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D R Berlowitz

Publications and source records attributed to D R Berlowitz.

At least 19 recordsLinked to original sources
PubMed2001

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. DESIGN: Perspective observational study using MDS data from 1997. SETTING: A large, for-profit, nursing home chain. PARTICIPANTS: Our unit of analysis was 39,649 observations made on 14,607 nursing home residents who were without a stage 2 or larger pressure ulcer on an index assessment. MEASUREMENTS: Pressure ulcer status was determined at an outcome assessment approximately 90 days after an index assessment. Potential predictors of pressure ulcer development were examined for bivariate associations, contributing to the development of a multivariate logistic regression model. RESULTS: A stage 2 or larger pressure ulcer developed in 2.3% of the observations. Seventeen resident characteristics were found to be associated with pressure ulcer development. These included dependence in mobility and transferring, diabetes mellitus, peripheral vascular disease, urinary incontinence, lower body mass index, and end-stage disease. A risk-adjustment model based on these characteristics was well calibrated and able to discriminate among residents with different levels of risk for ulcer development (model c-statistic = 0.73). CONCLUSION: A clinically credible risk-adjustment model with good performance properties can be developed using the MDS. This model may be useful in profiling nursing homes on their rate of pressure ulcer development.

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PubMed2001

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. DESIGN: Retrospective observational study using Minimum Data Set (MDS) data from 1998. SETTING: A large, for-profit, nursing home chain. PARTICIPANTS: Twenty-nine thousand and forty observations were made on 13,457 nursing home residents who were without a pressure ulcer on an index assessment. MEASUREMENTS: We used logistic regression in our validation sample to calculate new coefficients for the 17 previously identified predictors of pressure ulcer development. Coefficients from this new sample were compared with those previously derived. Expected rates of pressure ulcer development were determined for 108 nursing homes. Unadjusted and risk-adjusted rates of pressure ulcer development from these homes were also calculated and outlier identification using these two approaches was compared. RESULTS: Predictors of pressure ulcer development in the derivation sample generally showed similar effects in the validation sample. The model c-statistic was also unchanged at 0.73, but it was not calibrated as well in the validation sample. On applying the model to the nursing homes, expected rates of ulcer development ranged from 1.1% to 3.2% (P <.001). The observed rates ranged from 0% to 12.1% (P <.001). There were 12 outliers using unadjusted rates and 15 using adjusted performance. Ten nursing homes were identified as outliers using both approaches. CONCLUSIONS: Our MDS risk-adjustment model for pressure ulcer development performed well in this new sample. Nursing homes differ significantly in their expected rates of pressure ulcer development. Outlier identification also differs depending on whether unadjusted or risk-adjusted performance is evaluated.

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PubMed2001

Health care reorganization and quality of care: unintended effects on pressure ulcer prevention.

BACKGROUND: Health care reorganizations, with a change in focus from inpatient to outpatient care, are becoming increasingly frequent. Little is known regarding how reorganizations may affect risk-adjusted outcomes for those programs, usually inpatient, that lose resources as a result of the change in organizational focus. OBJECTIVES: To determine changes in risk-adjusted rates of pressure ulcer development over an 8-year period, the final 3 of which were characterized by a significant reorganization of the health care system. DESIGN: This was an observational study that used an existing database. SUBJECTS: Subjects were residents of Department of Veterans Affairs long-term care units between 1990 and 1997 who were without a pressure ulcer at an index assessment. MEASURES: The study examined risk-adjusted rates of pressure ulcer development, and proportions of new ulcers that were severe (stages 3 or 4) were calculated for successive 6-month periods. RESULTS: Between 1990 and 1994, risk-adjusted rates of pressure ulcer development declined significantly, by 27%. However, beginning in 1995, rates began to increase, and in 1997 they were similar to those in 1990. The proportion of new ulcers that were severe increased significantly over time (P = 0.01). CONCLUSIONS: The reorganization of the VA that began in 1995, with its emphasis on outpatient care, was associated with an increase in rates of pressure ulcer development. This highlights the need to carefully monitor the quality of care in programs that may be losing resources as a result of the reorganization.

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PubMed2001

Evaluating diagnosis-based case-mix measures: how well do they apply to the VA population?

