Darcy M. Moudouni

Asymptomatic bacteriuria, antibiotic use, and suspected urinary tract infections in four nursing homes

BackgroundUrinary tract infections (UTIs) are the most commonly treated infection among nursing home residents. Even in the absence of specific (e.g., dysuria) or non-specific (e.g., fever) signs or symptoms, residents frequently receive an antibiotic for a suspected infection. This research investigates factors associated with the use of antibiotics to treat asymptomatic bacteriuria (ASB) among nursing home residents.MethodsThis was a cross-sectional study involving multi-level multivariate analyses of antibiotic prescription data for residents in four nursing homes in central Texas. Participants included all nursing home residents in these homes who, over a six-month period, received an antibiotic for a suspected UTI. We investigated what factors affected the likelihood that a resident receiving an antibiotic for a suspected UTI was asymptomatic.ResultsThe most powerful predictor of antibiotic treatment for ASB was the presence of an indwelling urinary catheter. Over 80 percent of antibiotic prescriptions written for catheterized individuals were written for individuals with ASB. For those without a catheter, record reviews identified 204 antibiotic prescriptions among 151 residents treated for a suspected UTI. Almost 50% of these prescriptions were for residents with no documented UTI symptoms. Almost three-quarters of these antibiotics were ordered after laboratory results were available to clinicians. Multivariate analyses indicated that resident characteristics did not affect the likelihood that an antibiotic was prescribed for ASB. The only statistically significant factor was the identity of the nursing home in which a resident resided.ConclusionsWe confirm the findings of earlier research indicating frequent use of antibiotics for ASB in nursing homes, especially for residents with urinary catheters. In this sample of nursing home residents, half of the antibiotic prescriptions for a suspected UTI in residents without catheters occurred with no documented signs or symptoms of a UTI. Urine studies were performed in almost all suspected UTI cases in which an antibiotic was prescribed. Efforts to improve antibiotic stewardship in nursing homes must address clinical decision-making solely on the basis of diagnostic testing in the absence of signs or symptoms of a UTI.

Factors Associated With Successful Completion of the Chronic Disease Self-Management Program by Adults With Type 2 Diabetes

This study examines factors associated with completion (attendance ≥4 of 6 sessions) of the Chronic Disease Self-Management Program (CDSMP) by adults with type 2 diabetes. Patients with glycated hemoglobin ≥ 7.5 within 6 months were enrolled and completed self-report measures on demographics, health status, and self-care (n = 146). Significant differences in completion status were found for several self-care factors including healthful eating plan, spacing carbohydrates, frequent exercise, and general health. Completion was not influenced by race/ethnicity or socioeconomics. Results suggest better attention to exercise and nutrition at the start of CDSMP may be associated with completion, regardless of demographic subgroup.

Self-reported physical and mental health of older adults: The roles of caregiving and resources

OBJECTIVES This study examined factors associated with self-reported physical and mental health, focusing on caregiving status and the availability of social supports and financial resources. METHODS Two bivariate analyses were performed to examine the sociodemographic characteristics as well as perceived health outcomes among caregiving and non-caregiving participants. Two-equation probit models were used to determine independent predictors of self-reported physical and mental health, using data from 1071 community-based adults (≥ 60 years). An additional bivariate analysis was conducted to investigate the characteristics of caregivers who reported better physical health. RESULTS Approximately 17% (n=183) of respondents reported being caregivers, and those in caregiving roles tended to be ethnic minorities, married, and have telephone communication with family or friends on a daily basis. Better physical and mental health outcomes were common for caregivers and non-caregivers who reported having more resources (e.g., higher income, better preparedness for future financial need, higher satisfaction with transportation and housing, and no limitation of usual daily activities). However, sociodemographic and social support factors were not significantly associated with physical and mental health among caregivers, unlike their non-caregiver counterparts. In the probit model, caregivers were more likely to be physically healthy compared to non-caregivers (Coefficient=0.34; p-value=0.031). Compared with healthy non-caregivers (n=631), healthy caregivers (n=141) tended to be ethnic minorities, married, and have telephone communication with family or friends on a daily basis. CONCLUSIONS Findings suggest that preparing resources and maintaining strong social support systems may foster health status among older family caregivers.

The relationship between formal and informal care among adult Medicaid Personal Care Services recipients.

OBJECTIVES To test hypotheses concerning the relationship between formal and informal care and to estimate the impact of hours of formal care authorized for Medicaid Personal Care Services (PCS) on the utilization of informal care. DATA SOURCES/STUDY SETTING Data included home care use and adult Medicaid beneficiary characteristics from assessments of PCS need in four Medicaid administrative areas in Texas. STUDY DESIGN Cross-sectional design using ordinary least-squares (OLS) and instrumental variable (IV) methods. DATA COLLECTION/EXTRACTION METHODS The study database consisted of assessment data on 471 adults receiving Medicaid PCS from 2004 to 2006. PRINCIPAL FINDINGS Both OLS and IV estimates of the impact of formal care on informal care indicated no statistically significant relationship. The impact of formal care authorized on informal care utilization was less important than the influence of beneficiary need and caregiver availability. Living with a potential informal caregiver dramatically increased the hours of informal care utilized by Medicaid PCS beneficiaries. CONCLUSIONS More formal home care hours were not associated with fewer informal home care hours. These results imply that policies that decrease the availability of formal home care for Medicaid PCS beneficiaries will not be offset by an increase in the provision of informal care and may result in unmet care needs.

In-Hospital Mortality and Unintentional Falls Among Older Adults in the United States

Purpose of the Study: To estimate the odds of death associated with documented unintentional falls and acute care hospitalization among older adults in the United States. Design and Method: Data were abstracted from the 2005 Nationwide Inpatient Sample (NIS) and odds of death were modeled using logistic regression. Results: The age 65 and older fall rate per 1,000 discharges was 53.0 while the mortality rate for those who fell was 33.2. Older-old (odds ration [OR] = 2.93; confidence interval [CI] = [2.50, 3.43]), men (OR = 1.64, CI = [1.54, 1.75]), and non-White (OR = 1.09; CI = [1.01, 1.19]) had higher odds of death compared to younger-old, women, and Whites. Additional comorbidity (OR = 3.41, CI = [3.05, 3.82]), dehydration (OR = 1.14; CI = [1.05, 1.25]) and intracranial fractures (OR = 4.46; CI = [4.02, 4.95]) resulted in greater odds of death. Implications: Among older adults who experienced a fall and hospitalization, odds of mortality appear influenced by factors beyond injury severity related to falling. Additional research is necessary to delineate the mechanisms behind these phenomena to inform the public about falls-prevention programs.

Nursing Homes and the Affordable Care Act: A Cease Fire in the Ongoing Struggle Over Quality Reform

Most provisions in the Affordable Care Act that affect nursing homes originated in two earlier attempts at reform, both of which failed multiple times in prior Congressional sessions: the Elder Justice Act and the Nursing Home Transparency and Improvement Act. Both of these earlier efforts focused on improving quality and reducing elder abuse in nursing homes by strengthening oversight and enforcement penalties, expanding staff training, and increasing the information on nursing home quality available to consumers and regulators. Each bill addressed problems that were serious, widespread, and had persisted for years, but each failed to pass on its own. The Affordable Care Act, with its own momentum, became the vehicle for their passage. However, the reasons the bills failed in these earlier efforts suggest implementation challenges now that they have ridden into law on the coattails of the more general effort to reform the health care sector.