National Release of the Nursing Home Quality Report Cards: Implications of Statistical Methodology for Risk Adjustment

Objective. To determine how alternative statistical risk-adjustment methods may affect the quality measures (QMs) in nursing home (NH) report cards.
Data Sources/Study Settings. Secondary data from the national Minimum Data Set files of 2004 and 2005 that include 605,433 long-term residents in 9,336 facilities.
Study Design. We estimated risk-adjusted QMs of decline in activities of daily living (ADL) functioning using classical, fixed-effects, and random-effects logistic models. Risk-adjusted QMs were compared with each other, and with the published QM (unadjusted) in identifying high- and low-quality facilities by either the rankings or 95 percent confidence intervals of QMs.
Principal Findings. Risk-adjusted QMs showed better overall agreement (or convergent validity) with each other than did the unadjusted versus each adjusted QM; the disagreement rate between unadjusted and adjusted QM can be as high as 48 percent. The risk-adjusted QM derived from the random-effects shrinkage estimator deviated nonrandomly from other risk-adjusted estimates in identifying the best 10 percent facilities using rankings.
Conclusions. The extensively risk-adjusted QMs of ADL decline, even when estimated by alternative statistical methods, show higher convergent validity and provide more robust NH comparisons than the unadjusted QM. Outcome rankings based on ADL decline tend to show lower convergent validity when estimated by the shrinkage estimator rather than other statistical methods.     

Association Between Clinician Specialization in Nursing Home Care and Nursing Home Clinical Quality Scores

ImportanceWhile the number of prescribing clinicians (physicians and nurse practitioners) who provide any nursing home care remained stable over the past decade, the number of clinicians who focus their practice exclusively on nursing home care has increased by over 30%.ObjectivesTo measure the association between regional trends in clinician specialization in nursing home care and nursing home quality.DesignRetrospective cross-sectional study.Setting and ParticipantsPatients treated in 15,636 nursing homes in 305 US hospital referral regions between 2013 and 2016.MeasuresClinician specialization in nursing home care for 2012–2015 was measured using Medicare fee-for-service billings. Nursing home specialists were defined as generalist physicians (internal medicine, family medicine, geriatrics, and general practice) or advanced practitioners (nurse practitioners and physician assistants) with at least 90% of their billings for care in nursing homes. The number of clinicians was aggregated at the hospital referral region level and divided by the number of occupied Medicare-certified nursing home beds. Nursing Home Compare quality measure scores for 2013–2016 were aggregated at the HHR level, weighted by occupied beds in each nursing home in the hospital referral region. We measured the association between the number of nursing home specialists per 1000 beds and the clinical quality measure scores in the subsequent year using linear regression.ResultsAn increase in nursing home specialists per 1000 occupied beds in a region was associated with lower use of long-stay antipsychotic medications and indwelling bladder catheters, higher prevalence of depressive symptoms, and was not associated with urinary tract infections, use of restraints, or short-stay antipsychotic use.Conclusions and ImplicationsHigher prevalence of nursing home specialists was associated with regional improvements in 2 of 6 quality measures. Future studies should evaluate whether concentrating patient care among clinicians who specialize in nursing home practice improves outcomes for individual patients. The current findings suggest that prescribing clinicians play an important role in nursing home care quality.     

风险管理对提高急诊护理干预质量及降低护理风险的影响

目的探讨风险管理对提高急诊护理干预质量及降低护理风险的影响。方法我院急诊科自2014年1-6月对所有护理人员实施风险管理,与2013年7-12月未实施风险管理进行比较,分析风险管理实施前后护理质量评分、护理风险发生率以及患者满意度情况。结果实施风险管理后,基础护理、技术操作、急救仪器药品管理、消毒隔离评分明显高于实施前;护理缺陷、护理差错、护理投诉明显低于实施前;主动上报、患者满意度明显高于实施前。结论风险管理有助于提高急诊护理质量,降低护理风险的发生。     

Smart Case Review: A Model For Successful Remote Medical Direction and Enhanced Nursing Home Quality Improvement

This article describes how medical directors can use a strategic approach [Smart Case Review (SCR)] to perform effective and efficient clinical case reviews and key medical director oversight functions simultaneously. SCR can be done either on-site or remotely, by using existing information in the medical record for a focused clinical discussion of patient symptoms and issues while simultaneously evaluating related clinical practices and facility processes and performance. Common problem-solving and cause identification methods apply to both patient- and process-related reviews. This approach supports effective and efficient medical direction and facility quality improvement. Unlike most current approaches to quality assurance and performance improvement, SCR begins by reviewing cases and then aggregates the findings, instead of vice versa. Although the electronic medical record (EMR) facilitates the process, it can be done without an EMR. Any medical director can potentially use this approach, and it is relevant to any long-term and postacute care facility. This method could potentially transform the approach to medical direction, evaluating quality and improving care, and the nursing home survey process.     