BACKGROUND: Diagnosis-based case-mix measures are increasingly used for provider profiling, resource allocation, and capitation rate setting. Measures developed in one setting may not adequately capture the disease burden in other settings. OBJECTIVES: To examine the feasibility of adapting two such measures, Adjusted Clinical Groups (ACGs) and Diagnostic Cost Groups (DCGs), to the Department of Veterans Affairs (VA) population. RESEARCH DESIGN: A 60% random sample of veterans who used health care services during FY 1997 was obtained from VA inpatient and outpatient administrative databases. A split-sample technique was used to obtain a 40% sample (n = 1,046,803) for development and a 20% sample (n = 524,461) for validation. METHODS: Concurrent ACG and DCG risk adjustment models, using 1997 diagnoses and demographics to predict FY 1997 utilization (ambulatory provider encounters, and service days-the sum of a patient's inpatient and outpatient visit days), were fitted and cross-validated. RESULTS: Patients were classified into groupings that indicated a population with multiple psychiatric and medical diseases. Model R-squares explained between 6% and 32% of the variation in service utilization. Although reparameterized models did better in predicting utilization than models with external weights, none of the models was adequate in characterizing the entire population. For predicting service days, DCGs were superior to ACGs in most categories, whereas ACGs did better at discriminating among veterans who had the lowest utilization. CONCLUSIONS: Although "off-the-shelf" case-mix measures perform moderately well when applied to another setting, modifications may be required to accurately characterize a population's disease burden with respect to the resource needs of all patients.

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PubMed2000

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. METHODS: We used the Minimum Data Set to study National HealthCare Corporation nursing homes from 1991 through 1995. Rates of pressure ulcer development were calculated for successive 6-month periods by determining the proportion of residents initially ulcer-free having a stage 2 or larger pressure ulcer on subsequent assessments. Rates were risk-adjusted for patient characteristics. The proportion of new ulcers that were deep (stages 3 or 4) were also calculated. RESULTS: We examined risk-adjusted rates of pressure ulcer development based on 144,379 observations of 30,510 residents at 107 nursing homes. The number of observations per 6-month period ranged from 11,041 to 15,805. Between 1991 and 1995, there was a significant (P<.05) rate decline of more than 25%. Additionally, the proportion of new ulcers that were stages 3 or 4 declined from 30 to 22% (P<.01). CONCLUSIONS: Nursing homes showed significant improvement in the quality of pressure ulcer preventive care from 1991 to 1995.

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PubMed1999

Functional status outcomes for assessment of quality in long-term care.

OBJECTIVE: Although decline in functional status has been recommended as a quality indicator in long-term care, studies examining its use provide no consensus on which definition of functional status outcome is the most appropriate to use for quality assessment. We examined whether different definitions of decline in functional status affect judgments of quality of care provided in Department of Veterans Affairs (VA) long-term care facilities. METHODS: Six measures of functional status outcome that are prominent in the literature were considered. The sample consisted of 15 409 individuals who resided in VA long-term care facilities at any time from 4/1/95 to 10/1/95. Activities of daily living variables were used to generate measures of functional status. Differences between residents' baseline and semi-annual assessments were considered and facility performance using the various definitions of functional status were described. RESULTS: The percentage of residents seen as declining in functional status ranged from 7.7% to 31.5%, depending upon the definition applied. The definition of functional status also affected rankings, z-scores, and 'outlier' status for facilities. CONCLUSION: Judgments of facility performance are sensitive to how outcome measures are defined. Careful selection of an appropriate definition of functional status outcome is needed when assessing quality in long-term care.

Activities of Daily Living↗
PubMed1999

Geriatric syndromes as outcome measures of hospital care: can administrative data be used?

OBJECTIVE: To determine how often hospital administrative databases capture the occurrence of two common geriatric syndromes, pressure ulcers and incontinence. DESIGN: Retrospective comparison of a nursing home and hospital database. SETTING: Department of Veterans Affairs (VA) hospitals. PARTICIPANTS: All patients between 1992 and 1996 discharged from VA acute medical care and admitted to a VA nursing home. MEASUREMENTS: The presence of incontinence or a pressure ulcer (stage 2 or larger) on admission to the nursing home was determined. Hospital discharge diagnoses were then reviewed to determine whether these conditions were recorded. The effect of ulcer stage, total number of discharge diagnoses, and temporal trends on the recording of these conditions in discharge diagnoses was also noted. RESULTS: There were 17,004 admissions to nursing homes from acute care in 1996; 12.7% had a pressure ulcer and 43.4% were incontinent. Among these patients with a pressure ulcer, the hospital discharge diagnosis listed an ulcer in 30.8% of cases, and incontinence was included correctly as a discharge diagnosis in 3.4%. While deeper pressure ulcers were more likely to be recorded than superficial ulcers (P < .01), nearly 50% of stage 4 ulcers were not listed among hospital discharge diagnoses. Patients with more discharge diagnoses were more likely to record both conditions correctly. From 1992 to 1996, small but significant (P = .001) improvements were noted in the correct recording of these geriatric syndromes as discharge diagnoses. CONCLUSIONS: The occurrence of pressure ulcers and incontinence cannot be determined from hospital administrative databases and should not be used as outcomes when measuring quality of care among hospitalized patients.

