Assessment Protocol (RAP) scales (including cognitive loss/dementia, communication, activities of daily living/rehabilitation potential, and mood symptoms) were examined and we found acceptable test-retest reliability. Secondly, inter-rater reliability of these four RAPs was found to be acceptable. Concurrent validity was also obtained for these four areas in MDS-RAI and most associations were in the range from 0.4 to 0.6. Results suggest that the Chinese version of MDS-RAI is a reliable and valid assessment tool for elderly Chinese residents in a long-term care facility in Hong Kong.     

Evaluation of a risk-adjustment model for pressure ulcer development using the Minimum Data Set

OBJECTIVE: To validate a previously derived risk-adjustment model for pressure ulcer development in a separate sample of nursing home residents and to determine the extent to which use of this model affects judgments of nursing home performance. DESIGN: Retrospective observational study using Minimum Data Set (MDS) data from 1998. SETTING: A large, for-profit, nursing home chain. PARTICIPANTS: Twenty-nine thousand and forty observations were made on 13,457 nursing home residents who were without a pressure ulcer on an index assessment. MEASUREMENTS: We used logistic regression in our validation sample to calculate new coefficients for the 17 previously identified predictors of pressure ulcer development. Coefficients from this new sample were compared with those previously derived. Expected rates of pressure ulcer development were determined for 108 nursing homes. Unadjusted and risk-adjusted rates of pressure ulcer development from these homes were also calculated and outlier identification using these two approaches was compared. RESULTS: Predictors of pressure ulcer development in the derivation sample generally showed similar effects in the validation sample. The model c-statistic was also unchanged at 0.73, but it was not calibrated as well in the validation sample. On applying the model to the nursing homes, expected rates of ulcer development ranged from 1.1% to 3.2% (P <.001). The observed rates ranged from 0% to 12.1% (P <.001). There were 12 outliers using unadjusted rates and 15 using adjusted performance. Ten nursing homes were identified as outliers using both approaches. CONCLUSIONS: Our MDS risk-adjustment model for pressure ulcer development performed well in this new sample. Nursing homes differ significantly in their expected rates of pressure ulcer development. Outlier identification also differs depending on whether unadjusted or risk-adjusted performance is evaluated.     

The Role of Nursing Home Admission and Dementia Status on Care for Diabetes Mellitus

OBJECTIVES: To study the role of nursing home (NH) admission and dementia status on the provision of five procedures related to diabetes mellitus.
DESIGN: Retrospective cohort study using data from a large prospective study in which an expert panel determined the prevalence of dementia.
SETTING: Fifty-nine Maryland NHs.
PARTICIPANTS: Three hundred ninety-nine new admission NH patients with diabetes mellitus.
MEASUREMENTS: Medicare administrative claims records matched to the NH medical record data were used to measure procedures related to diabetes mellitus received in the year before NH admission and up to a year after admission (and before discharge). Procedures included glycosylated hemoglobin, fasting blood glucose, dilated eye examination, lipid profile, and serum creatinine.
RESULTS: For all but dilated eye examinations, higher rates of procedures related to diabetes mellitus were seen in the year after NH admission than in the year before. Residents without dementia received more procedures than those with dementia, although this was somewhat attenuated after controlling for demographic, health, and healthcare utilization variables. Persons without dementia experience greater increases in procedure rates after admission than those with dementia.
CONCLUSION: The structured environment of care provided by the NH may positively affect monitoring procedures provided to elderly persons with diabetes mellitus, especially those without dementia. Medical decisions related to the risks and benefits of intensive treatment for diabetes mellitus to patients of varying frailty and expected longevity may lead to lower rates of procedures for residents with dementia.     

A Practice Improvement Education Program Using a Mentored Approach to Improve Nursing Facility Depression Care—Preliminary Data

