Jeffrey W. Poss

A review of evidence on the reliability and validity of Minimum Data Set data

This paper reviews the reliability and validity of the Minimum Data Set (MDS) assessment, which is being used increasingly in Canadian nursing homes and continuing care facilities. The central issues that surround the development and implementation of a standardized assessment such as the MDS are presented, including implications for health care managers in how to approach data quality concerns. With other sectors such as home care and inpatient psychiatry using MDS for national reporting, these issues have importance in and beyond residential care management.

Validation of Resource Utilization Groups version III for Home Care (RUG-III/HC): evidence from a Canadian home care jurisdiction.

Background:The case-mix system Resource Utilization Groups version III for Home Care (RUG-III/HC) was derived using a modest data sample from Michigan, but to date no comprehensive large scale validation has been done. Objectives:This work examines the performance of the RUG-III/HC classification using a large sample from Ontario, Canada. Methods:Cost episodes over a 13-week period were aggregated from individual level client billing records and matched to assessment information collected using the Resident Assessment Instrument for Home Care, from which classification rules for RUG-III/HC are drawn. The dependent variable, service cost, was constructed using formal services plus informal care valued at approximately one-half that of a replacement worker. Results:An analytic dataset of 29,921 episodes showed a skewed distribution with over 56% of cases falling into the lowest hierarchical level, reduced physical functions. Case-mix index values for formal and informal cost showed very close similarities to those found in the Michigan derivation. Explained variance for a function of combined formal and informal cost was 37.3% (20.5% for formal cost alone), with personal support services as well as informal care showing the strongest fit to the RUG-III/HC classification. Conclusions:RUG-III/HC validates well compared with the Michigan derivation work. Potential enhancements to the present classification should consider the large numbers of undifferentiated cases in the reduced physical function group, and the low explained variance for professional disciplines.

Adjustment of nursing home quality indicators

BackgroundThis manuscript describes a method for adjustment of nursing home quality indicators (QIs) defined using the Center for Medicaid & Medicare Services (CMS) nursing home resident assessment system, the Minimum Data Set (MDS). QIs are intended to characterize quality of care delivered in a facility. Threats to the validity of the measurement of presumed quality of care include baseline resident health and functional status, pattern of comorbidities, and facility case mix. The goal of obtaining a valid facility-level estimate of true quality of care should include adjustment for resident- and facility-level sources of variability.MethodsWe present a practical and efficient method to achieve risk adjustment using restriction and indirect and direct standardization. We present information on validity by comparing QIs estimated with the new algorithm to one currently used by CMS.ResultsMore than half of the new QIs achieved a Moderate validation level.ConclusionsGiven the comprehensive approach and the positive findings to date, research using the new quality indicators is warranted to provide further evidence of their validity and utility and to encourage their use in quality improvement activities.

Acute care inpatients with long-term delayed-discharge: evidence from a Canadian health region

BackgroundAcute hospital discharge delays are a pressing concern for many health care administrators. In Canada, a delayed discharge is defined by the alternate level of care (ALC) construct and has been the target of many provincial health care strategies. Little is known on the patient characteristics that influence acute ALC length of stay. This study examines which characteristics drive acute ALC length of stay for those awaiting nursing home admission.MethodsPopulation-level administrative and assessment data were used to examine 17,111 acute hospital admissions designated as alternate level of care (ALC) from a large Canadian health region. Case level hospital records were linked to home care administrative and assessment records to identify and characterize those ALC patients that account for the greatest proportion of acute hospital ALC days.ResultsALC patients waiting for nursing home admission accounted for 41.5% of acute hospital ALC bed days while only accounting for 8.8% of acute hospital ALC patients. Characteristics that were significantly associated with greater ALC lengths of stay were morbid obesity (27u2009day mean deviation, 99% CIu2009=u2009±14.6), psychiatric diagnosis (13u2009day mean deviation, 99% CIu2009=u2009±6.2), abusive behaviours (12u2009day mean deviation, 99% CIu2009=u2009±10.7), and stroke (7u2009day mean deviation, 99% CIu2009=u2009±5.0). Overall, persons with morbid obesity, a psychiatric diagnosis, abusive behaviours, or stroke accounted for 4.3% of all ALC patients and 23% of all acute hospital ALC days between April 1st 2009 and April 1st, 2011. ALC patients with the identified characteristics had unique clinical profiles.ConclusionsA small number of patients with non-medical days waiting for nursing home admission contribute to a substantial proportion of total non-medical days in acute hospitals. Increases in nursing home capacity or changes to existing funding arrangements should target the sub-populations identified in this investigation to maximize effectiveness. Specifically, incentives should be introduced to encourage nursing homes to accept acute patients with the least prospect for community-based living, while acute patients with the greatest prospect for community-based living are discharged to transitional care or directly to community-based care.

