Epidemiology of hip fracture in nursing home residents with multiple sclerosis

Background

Hip fracture risk is high in young people with multiple sclerosis (MS), but has not been examined in an institutionalized aging population with MS.

Vision-specific health-related quality of life: Content areas for nursing home residents

Nursing home residents have a high prevalence of remediable visual impairment and blindness. Future research on the effectiveness of providing eye care to nursing home residents will need to include a vision-targeted health-related quality of life (HRQOL) instrument appropriate for this population. The purpose of this study was to identify the core content areas for such an instrument. In-depth interviews on vision-related issues were conducted with 40 residents. Interviews were audio-taped, transcribed, and coded using a standardized protocol. Binocular distance and near visual acuity were assessed using the resident's walking around correction to examine whether one vision-specific HRQOL measure could address the needs of residents with good and poor vision. Overall 1070 vision-related comments were identified. Residents mentioned 315 problem comments that were grouped into 13 categories, including ocular symptoms (18% of comments), reading (15%), general vision (13%), psychological distress (12%), and activities of daily living (ADLs) (7%). Compared to published data on vision-specific content areas most relevant to community based persons, nursing home residents focused more on ocular symptoms and basic ADLs, with no mention of issues related to driving, home care, and finances. The majority of categories mentioned did not differ on the proportion of comments made by those with good and poor visual acuity, suggesting that one vision-specific HRQOL instrument would be appropriate for residents with varying levels of visual acuity. Future work will focus on developing a vision-specific HRQOL instrument for nursing home residents.     

A literature review of clinical outcomes associated with antipsychotic medication use in North American nursing home residents

The benefits and harms of antipsychotic medication (APM) use in nursing home residents need to be examined because, although commonly used, APMs are considered an off-label use by the Food and Drug Administration for residents with dementia and behavioral problems. The objective of this study was to provide a realist literature review, summarizing original research studies on the clinical effects of conventional and atypical APM use in nursing home residents. Searches of multiple databases identified 424 potentially relevant research articles, of which 25 met the inclusion criteria. Antipsychotic medication use in nursing home residents was found to have variable efficacy when used off-label with an increased risk of many adverse events, including mortality, hip fractures, thrombotic events, cardiovascular events and hospitalizations. Findings suggested certain APM dosing regimens (e.g. fixed-dose) and shorter duration of use might have fewer adverse events. Non-pharmacological interventions should still be considered the first-line treatment option for nursing home residents with dementia related behavioral disturbances, as more studies are needed to establish safer criteria for APM use in nursing homes residents.     

A comparison of previous antibiotic therapy following isolation of MRSA versus MSSA in nursing home residents: a preliminary investigation

OBJECTIVE: Antibiotic exposure is a risk factor for isolation of methicillin-resistant Staphylococcus aureus (MRSA). We reasoned that this relationship might be especially strong if the comparison was targeted to antibiotics with activity against methicillin-sensitive Staphylococcus aureus (MSSA), but not MRSA. SUBJECTS: Forty-eight cases with initial MRSA clinical isolates (15 urinary, 19 wound, 11 sputum, 3 blood) were matched to 48 with MSSA clinical isolates from the same location. In addition, 10 whose MRSA was noted screening around an index case were matched to 10 with negative screening cultures sampled around the same index case. DESIGN: MSSA was always/usually sensitive to dicloxacillin, amoxicillin/clavulanate, cephalosporins, imipenem, quinolones, and erythromycin, whereas MRSA was always/usually resistant. These antibiotics were defined as "targeted" and would be expected to facilitate the proliferation of MRSA by suppressing competing bacteria. We compared the use of all antibiotics over 60 days in cases and controls. RESULTS: The comparison of antibiotic exposure in the 48 clinical isolates revealed that 29 (60%) with MRSA isolates versus 16 (33%) with MSSA isolates had received a targeted antibiotic (RR 1.81, CI 1.33-3.34, P = 0.006). Twelve (25%) with MRSA clinical isolates versus 3 with MSSA isolates (6%) had received a nontargeted antibiotic (RR 4.00, CI 2.10-14.18, P = 0.009). The comparison of antibiotic exposure in MRSA screening isolates versus negative controls revealed that 7 (70%) had received a targeted antibiotic versus 2 (20%) of controls (RR 3.50, CI 1.57-16.85, P = 0.009)). One in the screening group versus 2 controls had received a nontargeted antibiotic. Twenty-one (62%) of 34 with MRSA (urine or wound) isolates versus 4 MSSA controls (12%) had received a quinolone (RR 5.25, CI 1.80-15.30, P < 0.000). CONCLUSION: There was a significant association between antibiotic exposure and MRSA isolates. The association was especially strong for quinolones with urinary or wound isolation of MRSA. Our data do not support the hypothesis that targeted antibiotic use was more likely to be associated with MRSA isolation than nontargeted antibiotic use. The use of nontargeted antibiotics was low, with greater use in the MRSA clinical group.     

