Gary H. Brandeis

A longitudinal study of risk factors associated with the formation of pressure ulcers in nursing homes.

Objective: To determine risk factors associated with the formation of stage II—IV pressure ulcers in nursing homes.

The Prevalence of Potentially Remediable Urinary Incontinence in Frail Older People: A Study Using the Minimum Data Set

OBJECTIVES: To use the Minimum Data Set (MDS) to describe the frequency and correlates of potentially treatable causes of urinary incontinence among a representative sample of American nursing home residents. To describe current management practices of urinary incontinence in the same population.

Rating long-term care facilities on pressure ulcer development : Importance of case-mix adjustment

Health care providers, regulators, quality managers, and consumers are increasingly interested in rating facilities on outcomes of patient care [1, 2]. Such information is widely disseminated through report cards [3] and government releases [4] and often appears in the lay press. Some health care organizations may use these ratings to limit reimbursements and practice opportunities for providers with poor grades [1, 2]. Alternatively, when provided regularly to individual facilities, these ratings can give important feedback for improving quality [5]. Large administrative databases are a particularly useful source of information on health outcomes and have been used extensively for rating short-term hospital care [4, 6]. Studies have shown, however, that case-mix adjustment is essential for interpreting these hospital rates [7-9]. Although large administrative databases have rarely been used in rating long-term care facilities [10], their use for this purpose will probably increase with the availability of new data sources. However, the need for case-mix adjustment in this setting has not been examined. Pressure ulcer development is an important outcome measure in long-term care [11, 12] because it is a common, preventable, and potentially serious adverse event that may substantially affect health and survival [13-15]. The Department of Veterans Affairs currently uses its administrative databases to calculate and disseminate facility-level rates of pressure ulcer development for its long-term care facilities. Facilities with high rates are encouraged to examine their practices and implement preventive interventions. However, these incidence rates do not consider the case mix of residents of individual facilities. Thus, facilities cannot determine whether a high rate is caused by poor quality of care or by care of a frailer and more functionally impaired population. We used Veterans Affairs administrative files to examine the effect of case-mix adjustment in comparing facility-level rates for pressure ulcers. Specifically, we 1) identified clinical and functional status variables that predict pressure ulcer development in residents of Veterans Affairs long-term care institutions; 2) evaluated the performance properties of a prediction model based on these factors; 3) used this model to measure differences in case mix among Veterans Affairs long-term care facilities; and 4) examined whether case-mix adjustment results in perceptions about the performance of individual facilities that differ from perceptions based on unadjusted rates. Our study shows the way in which existing administrative data can be used to monitor case-mix-adjusted outcomes for long-term care. Methods Database We used the Department of Veterans Affairs Patient Assessment File, which was developed for case-mix-based reimbursements for long-term care on the basis of Resource Utilization Groups [16]. The Patient Assessment File contains demographic, diagnostic, and functional information on all patients receiving long-term care. Data are collected by local staff at each facility semiannually on 1 April and 1 October of each year. The form is also completed at the time of admission or transfer to one of these units. If the date of admission is within 1 week of the semiannual evaluation, only one entry is likely to be made. Assessments are guided by an instruction manual. The Patient Assessment File records whether a patient had a pressure ulcer on the evaluation date and, if so, the stage of the largest ulcer. Pressure ulcers are staged on a scale of 1 to 5 as follows: stage 1, erythematous skin; stage 2, a superficial layer of broken or blistered skin; stage 3, involvement of subcutaneous tissues; stage 4, extension to muscle or bone; and stage 5, stage 4 ulcers for which no treatment plan is documented in the medical record. For our study, we combined stages 4 and 5. Additional information is present in specific sections of the Patient Assessment File. The administrative data section includes sex, year of birth, whether the assessment was for a new admission or was one of the semiannual assessments, the treating facility, and the bed section. The bed section may be either nursing home or intermediate medicine; residents of the latter have various needs, including short-course rehabilitation and long-term interventions more intensive than those provided in a typical nursing home. The medical treatments section of the Patient Assessment File records whether residents are receiving specific interventions, such as oxygen therapy, respiratory care, tube feedings, care of non-pressure ulcer wounds, dialysis, chemotherapy, and radiation therapy. The medical events section identifies specific conditions present during the previous 4 weeks, including dehydration, internal bleeding, stasis ulcer, and terminal illness. The selected diagnoses section documents whether residents have multiple sclerosis, urinary tract infection, hemiplegia, or quadriplegia. The activities of daily living section, consisting of data on eating, mobility, transfer, and toileting, has been fully described elsewhere [17]. In brief, each activity of daily living is rated on a scale of 1 to 5; 1 indicates no need for supervision or physical assistance, and 5 indicates complete dependence. For toileting, however, we reversed scores 4 (patient has bowel or bladder incontinence and is not taken to a toilet) and 5 (patient has bowel or bladder incontinence but is taken to a toilet every 2 to 4 hours), because we believed that a score of 4 indicated greater risk for the development of pressure ulcers. Other sections of the Patient Assessment File used in our study were those on behaviors (presence of verbal disruption, physical aggression, disruptive behavior, and hallucinations) and specialized services (receipt of rehabilitation services, including physical, occupational, corrective, manual arts, and educational therapies). Study Samples If consecutive entries for the same person are linked within the database, patients may be followed for changes in health status. We developed two such samples for our study, one for model derivation and the other for model validation. We created the derivation sample by merging three consecutive 6-month periods from the Patient Assessment File: the periods ending 1 April 1992, 1 October 1992, and 1 April 1993. Within each period, each newly admitted or continuing care patient was eligible to contribute a case to the derivation sample only if he or she had not had a stage 2 or greater pressure ulcer at the initial evaluation and remained institutionalized as of the semiannual assessment that ended the period. Thus, cases in the sample were followed for different amounts of time, to a maximum of 6 months. For patients with eligible data in more than one of the three periods, one period was selected randomly; no patient contributed more than one case to the derivation sample. The validation sample drew cases from the single 6-month period ending 1 October 1993. The included cases had no ulcer at initial assessment and remained institutionalized as of 1 October 1993. Selection of Study Variables Because stage 1 ulcers often do not advance to a more serious lesion with appropriate interventions [15], we followed the usual practice of not counting them as outcome events [18-20]. Thus, the outcome event was defined as a new stage 2 or greater pressure ulcer at the period-ending evaluation. Potential predictors of pressure ulcer development were identified from the Patient Assessment File. We evaluated each variable in the file for evidence from the literature showing an association with pressure ulcer development or a clinically plausible association between that variable and known risk factors such as immobility, poor nutrition, and medical illness [13-15]. Only variables with such evidence were included in subsequent analyses. Because stage 1 ulcers are associated with the development of larger ulcers [21], we included the presence of stage 1 ulcers as a potential predictor. Additionally, because the clinical literature has suggested that recency of admission may be an important predictor [22-24], we captured this variable by dividing patients into four groups. We defined cases in group 1 as new admissions institutionalized for less than 2 months between their initial and follow-up assessments; group 2, for 2 to less than 4 months; and group 3, for 4 to less than 6 months. Group 4 consisted of continuing care patients who had been institutionalized for a full 6 months between assessments. We also examined whether predictors of pressure ulcer development differ between patients in intermediate medicine and those in nursing homes and whether incontinence is a stronger predictor in patients with greater immobility. However, because interaction terms were weakly associated with pressure ulcer development, we have not included them in the analyses presented here. Predictors of Pressure Ulcer Development We identified predictors of pressure ulcer development from the derivation sample. We did bivariate testing, including chi-square tests for ordinal variables and t-tests for continuous variables, to identify candidate variables associated with pressure ulcers. We also examined variables with more than two levels of risk to ensure that increasing levels of that variable were associated with a greater risk for pressure ulcer development. Variables significantly (P < 0.1) associated with pressure ulcers in the derivation sample were entered into a logistic regression model to identify independent predictors (P < 0.05). Analyses were done using the Statistical Analysis System, Version 6 (SAS Institute, Cary, North Carolina). Evaluation of Model Performance We evaluated the performance of the logistic model first in the derivation sample and then by applying it (using the same coefficients) to the validation sample. Each sample was divided into deciles of increasin