探讨多方位护理管理对产科提高护理质量及护理满意度的影响

目的探讨与分析多方位护理管理在产科护理工作中的应用效果。方法搜集2018年1月-2019年1月期间前来该院产科就诊116例产妇为研究对象,根据护理管理方案划分为参照组(传统护理)、研究组(多方位护理管理),各58例,统计两组产妇实施管理后护理质量评分、生活质量评分、护理纠纷及护理满意度情况,并予以评估。结果研究组基础护理、产前护理、产后护理、针对性护理及整体护理指标评分分别高于参照组,差异有统计学意义(P<0.05);研究组躯体疼痛、生理功能、生理职能、社会功能、情感职能及精神健康有关生活质量评分均优于参照组(P<0.05);研究组护理工作满意度、护理纠纷率分别为(96.55%)、(3.45%),均与参照组护理工作满意度(82.76%)、护理纠纷率为(15.52%)比较,差异有统计学意义(P<0.05)。结论针对产科护理管理中实施多方位护理管理模式可有效提高护理质量及护理满意度,降低护理纠纷事件,可作为首选的护理管理办法。     

The Negative Impact of Psychotropic Drug Use on Quality of Life in Nursing Home Patients at Different Stages of Dementia: Cross-Sectional Analyses from the COSMOS Trial

ObjectivesThe quality of life (QoL) in nursing home (NH) patients with dementia is threatened by neuropsychiatric symptoms. This may trigger the use of psychotropic drugs, yet it is unknown if this practice improves the QoL. We investigated the association between the number of psychotropic drugs and QoL at different stages of dementia, adjusted for neuropsychiatric symptoms.DesignCross-sectional analysis of baseline data from the COSMOS study, a multicenter, cluster-randomized, single-blinded, controlled trial.Setting and ParticipationFour hundred thirty-one patients (aged ≥65 years) with and without dementia from 33 Norwegian NHs comprising 67 wards.MeasuresQoL assessed by Quality of Life in Late Stage Dementia (QUALID) and Quality of Life in Dementia (QUALIDEM), neuropsychiatric symptoms by Neuropsychiatric Inventory–Nursing Home version, and cognition by Mini-Mental State Examination.ResultsAt least 1 psychotropic drug was prescribed to 71% of the 431 participants included in the final sample. We estimated the trend in mean QoL scores over the number of psychotropic drugs in patients with clinical significant neuropsychiatric symptom load. QoL assessed by QUALID and QUALIDEM decreased by increasing number of psychotropic drugs (P < .001). No psychotropic drugs (mean QUALID score 20 ± 0.5, mean QUALIDEM score 40 ± 8.1) compared to ≥3 psychotropic drug (mean QUALID score 25 ± 7.8, mean QUALIDEM score 33 ± 8.0). This association was evident in mild, moderate, and severe dementia but absent in people without dementia. Use of antidepressant agents in mild and moderate dementia was associated with increased QoL compared with no use of antidepressant agents.Conclusions and ImplicationsOverall, our findings suggest that psychotropic drugs might pose a threat to QoL in NH patients at all stages of dementia, possibly with the exception of use of antidepressant agents in mild to moderate dementia. This underlines the need for updated knowledge on psychopharmacologic treatment and implementation of procedures for maintaining QoL in dementia care facilities.     

Serious Mental Illness and Nursing Home Quality of Care

Objective

To estimate the effect of a nursing home''s share of residents with a serious mental illness (SMI) on the quality of care.

Data Sources

Secondary nursing home level data over the period 2000 through 2008 obtained from the Minimum Data Set, OSCAR, and Medicare claims.

Study Design

We employ an instrumental variables approach to address the potential endogeneity of the share of SMI residents in nursing homes in a model including nursing home and year fixed effects.

Principal Findings

An increase in the share of SMI nursing home residents positively affected the hospitalization rate among non-SMI residents and negatively affected staffing skill mix and level. We did not observe a statistically significant effect on inspection-based health deficiencies or the hospitalization rate for SMI residents.

Conclusions

Across the majority of indicators, a greater SMI share resulted in lower nursing home quality. Given the increased prevalence of nursing home residents with SMI, policy makers and providers will need to adjust practices in the context of this new patient population. Reforms may include more stringent preadmission screening, new regulations, reimbursement changes, and increased reporting and oversight.     