Relationship between state medicaid policies, nursing home racial composition, and the risk of hospitalization for black and white residents

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.     

Clinical characteristics of nursing home residents hospitalized with heart failure

OBJECTIVE: The purpose of this retrospective study was to describe the clinical characteristics of heart failure among nursing home residents hospitalized with heart failure and determine the validity of dyspnea at rest in the diagnosis of heart failure. METHODS: Subjects were nursing home residents hospitalized with a diagnosis of heart failure. Data on demographic and various admission characteristics were collected by chart abstraction. Proportions of patients presenting with various symptoms and signs of heart failure have been described. The diagnosis of heart failure was confirmed using modified Framingham criteria. The sensitivity, specificity, and positive predictive value of the symptom of dyspnea at rest in the diagnosis of heart failure in nursing home residents hospitalized with heart failure were then estimated. RESULTS: Patients (N = 98) were elderly, predominantly female and about one-fifth African-American. Dyspnea at rest was the presenting symptom of 85 (87%) patients. Sixty-eight (69%) patients met modified Framingham criteria for the diagnosis of heart failure. Dyspnea at rest had a sensitivity of 91%, specificity of 23%, and predictive value positive of 73% for diagnosis of heart failure. CONCLUSION: Dyspnea at rest was the most common symptom among this cohort of nursing home residents hospitalized with heart failure and has a potential to play a useful role in the diagnosis of heart failure in these patients.     

Testing the effect of specific orders to provide oral liquid nutritional supplements to nursing home residents: A quality improvement project

Objectives: To improve nursing home (NH) staff delivery of oral liquid nutritional supplements between meals to residents with a history of weight loss.Design: Pre-Post intervention study.Setting: Two skilled nursing homes.Participants: Eighteen long term care residents.Intervention: At baseline all participants had a non-specific physician’s order to receive a nutritional supplement. The intervention consisted of specifying the physician’s order as follows: “Give 4 oz high protein supplement at 10am, 2pm, and 7pm”.Measurements: Research staff conducted direct observations for two days during and between meals for a total of 4 days, or 12 possible observation periods per participant before and one week following the intervention. Research staff documented NH staff delivery of snacks (including high protein supplements) and amount consumed (fluid ounces) for the high protein supplements using a standardized protocol during each observation period.Results: Before the specific order was written participants were offered any type of snack an average of 1.82 times per day and a high protein supplement 0.59 times per day. After the specific order was written participants were offered any type of snack an average of 1.59 times per day and a high protein supplement 0.91 times per day. There were no statistically significant differences in the average number of times snacks or supplements were offered before and after the specific order was written. The proportion of snacks offered that were high protein supplements did increase after the specific order was written (p<0.001). When a high protein supplement was provided, most residents consumed 100% of it.Conclusions: Oral liquid nutritional supplements were not provided consistent with orders in NH practice. The specificity of the order related to type of supplement and time of delivery did not influence when and how often supplements are provided to residents but it did influence the type of nutritional supplement offered.     

Explaining direct care resource use of nursing home residents: findings from time studies in four states

OBJECTIVE: To explain variation in direct care resource use (RU) of nursing home residents based on the Resource Utilization Groups III (RUG-III) classification system and other resident- and unit-level explanatory variables. DATA SOURCES/STUDY SETTING: Primary data were collected on 5,314 nursing home residents in 156 nursing units in 105 facilities from four states (CO, IN, MN, MS) from 1998 to 2004. Study Design. Nurses and other direct care staff recorded resident-specific and other time caring for all residents on sampled nursing units. Care time was linked to resident data from the Minimum Data Set assessment instrument. Major variables were: RUG-III group (34-group), other health and functional conditions, licensed and other professional minutes per day, unlicensed minutes per day, and direct care RU (wage-weighted minutes). Resident- and unit-level relationships were examined through hierarchical linear modeling. DATA COLLECTION/EXTRACTION METHODS: Time study data were recorded with hand-held computers, verified for accuracy by project staff at the data collection sites and then merged into resident and unit-level data sets. PRINCIPAL FINDINGS: Resident care time and RU varied between and within nursing units. RUG-III group was related to RU; variables such as length of stay and unit percentage of high acuity residents also were significantly related. Case-mix indices (CMIs) constructed from study data displayed much less variation across RUG-III groups than CMIs from earlier time studies. CONCLUSIONS: Results from earlier time studies may not be representative of care patterns of Medicaid and private pay residents. New RUG-III CMIs should be developed to better reflect the relative costs of caring for these residents.     