An evaluation of data quality in Canada's Continuing Care Reporting System (CCRS): secondary analyses of Ontario data submitted between 1996 and 2011.

BackgroundEvidence informed decision making in health policy development and clinical practice depends on the availability of valid and reliable data. The introduction of interRAI assessment systems in many countries has provided valuable new information that can be used to support case mix based payment systems, quality monitoring, outcome measurement and care planning. The Continuing Care Reporting System (CCRS) managed by the Canadian Institute for Health Information has served as a data repository supporting national implementation of the Resident Assessment Instrument (RAI 2.0) in Canada for more than 15xa0years. The present paper aims to evaluate data quality for the CCRS using an approach that may be generalizable to comparable data holdings internationally.MethodsData from the RAI 2.0 implementation in Complex Continuing Care (CCC) hospitals/units and Long Term Care (LTC) homes in Ontario were analyzed using various statistical techniques that provide evidence for trends in validity, reliability, and population attributes. Time series comparisons included evaluations of scale reliability, patterns of associations between items and scales that provide evidence about convergent validity, and measures of changes in population characteristics over time.ResultsData quality with respect to reliability, validity, completeness and freedom from logical coding errors was consistently high for the CCRS in both CCC and LTC settings. The addition of logic checks further improved data quality in both settings. The only notable change of concern was a substantial inflation in the percentage of long term care home residents qualifying for the Special Rehabilitation level of the Resource Utilization Groups (RUG-III) case mix system after the adoption of that system as part of the payment system for LTC.ConclusionsThe CCRS provides a robust, high quality data source that may be used to inform policy, clinical practice and service delivery in Ontario. Only one area of concern was noted, and the statistical techniques employed here may be readily used to target organizations with data quality problems in that (or any other) area. There was also evidence that data quality was good in both CCC and LTC settings from the outset of implementation, meaning data may be used from the entire time series. The methods employed here may continue to be used to monitor data quality in this province over time and they provide a benchmark for comparisons with other jurisdictions implementing the RAI 2.0 in similar populations.

Use of the interRAI CHESS Scale to Predict Mortality among Persons with Neurological Conditions in Three Care Settings

Background Persons with certain neurological conditions have higher mortality rates than the population without neurological conditions, but the risk factors for increased mortality within diagnostic groups are less well understood. The interRAI CHESS scale has been shown to be a strong predictor of mortality in the overall population of persons receiving health care in community and institutional settings. This study examines the performance of CHESS as a predictor of mortality among persons with 11 different neurological conditions. Methods Survival analyses were done with interRAI assessments linked to mortality data among persons in home care (nu200a=u200a359,940), complex continuing care hospitals/units (nu200a=u200a88,721), and nursing homes (nu200a=u200a185,309) in seven Canadian provinces/territories. Results CHESS was a significant predictor of mortality in all 3 care settings for the 11 neurological diagnostic groups considered after adjusting for age and sex. The distribution of CHESS scores varied between diagnostic groups and within diagnostic groups in different care settings. Conclusions CHESS is a valid predictor of mortality in neurological populations in community and institutional care. It may prove useful for several clinical, administrative, policy-development, evaluation and research purposes. Because it is routinely gathered as part of normal clinical practice in jurisdictions (like Canada) that have implemented interRAI assessment instruments, CHESS can be derived without additional need for data collection.

Dying in a nursing home: treatable symptom burden and its link to modifiable features of work context.

