Vince Mor

Correlates and Management of Nonmalignant Pain in the Nursing Home

Nonmalignant pain is a common problem among older people. The prevalence of pain in the nursing home is not well studied. We looked at the association between nonmalignant pain, psychological and functional health, and the practice patterns for pain management in the nursing home.

Integrated Health Information Systems Based on the RAI/MDS Series of Instruments

There is a growing need for an integrated health information system to be used in community, institutional and hospital based settings. For example, changes in the structure, process and venues of service delivery mean that individuals with similar needs may be cared for in a variety of different settings. Moreover, as people make transitions from one sector of the healthcare system to another, there is a need for comparable information to ensure continuity of care and reduced assessment burden. The RAI/MDS series of assessment instruments comprise an integrated health information system because they have consistent terminology, common core items, and a common conceptual basis in a clinical approach that emphasizes the identification of functional problems.

Effect of the National Resident Assessment Instrument on Selected Health Conditions and Problems

OBJECTIVE: To evaluate the effect of the implementation of the National Resident Assessment Instrument (RAI) system on selected conditions representing outcomes for nursing home residents.

Nurse Staffing Patterns and Quality of Care in Nursing Homes

Using the structure-process-outcome framework and the resource-based view of the firm, this study considers both direct and indirect effects of registered nurse staffing patterns on the quality of patient care outcomes. Consistent with theory, registered nurse staffing patterns were found to affect quality of patient care both directly and indirectly through their positive effect on the processes of delivering care.

The Residential History File: Studying Nursing Home Residents' Long-Term Care Histories

OBJECTIVE To construct a data tool, the Residential History File (RHF), that summarizes information from Medicare claims and nursing home (NH) Minimum Data Set (MDS) assessments to track people through health care locations, including non-Medicare-paid NH stays. DATA SOURCES Online Survey of Certification and Reporting (OSCAR) data for 202 free-standing NHs, Medicare Denominator, claims (parts A and B), and MDS assessments for 60,984 people who were present in one of these NHs in 2006. METHODS The algorithm creating the RHF is outlined and the RHF for the study data are used to describe place of death. The identification of residents in NHs is compared with the reports in OSCAR and part B claims. PRINCIPAL FINDINGS The RHF correctly identified 84.8 percent of part B claims with place-of-service in NH, and it identified 18.3 less residents on average than reported in the OSCAR on the day of the survey. The RHF indicated that 17.5 percent non-Medicare NH decedents were transferred to the hospital to die versus 45.6 percent skilled nursing facility decedents. CONCLUSIONS The population-based design of the RHF makes it possible to conduct policy-relevant research to examine the variation in the rate and type of health care transitions across the United States.

Gender differences in the relation between comorbidity and mortality of patients with Alzheimer’s disease

Objective: To investigate whether differences in the number and type of comorbid conditions may help explain the gender gap in mortality among patients with AD. Background: The prevalence and incidence of AD are higher among women, who also have more severe cognitive impairment and accelerated decline. However, men have an exceedingly higher mortality. Methods: The authors conducted a retrospective cohort study on 5,831 men and 17,918 women with a diagnosis of AD. Data were from the Systematic Assessment of Geriatric drug use via Epidemiology (SAGE) database, which includes information on residents of 1,492 nursing homes in five US states (1992–1995). Men and women were compared with respect to demographic characteristics, dementia severity, psychiatric and behavioral symptoms, indicators of physical disability, and general health status. Also compared were age- and race-adjusted prevalence of all comorbid conditions at each level of cognitive impairment. In survival analyses, the risk of death and of hospitalization were determined by gender and level of cognitive impairment. Finally, gender-related differences in the intensity of pharmacologic treatment were examined. Results: Women were older than men (83 ± 7 versus 81 ± 7 years) and were more likely to exhibit severe cognitive deterioration (27% versus 19% among men). Overall, there were no significant gender-related differences on several measures of physical disability (activities of daily living performance, gait and history of falls, incontinence, pressure sores), but significantly more women were underweight (45% versus 37% among men). However, the age- and race-adjusted 1-year mortality rate was 17% for women and 31% for men. The mortality rate of women at the highest degree of dementia severity was lower than the rate for men with minimal cognitive impairment. At any level of cognitive impairment, the prevalence of arrhythmia, chronic obstructive pulmonary disease, PD, and cancer was higher among men. Women were also less likely to be hospitalized, and they received fewer medications for each given disease. Conclusions: The survival advantage of women with AD relative to men may occur as a result of fewer comorbid clinical conditions associated with the diagnosis of dementia.