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PubMed1998

Inadequate management of blood pressure in a hypertensive population.

BACKGROUND: Many patients with hypertension have inadequate control of their blood pressure. Improving the treatment of hypertension requires an understanding of the ways in which physicians manage this condition and a means of assessing the efficacy of this care. METHODS: We examined the care of 800 hypertensive men at five Department of Veterans Affairs sites in New England over a two-year period. Their mean (+/-SD) age was 65.5+/-9.1 years, and the average duration of hypertension was 12.6+/-5.3 years. We used recursive partitioning to assess the probability that antihypertensive therapy would be increased at a given clinic visit using several variables. We then used these predictions to define the intensity of treatment for each patient during the study period, and we examined the associations between the intensity of treatment and the degree of control of blood pressure. RESULTS: Approximately 40 percent of the patients had a blood pressure of > or =160/90 mm Hg despite an average of more than six hypertension-related visits per year. Increases in therapy occurred during 6.7 percent of visits. Characteristics associated with an increase in antihypertensive therapy included increased levels of both systolic and diastolic blood pressure at that visit (but not previous visits), a previous change in therapy, the presence of coronary artery disease, and a scheduled visit. Patients who had more intensive therapy had significantly (P<0.01) better control of blood pressure. During the two-year period, systolic blood pressure declined by 6.3 mm Hg among patients with the most intensive treatment, but increased by 4.8 mm Hg among the patients with the least intensive treatment. CONCLUSIONS: In a selected population of older men, blood pressure was poorly controlled in many. Those who received more intensive medical therapy had better control. Many physicians are not aggressive enough in their approach to hypertension.

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PubMed1998

Mortality associated with an influenza outbreak on a dementia care unit.

The purpose of this study was to describe an episode of increased mortality, whose cause was initially unknown. This retrospective cohort investigation was conducted on a dementia special care unit of a Department of Veterans Affairs facility, with more than 75% of residents clinically diagnosed with dementia of the Alzheimer type. One hundred five residents residing in the facility during February 1995 were included as subjects. A cluster of deaths occurred, triggering the investigation. Ultimately, 21 deaths (three times greater than any previous month in the past 5 years) occurred during the 1-month period. Measures included the presence of clinical influenza-like illness based on signs, serology, and autopsy results. Of the 105 residents, 45 (42.8%) met the clinical definition for influenza-like illness. Eight autopsies were performed, and the causes of death consisting of bronchopneumonia in seven and aspiration pneumonia in one were compatible with influenza. There were no differences among those who died from those who lived with regards to age, race, gender, clinical influenza-like illness, vaccination status, diagnosis of Alzheimer disease, or duration of dementia (all p > or = 0.2). However, those who died were at a higher risk of dying due to a greater number of coexisting conditions (p < 0.01). Also, overall the groups differed in Mini-Mental State Examination and Bedford Alzheimer Nursing Scale scores with those who died being more impaired (p < 0.01). Thus, the presentation of influenza-like illness can be subtle in onset, underappreciated in this population, and not recognized until excess mortality, which affects the most frail, is noted. Care providers need to be vigilant during the winter months for the presence of influenza.

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PubMed1998

Reducing random variation in reported rates of pressure ulcer development.

OBJECTIVES: The authors evaluated methods of reporting on rates of pressure ulcer development in long-term care to identify approaches that lead to more stable estimates of actual performance. METHODS: Performance measures for facilities that adequately adjust for both random variation and casemix should be relatively stable from one time period to the next. The authors calculated facility rates of pressure ulcer development over eight consecutive time periods and correlated measures over time using different reporting methods including z-scores, combining rates from several time periods, and limiting analyses to large facilities. Results were compared with a Monte Carlo simulation. RESULTS: Observed facility rates of pressure ulcer development varied considerably over time. The average correlation coefficient across seven time comparisons for observed rates was 0.17. Reporting performance as a z-score or limiting the analyses to large facilities increased the correlation. Combining two time periods was effective only when used with one of these other approaches. The correlation coefficient based on a simulation using only large facilities was 0.51. CONCLUSIONS: Random variation affects reported rates of pressure ulcer development. Using only large facilities and combining two time periods limits the effects of random variation and results in more stable estimates of performance. When describing performance, management must consider tradeoffs between having more accurate data, the frequency with which data are provided, and whether it is given to all providers.

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PubMed1998

Profiling outcomes of ambulatory care: casemix affects perceived performance.