IMPORTANCEnHigh-quality care at the end of life supports freedom from pain and other potentially burdensome symptoms. Lowering symptom burden at the end of life is an urgent and achievable goal in delivering services in nursing home settings. Few published reports describe symptom burden among older adults in nursing homes; none examine links between symptom burden and modifiable features of nursing home organizational context (work environment).nnnOBJECTIVESnTo examine the influence of organizational context on symptom burden and to compare symptom burden in the last year of life between nursing home residents with and without dementia.nnnDESIGNnRetrospective analysis of longitudinal survey data.nnnSETTINGnA stratified random sample of 36 nursing homes in the Canadian provinces of Alberta, Manitoba, and Saskatchewan.nnnPARTICIPANTSnA total of 2635 residents with dementia and 1012 without dementia; 1381 front-line care staff.nnnMEASUREMENTSn(1) Trajectories of 6 symptoms (dyspnea, pain, pressure ulcers, urinary tract infections, challenging behavior, delirium), assessed with the Resident Assessment Instrument-Minimum Data Set, version 2.0, between 2008 and 2012. All residents received assessments in each quarter of the year before death. (2) Modifiable organizational context, assessed with the Alberta Context Tool. Hierarchical mixed model, repeated measures regression, to simultaneously evaluate effects of time, dementia, and context on symptom trajectories.nnnRESULTSnFor all residents, prevalence of symptoms increased over time. In the last quarter before death, challenging behavior was the most frequent symptom in the dementia group (40.2%), delirium the most frequent symptom in the nondementia group (31.0%), and urinary tract infections least frequent (9.0% to 10.0%). Facilities with more favorable context had significantly higher prevalence of challenging behavior and delirium and significantly lower use of antipsychotics without diagnosis of psychosis.nnnCONCLUSIONnSymptom burden increases as the end of life approaches but differs between high- and low-context facilities and between residents with and without dementia. Trajectories of treatable, burdensome symptoms at the end of life in nursing homes should be a priority focus for quality improvement. Modifiable features of organizational context that are linked to symptom burden offer new potential strategies and interventions for quality improvement.

Rehabilitation in Home Care Is Associated With Functional Improvement and Preferred Discharge

OBJECTIVEnTo investigate the impact of physiotherapy (PT) and occupational therapy (OT) services on long-stay home care patients with musculoskeletal disorders.nnnDESIGNnObservational study.nnnSETTINGnHome care programs.nnnPARTICIPANTSnAll long-stay home care patients between 2003 and 2008 (N=99,764) with musculoskeletal disorders who received a baseline Resident Assessment Instrument for Home Care assessment, 1 follow-up assessment, and had discharge or death records.nnnINTERVENTIONSnPT and OT.nnnMAIN OUTCOME MEASURESnThe effects of PT and OT services on transitions in functional state, discharge from home care with service plans complete, institutionalization, and death were assessed via multistate Markov models.nnnRESULTSnHome care patients with deficiencies in instrumental activities of daily living and/or activities of daily living at baseline and who received home-based rehabilitation had significantly increased odds of showing functional improvements by their next assessment (for a state 3 to state 2 transition: odds ratio [OR]=1.17; 95% confidence interval [CI], 1.10-1.26; P<.0001; for a state 2 to state 1 transition: OR=1.36; 95% CI, 1.14-1.61; P=.0005). Receipt of PT/OT also significantly reduced the odds of mortality and institutionalization in this group.nnnCONCLUSIONSnWith increasing numbers of older adults with chronic conditions and limited funding for health care services, it is essential to provide the right services at the right time in a cost-effective manner. Long-stay home care patients who receive rehabilitation at home have improved outcomes and lower utilization of costly health services. Our findings suggest that investment in PT and OT services for relatively short periods may provide savings to the health care system over the longer term.

Predictors of emergency room visits or acute hospital admissions prior to death among hospice palliative care clients in Ontario: a retrospective cohort study