Are we improving the quality of nursing home care : The case of pressure ulcers

BACKGROUND: There are widespread concerns regarding the quality of nursing home care and whether care is improving. We evaluated a large provider of nursing home care to determine whether risk‐adjusted rates of pressure ulcer development have changed.

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.

Predictors of Pressure Ulcer Healing Among Long‐Term Care Residents

OBJECTIVES: To identify predictors of pressure ulcer healing among long‐term care residents.

Evaluating a national assessment strategy for urinary incontinence in nursing home residents: Reliability of the minimum data set and validity of the resident assessment protocol

Evaluation of 1 million incontinent American nursing home residents is hampered by both failure to detect incontinence and logistical barriers to diagnostic testing. The nationally mandated Minimum Data Set (MDS) and Resident Assessment Protocol (RAP) were devised to address these deficiencies. Although both instruments are also used in at least 18 other countries, neither has been evaluated. Our goal was to determine the reliability of the MDS and the accuracy of the RAP in predicting the lower urinary tract cause of incontinence.

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.

Misdiagnosis of urinary incontinence in nursing home women: prevalence and a proposed solution.

Because of the high prevalence of detrusor hyperactivity with impaired contractility (DHIC) in incontinent institutionalized women, we postulated that: 1) single‐channel cystometry, the most commonly used diagnostic test, would be inadequate when used alone but that 2) its accuracy could be greatly enhanced by combining it with a previously‐performed stress test. To test the hypothesis, we used blinded comparison of a clinical stress test and single‐channel cystometry with multichannel videourodynamic evaluation (criterion standard), a strategy designed a priori. Subjects were 97 incontinent women who were considered representative of incontinent nursing home women nationally. With cystometry alone, 9 of 37 women with DHIC (24%) were misdiagnosed as stress‐incontinent vs. 1 of 25 with DH (P = .03). In each case, misdiagnosis was due to failure to recognize low‐pressure involuntary bladder contractions. Combining cystometry with the stress test improved diagnostic accuracy markedly. Of the 77% of women in whom the results of both tests were congruent, all were correctly classified. When results of the two tests were discordant, neither was superior. Significantly, no woman with stress incontinence was missed by the two‐test strategy, nor was anyone with detrusor hyperactivity misclassified. We conclude that in institutionalized elderly women, DHIC commonly mimics other types of urinary tract dysfunction. Thus, single‐channel cystometry alone is an inadequate diagnostic test in this population. However, a strategy that combines cystometry with a clinical stress test can correctly classify the majority of such women and identify those in whom the diagnosis is less secure. Use of this simple strategy would facilitate correct diagnosis and initial treatment of most institutionalized women without referral, and also enrich the referred population with those most likely to benefit. Such an approach could significantly improve the approach to this costly and morbid condition.

An exploration of job design in long-term care facilities and its effect on nursing employee satisfaction.

Abstract: This study used quantitative and qualitative methods to examine the design of nursing jobs in long-term care facilities and the effect of job design on employee satisfaction.