Gender differences in predictors of mortality in nursing home residents with AD

Objective: To evaluate whether the excess mortality in men with AD can be explained by a gender difference in the predictors of mortality. Methods: The authors studied 2,838 men and 6,385 women over 65 years of age with AD admitted, between 1992 and 1995, to 1 of nearly 1,500 nursing homes in five U.S. states (Kansas, Maine, Mississippi, New York, and South Dakota). Resident level data including sociodemographic characteristics, dementia severity, measures of physical disability, comorbidity, and other clinical variables were collected with the Minimum Data Set. Information on death was derived through linkage to Medicare enrollment files; the median follow-up was 23 months. Baseline characteristics were used to predict age at time of death in Cox proportional hazard models. Results: Men with AD had an increased risk of mortality relative to women, adjusted for differences in the distribution of age and race. The most important predictors of death in men were those related to the disease itself. These were the severity of dementia and the occurrence of episodes of delirium. Instead, death among women was associated with measures of disability, namely, impairment in performing the activities of daily living, presence of pressure sores, malnutrition, and comorbidity. Conclusion: These data suggest that the underlying mechanisms for AD may be different in men and women. Future studies of survival and progression of AD need to examine men and women separately.

Predictors of Physical Therapy Clinic Performance in the Treatment of Patients With Low Back Pain Syndromes

Background and Purpose: Little is known about organizational and service delivery factors related to quality of care in physical therapy. This study sought to identify characteristics related to differences in practice outcomes and service utilization. Subjects: The sample comprised 114 outpatient clinics and 1,058 therapists who treated 16,281 patients with low back pain syndromes during the period 2000–2001. Clinics participated with the Focus on Therapeutic Outcomes, Inc (FOTO) database. Methods: Hierarchical linear models were used to risk adjust treatment outcomes and number of visits per treatment episode. Aggregated residual scores from these models were used to classify each clinic into 1 of 3 categories in each of 3 types of performance groups: (1) effectiveness, (2) utilization, and (3) overall performance (ie, composite measure of effectiveness and utilization). Relationships between clinic classification and the following independent variables were examined by multinomial logistic regression: years of therapist experience, number of physical therapists, ratio of physical therapists to physical therapist assistants, proportion of patients with low back pain syndromes, number of new patients per physical therapist per month, utilization of physical therapist assistants, and setting. Results: Clinics that were lower utilizers of physical therapist assistants were 6.6 times more likely to be classified into the high effectiveness group compared with the low effectiveness group, 6.7 times more likely to be classified in the low utilization group compared with the high utilization group, and 12.4 times more likely to be classified in the best performance group compared with the worst performance group. Serving a higher proportion of patients with low back pain syndromes was associated with an increased likelihood of being classified in the lowest or middle group. Years of physical therapist experience was inversely associated with being classified in the middle utilization group compared with the highest utilization group. Discussion and Conclusion: These findings suggest that, in the treatment of patients with low back pain syndromes, clinics that are low utilizers of physical therapist assistants are more likely to provide superior care (ie, better patient outcomes and lower service use).

Benchmarking Physical Therapy Clinic Performance: Statistical Methods to Enhance Internal Validity When Using Observational Data

Many clinics and payers are beginning programs to collect and interpret outcomes related to quality of care and provider performance (ie, benchmarking). Outcomes assessment is commonly done using observational research designs, which makes it important for those involved in these endeavors to appreciate the underlying challenges and limitations of these designs. This perspective article discusses the advantages and limitations of using observational research to evaluate quality of care and provider performance in order to inform clinicians, researchers, administrators, and policy makers who want to use data to guide practice and policy or critically appraise observational studies and benchmarking efforts. Threats to internal validity, including potential confounding, patient selection bias, and missing data, are discussed along with statistical methods commonly used to address these limitations. An example is given from a recent study comparing physical therapy clinic performance in terms of patient outcomes and service utilization with and without the use of these methods. The authors demonstrate that crude differences in clinic outcomes and service utilization tend to be inflated compared with the differences that are statistically adjusted for selected threats to internal validity. The authors conclude that quality of care measurement and ranking procedures that do not use similar methods may produce findings that may be misleading.

The emergence of Medicare hospice care in US nursing homes.

Although Medicare-financed hospice care has been provided in nursing homes in the USA for over 10 years, very little is known regarding the use of this government health care benefit in nursing homes. Using resident assessment data and hospice and inpatient Medicare claim data from five US states, we were able to identify and describe nursing home residents receiving hospice care between 1992 and 1996, and their hospice utilization patterns. Six per cent of all dying nursing home residents received hospice care at some point in time and, in 1996, an estimated 24% of all Medicare hospice patients in the five study states received hospice while in a nursing home. Of those residents beginning hospice care after nursing home admission, 48% were 85 years or older, 70% were female, 94% were white, 76% were unmarried and 62% had a non-cancer principal diagnosis. The average length of stay in the hospice programme for residents receiving hospice care while in the nursing home was 90.6 days, the median 35 and the mode 2. Hospice care in US nursing homes is a prevalent model of care that appears further to extend the Medicare hospice benefit to older adults who are female and to those with non-cancer diagnoses. Lengths of stay in the programme are similar to those observed in the community and the average length of stay is substantially shorter than previously estimated by an influential government study.