精细化护理管理对提高神经内科护理质量的效果分析

目的探究在神经内科实施精细化护理管理对提高护理质量产生的影响。方法选取84例在2018年6月—2019年6月该院神经内科收治的患者,根据随机数字法分为观察组(精细化护理管理)和对照组(常规管理),各42例。比较两组不良事件发生和护理质量评分情况。结果与对照组(40.48%)相比,观察组不良事件发生率(14.28%)较低(P<0.05),且观察组护理质量评分较高(P<0.05)。结论在神经内科实施精细化护理管理,可以使不良事件发生率明显降低,提高护理质量水平,具有较显著的临床价值。     

The Effect of State Regulatory Stringency on Nursing Home Quality

Objective

To test the hypothesis that more stringent quality regulations contribute to better quality nursing home care and to assess their cost-effectiveness.

Data Sources/Setting

Primary and secondary data from all states and U.S. nursing homes between 2005 and 2006.

Study Design

We estimated seven models, regressing quality measures on the Harrington Regulation Stringency Index and control variables. To account for endogeneity between regulation and quality, we used instrumental variables techniques. Quality was measured by staffing hours by type per case-mix adjusted day, hotel expenditures, and risk-adjusted decline in activities of daily living, high-risk pressure sores, and urinary incontinence.

Data Collection

All states'' licensing and certification offices were surveyed to obtain data about deficiencies. Secondary data included the Minimum Data Set, Medicare Cost Reports, and the Economic Freedom Index.

Principal Findings

Regulatory stringency was significantly associated with better quality for four of the seven measures studied. The cost-effectiveness for the activities-of-daily-living measure was estimated at about 72,000 in 2011/ Quality Adjusted Life Year.

Conclusions

Quality regulations lead to better quality in nursing homes along some dimensions, but not all. Our estimates of cost-effectiveness suggest that increased regulatory stringency is in the ballpark of other acceptable cost-effective practices.     

International Survey of Nursing Home Research Priorities

This article reports the findings of a policy survey designed to establish research priorities to inform future research strategy and advance nursing home practice. The survey was administered in 2 rounds during 2013, and involved a combination of open questions and ranking exercises to move toward consensus on the research priorities. A key finding was the prioritization of research to underpin the care of people with cognitive impairment/dementia and of the management of the behavioral and psychological symptoms of dementia within the nursing home. Other important areas were end-of-life care, nutrition, polypharmacy, and developing new approaches to putting evidence-based practices into routine practice in nursing homes. It explores possible innovative educational approaches, reasons why best practices are difficult to implement, and challenges faced in developing high-quality nursing home research.     

Nursing Home Design and COVID-19: Balancing Infection Control,Quality of Life,and Resilience

Many nursing home design models can have a negative impact on older people and these flaws have been compounded by Coronavirus Disease 2019 and related infection control failures. This article proposes that there is now an urgent need to examine these architectural design models and provide alternative and holistic models that balance infection control and quality of life at multiple spatial scales in existing and proposed settings. Moreover, this article argues that there is a convergence on many fronts between these issues and that certain design models and approaches that improve quality of life, will also benefit infection control, support greater resilience, and in turn improve overall pandemic preparedness.     

护理质量考核在提升护理质量管理中的效果分析

目的创新的护理质量管理方法可以提升护理工作质量,为患者提供高质量的优质护理服务。方法制订包括护理核心制度执行、护理服务与安全质量管理、护理病历书写质量、病人护理质量四大项内容的18项子项护理质量考核细则,每月汇总形成各护理单元护理质量考核成绩,产生各护理单元的月度护理质量绩效奖。结果实施3年,医院护理质量考核平均成绩有较大幅度的提升,护士质量管理意识增强,护理不良事件明显减少。结论从考核体系的形成、考核指标的达成和修改、质控的实施和评价反馈、问题追踪和整改整个过程中,发挥了护士长及每一位护士的作用和潜能,保证了护理工作的及时性、正确性和完整性。     

The Association Between Quality of Care and Quality of Life in Long-Stay Nursing Home Residents With Preserved Cognition