Lower Dietary Calcium Intake is Associated with a Higher Risk of Mortality in Korean Adults

BackgroundCalcium, one of the most abundant minerals in the human body, has a pivotal role in human physiology. However, only a few studies have examined the association of dietary calcium intake with mortality in a population with low calcium intake.ObjectiveThe aim of this study was to examine the association of dietary calcium intake with risk of all-cause and cause-specific mortality among Korean adults with low calcium intake.DesignThis study was a prospective cohort study.Participants/settingThe analysis was conducted using data from 44,327 eligible Korean adults aged 19 years and older who participated in the Korea National Health and Nutrition Examination Survey 2007-2015. Dietary calcium intake was assessed using 1-day 24-hour recall data.Main outcome measuresThe main outcomes of this study were mortality from all causes, cancer, cardiovascular disease, respiratory disease, and all other causes combined. The outcome was ascertained through linkage to the death registry compiled by Statistics Korea with the use of the resident registration number.Statistical analyses performedWeighted Cox proportional hazard models were used to estimate the hazard ratios and 95% CIs of the all-cause and cause-specific mortality according to dietary calcium intake.ResultsDuring a mean follow-up of 7.28 person-years, 1,889 deaths were ascertained. After multivariable adjustment, the hazard ratios for all-cause mortality for the second quintile to the highest quintile of dietary calcium intake, respectively, compared with the first quintile were 0.86 (95% CI 0.73 to 1.00), 0.82 (95% CI 0.69 to 0.98), 0.85 (95% CI 0.69 to 1.03), and 0.78 (95% CI 0.64 to 0.96) (P for trend from the lowest to the highest quintile = .04). There were no statistically significant associations between dietary calcium intake and risk of mortality from cancer, cardiovascular, or respiratory disease.ConclusionsIn this large prospective cohort study of Korean adults, lower dietary calcium intake was associated with a higher risk of all-cause mortality.     

Feasibility of quality indicators for the management of geriatric syndromes in nursing home residents

PURPOSE: The assessment and management of dementia, falls and mobility disorders, malnutrition, end-of-life issues, pressure ulcers, and urinary incontinence have been identified as important quality improvement targets for vulnerable elders residing in nursing homes. This study aimed to identify valid and feasible measures of specific care processes associated with improved outcomes for these conditions. METHODS: Nine experts in nursing home (NH) care participated in a modified Delphi process to evaluate potential quality indicators (QIs) for care in NHs. Panelists met and discussed potential indicators before completing confidential ballots rating validity (process associated with improved outcomes), feasibility of measurement (with charts or interviews), feasibility of implementation (given staffing resources in average community NHs), and importance (expected benefit and prevalence in NHs). The NH panel's median votes were used to identify a final set of QIs that were subsequently reviewed by a clinical oversight committee. RESULTS: Sixty-eight geriatric syndrome QIs were identified as valid and important in NH populations. Panelists assessed 12 (18%) of these QIs as having questionable feasibility to implement in average community nursing homes trying to provide quality care. Nine (13%) would not be included in systems assessing quality of care for persons with advanced dementia or poor prognosis. CONCLUSIONS: Steps of care critical to the assessment and management of geriatric syndromes in NHs were identified. Feasibility is an important issue for a significant number of these, indicating that much remains to be done to design systems that efficiently and reliably implement these care processes.     

Hospital in the home is cost saving for appropriately selected patients: a comparison with in-hospital care.