Depression is common in nursing facility residents. Depression data obtained using the Minimum Data Set (MDS) 3.0 offer opportunities for improving diagnostic accuracy and care quality. How best to integrate MDS 3.0 and other data into quality improvement (QI) activity is untested. The objective was to increase nursing home (NH) capability in using QI processes and to improve depression assessment and management through focused mentorship and team building. This was a 6‐month intervention with five components: facilitated collection of MDS 3.0 nine‐item Patient Health Questionnaire (PHQ‐9) and medication data for diagnostic interpretation; education and modeling on QI approaches, team building, and nonpharmacological depression care; mentored team meetings; educational webinars; and technical assistance. PHQ‐9 and medication data were collected at baseline and 6 and 9 months. Progress was measured using team participation measures, attitude and care process self‐appraisal, mentor assessments, and resident depression outcomes. Five NHs established interprofessional teams that included nursing (44.1%), social work (20.6%), physicians (8.8%), and other disciplines (26.5%). Members participated in 61% of eight offered educational meetings (three onsite mentored team meetings and five webinars). Competency self‐ratings improved on four depression care measures (P = .05 to <.001). Mentors observed improvement in team process and enthusiasm during team meetings. For 336 residents with PHQ‐9 and medication data, depression scores did not change while medication use declined, from 37.2% of residents at baseline to 31.0% at 9 months (P < .001). This structured mentoring program improved care processes, achieved medication reductions, and was well received. Application to other NH‐prevalent syndromes is possible.     

Exergames and Their Acceptance Among Nursing Home Residents

The purpose of this uncontrolled, pre-post longitudinal pilot study was to evaluate how many persons among nursing home residents with dementia would accept the accelerometer-based exergames and to get to know their special characteristics. The pre-post assessment was conducted in a sample of 79 residents. Of these residents, a total of 41 (51.8%) showed cognitive impairment indicative of dementia according the Mini-Mental State Examination (MMSE). By the end of the first phase of the study, which lasted 3 weeks, 27 of the 79 residents had accepted the use of exergames and continued to play the games during the second phase of the study (which, depending on the nursing home, lasted either 3 weeks or 8 weeks). Participants who accepted the exergames were significantly younger, had less cognitive impairment, and were interested in more hobbies. In participants who accepted the games, cognitive function improved slightly over the study, but not in a statistically significant fashion. Our findings suggest that, with supervision, exergames may be suitable for every fifth person in a nursing home.     

Nursing Home Transition and Depressive Symptoms in Older Medical Rehabilitation Patients

Abstract

The present study of older medical rehabilitation patients investigated whether transition to a nursing home after rehabilitation was significantly related to increased depressive symptoms at baseline and at 3-, 6-, and 18-month follow-ups. All participants lived alone prior to their medical rehabilitation. Those returning to live alone (N = 86) were compared to those discharged to live with others (N = 62), or to a nursing home (N = 38). Cross-sectionally, patient's discharged to live alone reported the lowest levels of depressive symptoms followed by those living with others. Patients discharged to a nursing home reported higher levels of depressive symptoms that were marginally significant at baseline (p < .10) and 18 months (p < .10), while statistically significant at 3 months (p < .01). At 6 months post-discharge, results were not significant as the highest levels of depressive symptoms were seen in both nursing home patients and those who were living with others. Longitudinally, those who remained in a nursing home during all four assessment points reported higher levels of depressive symptoms compared to those who continuously lived alone or continuously lived with others after 18 months (p < .01). However, depressive symptomatology was stable over time among those who continuously resided in a nursing home following discharge. These findings provide additional support for a link between loss of independence and elevated depressive symptomatology.     

The Influence of Long-Term Care Insurance on the Likelihood of Nursing Home Admission

OBJECTIVES: To determine the effect of long-term care (LTC) insurance on nursing home use.
DESIGN: Longitudinal analysis, 1998 to 2006 waves of the Health Retirement Study.
SETTING: Community-dwelling nationally representative sample.
PARTICIPANTS: Nineteen thousand one hundred seventy adults aged 50 and older, 1998 wave.
METHODS: Two groups of respondents were created at baseline: those with and without an LTC insurance policy. Respondents admitted to the nursing home from 1998 to 2006 were identified. Propensity scores were used to control for known predictors of LTC insurance possession. A Cox proportional hazards model was used to compare the probability of nursing home admission over 8 years of follow-up for respondents possessing LTC insurance and those without a policy.
RESULTS: Of the 19,170 respondents aged 50 and older in 1998, 1,767 (9.2%) possessed LTC insurance. A total of 1,778 (8.5%) were admitted to a nursing home during the 8-year period: 149 (8.7%) of those with LTC insurance and 1,629 (8.4%) of those without LTC insurance. The hazard ratio, adjusted for propensity score, for those with LTC insurance entering a nursing home compared with those without was 1.07 (95% confidence interval=0.83–1.38). Likelihood of nursing home admission was relatively low because the low-risk population included in the study, limiting the power to detect small differences in risk of nursing home utilization between groups.
CONCLUSION: There was no difference in nursing home utilization between low-risk older adults who did and did not possess an LTC insurance policy.