BackgroundHospice palliative care (HPC) is a philosophy of care that aims to relieve suffering and improve the quality of life for clients with life-threatening illnesses or end of life issues. The goals of HPC are not only to ameliorate clients’ symptoms but also to reduce unneeded or unwanted medical interventions such as emergency room visits or hospitalizations (ERVH). Hospitals are considered a setting ill-prepared for end of life issues; therefore, use of such acute care services has to be considered an indicator of poor quality end of life care. This study examines predictors of ERVH prior to death among HPC home care clients.MethodsA retrospective cohort study of a sample of 764 HPC home care clients who received services from a community care access centre (CCAC) in southern Ontario, Canada. All clients were assessed using the Resident Assessment Instrument for Palliative Care (interRAI PC) as part of normal clinical practice between April 2008 and July 2010. The Andersen-Newman framework for health service utilization was used as a conceptual model for the basis of this study. Logistic regression and Cox regression analyses were carried out to identify predictors of ERVH.ResultsHalf of the HPC clients had at least one or more ERVH (nu2009=u2009399, 52.2%). Wish to die at home (ORu2009=u20090.54) and advanced care directives (ORu2009=u20090.39) were protective against ERVH. Unstable health (ORu2009=u20090.70) was also associated with reduced probability, while infections such as prior urinary tract infections (ORu2009=u20092.54) increased the likelihood of ERVH. Clients with increased use of formal services had reduced probability of ERVH (ORu2009=u20090.55).ConclusionsFindings of this study suggest that predisposing characteristics are nearly as important as need variables in determining ERVH among HPC clients, which challenges the assumption that need variables are the most important determinants of ERVH. Ongoing assessment of HPC clients is essential in reducing ERVH, as reassessments at specified intervals will allow care and service plans to be adjusted with clients’ changing health needs and end of life preferences.

Impact of Symptoms and Care Practices on Nursing Home Residents at the End of Life: A Rating by Front-line Care Providers

OBJECTIVESnBurdensome symptoms and potentially inappropriate care practices are common at the end of life for nursing home residents. Appropriately managing symptoms and limiting aggressive care practices is key to high-quality end-of-life care. Little research is available, however, on the opinions of nursing home care providers about the impact of symptoms and practices for both residents and care facilities. Our objectives were to (1) identify common burdensome symptoms and potentially inappropriate practices at the end of life for nursing home residents, (2) develop and assess the feasibility of a procedure to have various groups of nursing home care providers rate impact of symptoms and practices, and (3) generate recommendations for action and further research, with key policy and decision makers.nnnDESIGNnProof-of-concept study. Partnered research by researchers, health professionals, and decision makers to identify and explore the impact of burdensome symptoms and potentially inappropriate care practices for nursing home residents at the end of life.nnnSETTINGnThirty-six nursing homes from Alberta, Manitoba, and Saskatchewan.nnnPARTICIPANTSnA total of 6007 residents (prevalence rating); 4 medical directors, 5 directors of care, 4 nurse practitioners, 4 registered nurses, 5 licensed practical nurses, 5 care aides (impact rating); and 13 key policy or decision makers from Alberta, British Columbia, and Manitoba (expert panel).nnnMETHODSnBased on a literature search and data in the Resident Assessment Instrument-Minimum Data Set (RAI-MDS) 2.0, we generated lists of burdensome symptoms and potentially inappropriate care practices for nursing home residents at the end of life. We rated prevalence of those symptoms and practices in the last quarter before death as high, medium, or low. Care providers rated the burden of symptoms and inappropriateness of practices as high, medium, or low. Directors of care rated the unnecessary cost of those symptoms and practices to a nursing home as high, medium, or low. We ranked symptoms and practices based on those ratings. We discussed our findings in an interactive expert panel and generated recommendations for action and further research.nnnMEASUREMENTSnRAI-MDS 2.0 (symptom prevalence rating); online survey to rate symptoms and practices (impact rating).nnnRESULTSnThe 3 most prevalent symptoms were urinary incontinence (79.7%), fecal incontinence (66.7%), and responsive behaviors (63%). The 3 most prevalent practices were polypharmacy (9+xa0medications; 55.2%), antipsychotic use with no diagnosis of psychosis (29.2%), and physical restraint use (18.7%). The symptoms rated as having highest overall impact were pain, responsive behaviors, and urinary incontinence. Practices rated as having the most impact were polypharmacy, hospital and emergency department transitions, and antipsychotic use with no diagnosis of psychosis.nnnCONCLUSIONnBurdensome symptoms and inappropriate care practices near the end of life for residents in nursing homes are highly prevalent. Attending to those symptoms and practices is necessary to improve the quality of dying for nursing home residents. Our study provides preliminary demonstration of the feasibility and importance of engaging the spectrum of care providers in assessing the impact of symptoms and care practices on resident experience. Experiences of this proof-of-concept study will be the basis for the development of an indicator profile to monitor and improve quality of end-of-life care in nursing homes in the future.