BACKGROUND: As the cost of acute care in hospitals increases, there is an increasing need to find alternative means of providing acute care. Hospital in the home (HITH) has developed in response to this challenge. Current evidence is conflicting as to whether HITH provides cost savings compared with in-hospital care (IHC). The heterogeneous nature of HITH and the clinical complexity of patients is the greatest obstacle to making valid comparisons between the two modes of care. OBJECTIVE: To compare costs and outcomes of HITH to IHC in hospitals in Victoria, Australia. DATA SOURCES/STUDY SETTING: Hospital morbidity data and medical records from Victoria, Australia. STUDY DESIGN: A costing study of 924 randomly selected episodes of HITH care, individually matched to 924 comparable IHC episodes. METHODS: Unadjusted total episode costs (TEC) and averaged daily costs for HITH and IHC were calculated. Mortality and length of stay (LOS) were compared for HITH and IHC episodes. Simple linear and multiple regression were used to analyse costing data, while logistic regression was used to compare in-hospital mortality and LOS in HITH versus IHC episodes. PRINCIPAL FINDINGS: The 1848 episodes of care in the sample represented a heterogeneous range of acute conditions in 31 Victoria hospitals. HITH consisted of two distinct subgroups: pure-HITH (total episode substitution) and mixed-HITH (partial episode substitution). The cost of episodes of acute care containing a HITH component were overall 9% less expensive than IHC (P = 0.04), while pure-HITH was 38% cheaper than matched IHC (P < 0.001). The variable HITH, along with LOS and chemotherapy, explained the 60% variation in TEC. The mean cost of pure-HITH episodes was 22% lower compared to mixed-HITH (P = 0.004). The in-hospital mortality rate in HITH (3.8%) and IHC (5.2%) was not significantly different. Pure-HITH was associated with shorter LOS, while mixed HITH was strongly associated with longer LOS. CONCLUSION: In our study the adjusted cost of HITH was significantly cheaper than IHC, particularly as total episode substitution. The cost needs to be adjusted because many factors other than HITH or IHC can influence crude costs. There may be potential for wider use of HITH for appropriately selected patients.     

Fried表型和衰弱指数与死亡风险关联的比较分析

目的 比较Fried表型以及由不同数量的疾病缺陷构成的衰弱指数（FI）对衰弱状态评价的一致性以及与死亡风险的前瞻性关联。方法 利用中国慢性病前瞻性研究（CKB）第二次重复调查的23 615名研究对象的数据,采用5种表型指标构建Fried表型,并分别纳入28个和40个疾病缺陷构建FI-28和FI-40。计算加权Kappa系数比较3种指标对衰弱状态分类的一致性。采用Cox比例风险模型分析衰弱指标与死亡风险的关联。结果 采用Fried表型、FI-28和FI-40计算的衰弱率分别为5.4%、7.9%和4.0%。Fried表型与FI-28和FI-40的Kappa系数分别为0.357和0.408,FI-28与FI-40的Kappa系数为0.712。经过（3.9±0.5）年的随访,死亡755人。当采用Fried表型时,与无衰弱组相比,衰弱前期和衰弱组的死亡风险均增加,多因素调整后的风险比（HR）（95%CI）分别为1.60（1.32~1.94）和2.90（2.25~3.73）;采用FI-28时,衰弱前期和衰弱组的死亡HR值分别为1.71（1.39~2.11）和2.52（1.95~3.27）;采用FI-40时,衰弱前期和衰弱组的死亡HR值分别为1.98（1.60~2.44）和3.71（2.80~4.91）。衰弱状态与死亡风险的关联在不同年龄组间存在差异,在低年龄组中的关联强度高于高年龄组。结论 Fried表型和基于不同数量的变量构建的FI表现出较好的一致性,都能较好地预测死亡风险。     

Quality indicators for the management of medical conditions in nursing home residents

PURPOSE: The purpose of this study was to develop a set of specific care processes associated with better outcomes for general medical conditions identified as quality improvement targets for institutionalized vulnerable elders. METHODS: A national panel of nursing home experts used a modified-Delphi process to rate the validity (process linked to improved outcomes) and feasibility (of implementation and measurement) of candidate measures for depression, diabetes, hearing impairment, heart failure, hypertension, ischemic heart disease, osteoarthritis, osteoporosis, pneumonia, stroke, and vision impairment. Each quality indicator was written as an "if" statement, describing persons to whom the quality indicator applied followed by a "then" statement identifying the care process to be provided. A separate clinical committee reviewed the resulting set of indicators. RESULTS: One hundred fourteen quality indicators were identified across the 11 medical conditions. The quality indicators capture a broad range of medical care addressing assessment, management, and follow up. Fifty-five indicators (48%) were identical to quality measures for community-dwelling vulnerable elders. A limited number were rated as questionably feasible to implement or measure (6 and 2, respectively). Thirty-eight (33%) would not be applied to measures of care quality for persons with advanced dementia or poor prognosis. CONCLUSIONS: Explicit care processes linked to improved nursing home outcomes for general medical conditions can be identified. Most of these care processes can be measured by medical records or interview. Nursing home quality measures for medical conditions must account for exclusions related to poor prognosis and advanced dementia.