ObjectivesTo assess the overall quality of life of long-stay nursing home residents with preserved cognition, to examine whether the Centers for Medicare and Medicaid Service's Nursing Home Compare 5-star quality rating system reflects the overall quality of life of such residents, and to examine whether residents' demographics and clinical characteristics affect their quality of life.Design/measurementsQuality of life was measured using the Participant Outcomes and Status Measures—Nursing Facility survey, which has 10 sections and 63 items. Total scores range from 20 (lowest possible quality of life) to 100 (highest).Setting/participantsLong-stay nursing home residents with preserved cognition (n = 316) were interviewed.ResultsThe average quality- of-life score was 71.4 (SD: 7.6; range: 45.1–93.0). Multilevel regression models revealed that quality of life was associated with physical impairment (parameter estimate = −0.728; P = .04) and depression (parameter estimate = −3.015; P = .01) but not Nursing Home Compare's overall star rating (parameter estimate = 0.683; P = .12) and not pain (parameter estimate = −0.705; P = .47).ConclusionThe 5-star quality rating system did not reflect the quality of life of long-stay nursing home residents with preserved cognition. Notably, pain was not associated with quality of life, but physical impairment and depression were.     

Nursing Home Control of Physician Resources

ObjectivePhysician services are increasingly recognized as important contributors to quality care provision in nursing homes (NH)s, but knowledge of ways in which NHs manage/control physician resources is lacking.DataPrimary data from surveys of NH administrators and directors of nursing from a nationally representative sample of 1938 freestanding United States NHs in 2009–2010 matched to Online Survey Certification and Reporting, aggregated NH Minimum Data Set assessments, Medicare claims, and county information from the Area Resource File.MethodsThe concept of NH Control of Physician Resources (NHCOPR) was measured using NH administrators' reports of management implementation of rules, policies, and procedures aimed at coordinating work activities. The NHCOPR scale was based on measures of formal relationships, physician oversight and credentialing. Scale values ranged from weakest (0) to tightest (3) control. Several hypotheses of expected associations between NHCOPR and other measures of NH and market characteristics were tested.ResultsThe full NHCOPR score averaged 1.58 (standard deviation = 0.77) on the 0–3 scale. Nearly 30% of NHs had weak control (NHCOPR ≤1), 47.5% had average control (NHCOPR between 1 and 2), and the remaining 24.8% had tight control (NHCOPR >2). NHCOPR exhibited good face- and predictive-validity as exhibited by positive associations with more beds, more Medicare services, cross coverage, and number of physicians in the market.ConclusionsThe NHCOPR scale capturing NH's formal structure of control of physician resources can be useful in studying the impact of NH's physician resources on residents' outcomes with potential for targeted interventions by education and promotion of NH administration regarding physician staff.     

The Course of Quality of Life and Its Predictors in Nursing Home Residents With Young-Onset Dementia

ObjectiveTo explore the course of quality of life (QoL) and possible resident-related predictors associated with this course in institutionalized people with young-onset dementia (YOD).DesignAn observational longitudinal study.Setting and ParticipantsA total of 278 residents with YOD were recruited from 13 YOD special care units in the Netherlands.MethodsSecondary analyses were conducted with longitudinal data from the Behavior and Evolution in Young-ONset Dementia (BEYOND)-II study. QoL was assessed with proxy ratings, using the Quality of Life in Dementia (QUALIDEM) questionnaire at 4 assessment points over 18 months. Predictors included age, gender, dementia subtype, length of stay, dementia severity, neuropsychiatric symptoms, and psychotropic drug use at baseline. Multilevel modeling was used to adjust for the correlation of measurements within residents and clustering of residents within nursing homes.ResultsThe total QUALIDEM score (range: 0-111) decreased over 18 months with a small change of 0.65 (95% confidence interval −1.27, −0.04) points per 6 months. An increase in several domains of QoL regarding care relationship, positive self-image, and feeling at home was seen over time, whereas a decline was observed in the subscales positive affect, social relations, and having something to do. Residents with higher levels of QoL and more advanced dementia at baseline showed a more progressive decline in QoL over time. Sensitivity analyses indicated a more progressive decline in QoL for residents who died during the follow-up.Conclusion and ImplicationsThis study shows that although overall QoL in nursing home residents with YOD was relatively stable over 18 months, there were multidirectional changes in the QoL subscales that could be clinically relevant. Higher levels of QoL and more advanced stages of dementia at baseline predicted a more progressive decline in QoL over time. More longitudinal studies are needed to verify factors influencing QoL in YOD.     

Dysphagia in Nursing Home Residents: Management and Outcomes

Objectives

To define the prevalence of dysphagia and its associated factors and to investigate the influence of dysphagia and nutritional therapies performed in dysphagic subjects on clinical outcomes, including nutritional status, pressure ulcers, hospitalization, and mortality.