Julie C. Lima

Decision - Making and Outcomes of Feeding Tube Insertion: A Five - State Study

OBJECTIVES: To examine family members perceptions of decision‐making and outcomes of feeding tubes.

The Growth of Hospice Care in U.S. Nursing Homes

OBJECTIVES: To inform efforts aimed at reducing Medicare hospice expenditures by describing the longitudinal use of hospice care in nursing homes (NHs) and examining how hospice provider growth is associated with use.

Cancer Patient Assessment and Reports of Excellence: Reliability and Validity of Advanced Cancer Patient Perceptions of the Quality of Care

PURPOSE Consumer perceptions are important measures of the quality of cancer care. This article describes the validation of new measures of the quality of cancer care at the time of diagnosis and treatment for advanced cancer with life-limiting prognosis. METHODS Focus groups, review of guidelines, and an expert panel were used to construct two surveys of the quality of cancer care. A prospective cohort study examined the reliability and validity of three problem scores (ie, counts of the opportunities to improve the quality of care) that examine care at the time of diagnosis and initial treatment. RESULTS At the first interview, 58% of 206 cancer patients (54.9% females; 27.5% with lung cancer; 5.4% with pancreatic cancer; 30.4% with colorectal cancer; 18.6% with breast cancer; mean age, 66.6 years) identified one or more concerns with communication about being diagnosed with advanced cancer. At the second interview, 57.0% of the respondents voiced one or more concerns about treatment communication, and 30.2% expressed one or more concerns about the experience of treatment. Each of the problem scores demonstrated both internal consistency with Cronbachs alpha > .75 and short-term stability of responses in a subsample that had the survey administered twice in 72 hours. Factor analysis largely confirmed the proposed scale structure. All three measures demonstrated moderate correlations suggesting evidence of construct validity. CONCLUSION The three proposed problem scores demonstrate evidence of reliability and validity that warrants further testing to examine their responsiveness and discriminate validity in larger, more generalizable samples.

Effects of cumulative risk on behavioral and psychological well-being in first grade: Moderation by neighborhood context

This study builds upon existing research by examining whether risk indices for child psychological well-being behave in the same way in different types of neighborhoods. Specifically, we sought to determine if neighborhood characteristics acted to exacerbate or, alternatively, to buffer risk factors at the family and/or child level. Families with a child entering first grade in Fall 2002 were recruited from Baltimore City neighborhoods, defined as census block groups. This study included 405 children, and data came from an interview with the primary caregiver and an assessment of the first grader. The dependent variables were externalizing behavior and internalizing problems. A family risk index consisting of 13 measures, and a child risk index consisting of three measures were the main independent variables of interest. We examined the effects of these indices on child psychological well-being and behavior across two neighborhood characteristics: neighborhood potential for community involvement with children and neighborhood negative social climate. Results of multivariate analyses indicated that cumulative family risk was associated with an increase in both internalizing and externalizing behavior problems. Perceived negative social climate moderated the effect of family risks on behavior problems such that more risk was associated with a larger increment in both externalizing behavior problems and psychological problems for children living in high versus low risk neighborhoods. These findings further emphasize the importance of considering neighborhood context in the study of child psychological well-being.

Influence of Hospice on Nursing Home Residents with Advanced Dementia Who Received Medicare-Skilled Nursing Facility Care Near the End of Life

To examine differences in outcomes according to hospice status of skilled nursing facility (SNF) care recipients.

Dying in U.S. Nursing Homes with Advanced Dementia: How Does Health Care Use Differ for Residents with, versus without, End-of-Life Medicare Skilled Nursing Facility Care?

BACKGROUND Because Medicare policy restricts simultaneous Medicare hospice and skilled nursing facility (SNF) care, we compared hospice use and sites of death for SNF/non-SNF residents with advanced dementia; and, for those with SNF, we evaluated how subsequent hospice use was associated with dying in a hospital. METHODS This study includes (non-health maintenance organization [HMO]) residents of U.S. nursing homes (NHs) who died in 2006 with advanced dementia (n=99,370). Sites of death, Medicare SNF, and hospice use were identified using linked resident assessment and Medicare enrollment and claims data. Advanced dementia was identified by a diagnosis of Alzheimers disease or dementia on the Minimum Data Set (MDS) or a Medicare claim in the last year of life and severe to very severe cognitive impairment (5 or 6 on the MDS cognitive performance scale). For residents with SNF, we used multivariate logistic regression with generalized estimating equations to estimate the effect of subsequent hospice enrollment on dying in a hospital. RESULTS Forty percent of U.S. NH residents dying with advanced dementia in 2006 had SNF care in the last 90 days of life. Those with versus without SNF less frequently used hospice (30% versus 46%), more frequently had short (≤7 days) hospice stays (40% versus 19%), and more frequently died in hospitals (14% versus 9%). Among residents with SNF, those with subsequent hospice use had a 98% lower likelihood of a hospital death (95% confidence interval [CI]: 0.014, 0.025). CONCLUSIONS Dual hospice/SNF access may result in fewer hospital deaths and higher quality of life for dying NH residents.

Hospice Care for Persons With Dementia: The Growth of Access in US Nursing Homes

Background/Rationale: Persons with dementia often die in nursing homes (NHs); however, concerns exist about their low use of Medicare hospice. Methods: For 1999 through 2006 in all US states and DC we merged NH resident assessment data with Medicare claims and enrollment data to identify NH decedents with dementia and hospice use. We studied two groups, those with advanced dementia and those with mild-to-moderately severe dementia. Results: Across study years, 22.2% of all NH decedents had mild-to-moderately severe dementia and 19.6% had advanced dementia. In 1999, 14.5% of decedents with advanced and 13.2% with mild-to-moderately severe dementia accessed hospice, increasing to 42.5% and 37.9% respectively in 2006. Between 1999 and 2006, mean days of hospice stays increased from 46 to 118 for advanced dementia and from 39 to 79 for mild-to-moderately severe dementia. These mean length of stay differences resulted from a relatively lower proportion of short hospice stays (≤ 7 days) together with higher proportions of longer stays (≥ 181 days) among advanced versus mild-to-moderately severe dementia decedents. Hospice access and lengths of stay among US states varied widely. Conclusions: Over 40% of US NH decedents have mild-to-moderately severe or advanced dementia. For these NH decedents, access to and duration of Medicare hospice has increased. However, there is considerable variation in hospice use across US states.

Does the introduction of nursing home culture change practices improve quality

To understand whether nursing home (NH) introduction of culture change practices is associated with improved quality.

Palliative Care Consultations in Nursing Homes and Reductions in Acute Care Use and Potentially Burdensome End-of-Life Transitions.

To evaluate how receipt and timing of nursing home (NH) palliative care consultations (primarily by nurse practitioners with palliative care expertise) are associated with end‐of‐life care transitions and acute care use

Medicaid Capital Reimbursement Policy and Environmental Artifacts of Nursing Home Culture Change

PURPOSE OF THE STUDY To examine how Medicaid capital reimbursement policy is associated with nursing homes (NHs) having high proportions of private rooms and small households. DESIGN AND METHODS Through a 2009/2010 NH national survey, we identified NHs having small households and high proportions of private rooms (≥76%). A survey of state Medicaid officials and policy document review provided 2009 policy data. Facility- and county-level covariates were from Online Survey, Certification and Reporting, the Area Resource File, and aggregated resident assessment data (minimum data set). The policy of interest was the presence of traditional versus fair rental capital reimbursement policy. Average Medicaid per diem rates and the presence of NH pay-for-performance (p4p) reimbursement were also examined. A total of 1,665 NHs in 40 states were included. Multivariate logistic regression analyses (with clustering on states) were used. RESULTS In multivariate models, Medicaid capital reimbursement policy was not significantly associated with either outcome. However, there was a significantly greater likelihood of NHs having many private rooms when states had higher Medicaid rates (per