OBJECTIVES: The authors explored the role of casemix adjustment when profiling outcomes of ambulatory care. METHODS: The authors reviewed the medical records of 656 patients with hypertension, diabetes, or chronic obstructive pulmonary disease (COPD) receiving care at one of three Department of Veterans Affairs medical centers. Outcomes included measures of physiological control for hypertension and diabetes, and of exacerbations for COPD. Predictors of poor outcomes, including physical examination findings, symptoms, and comorbidities, were identified and entered into regression models. Observed minus expected performance was described for each site, both before and after casemix adjustment. RESULTS: Risk-adjustment models were developed that were clinically plausible and had good performance properties. Differences existed among the three sites in the severity of the patients being cared for. For example, the percentage of patients expected to have poor blood pressure control were 35% at site 1, 37% at site 2, and 44% at site 3 (P < 0.01). Casemix-adjusted measures of performance were different from unadjusted measures. Sites that were outliers (P < 0.05) with one approach had observed performance no different from expected with another approach. CONCLUSIONS: Casemix adjustment models can be developed for outpatient medical conditions. Sites differ in the severity of patients they treat, and adjusting for these differences can alter judgments of site performance. Casemix adjustment is necessary when profiling outpatient medical conditions.

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PubMed1998

Problems in assessing diabetes control in an ambulatory setting.

Problems in using medical records to assess outcomes of diabetes care have not been well defined. We reviewed the medical records of 288 patients with diabetes receiving ambulatory care over a 2-year period. We determined the availability of different tests of glycemic control and described site performance as the percentage of patients with a blood glucose exceeding either 180 or 240 mg/dl. Glycosylated hemoglobin determinations were performed in only 26.7% of patients. A blood glucose was available in 208 patients (72.2%) during a 6-month outcome period. For almost 50% of the sample, the glucose was greater than 180 mg/dl, whereas in 20% it exceeded 240 mg/dl. Judgments of whether sites differed in performance depended on how control was defined. Using a single glucose determination and a threshold of 180 mg/dl, similar fractions of patients were poorly controlled at each site (51.2 versus 45.0 versus 47.0%) (P = 0.75). At 240 mg/dl, although, one site performed much worse than the other two (14.6 versus 16.7 versus 31.8%) (P = 0.02). These results highlight difficulties in defining the outcome measure when using medical records to evaluate quality of care.

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PubMed1997

Evaluating and improving pressure ulcer care: the VA experience with administrative data.

BACKGROUND: A number of state initiatives are using databases originally developed for nursing home reimbursements to assess the quality of care. Since 1991 the Department of Veterans Affairs (VA; Washington, DC) has been using a long term care administrative database to calculate facility-specific rates of pressure ulcer development. This information is disseminated to all 140 long term care facilities as part of a quality assessment and improvement program. DATA ON PRESSURE ULCER DEVELOPMENT: Assessments are performed on all long term care residents on April 1 and October 1, as well as at the time of admission or transfer to a long term care unit. Approximately 18,000 long term care residents are evaluated in each six-month period; the VA rate of pressure ulcer development is approximately 3.5%. Reports of the rates of pressure ulcer development are then disseminated to all facilities, generally within two months of the assessment date. IMPLICATIONS FOR OTHER QUALITY IMPROVEMENT EFFORTS: The VA's more than five years' experience in using administrative data to assess outcomes for long term care highlights several important issues that should be considered when using outcome measures based on administrative data. These include the importance of carefully selecting the outcome measure, the need to consider the structure of the database, the role of case-mix adjustment, strategies for reporting rates to small facilities, and methods for information dissemination. CONCLUSION: Attention to these issues will help ensure that results from administrative databases lead to improvements in the quality of care.

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PubMed1997

Effect of pressure ulcers on the survival of long-term care residents.

BACKGROUND: Past studies have emphasized that patients with pressure ulcers are at high risk of dying. However, it remains unclear whether this increased risk is related to the ulcer or to coexisting conditions. In this study we examined the independent effect of pressure ulcers on the survival of long-term care residents. METHODS: We evaluated all 19,981 long-term care residents institutionalized in Department of Veterans Affairs (VA) long-term care facilities as of April 1, 1993. Baseline resident characteristics and survival status were obtained by merging data from five existing VA data bases. Survival experience over a 6-month period was described using a proportional hazards model. RESULTS: Pressure ulcers were present in 1,539 (7.7%) long-term care residents. Residents with pressure ulcers had a relative risk of 2.37 (95% CI = 2.13, 2.64) for dying as compared to those without ulcers. After adjusting for 16 other measures of clinical and functional status, the relative risk associated with pressure ulcers decreased to 1.45 (95% CI = 1.30, 1.65). No increased risk of death was noted for residents with deeper ulcers. CONCLUSIONS: Pressure ulcers are a significant marker for long-term care residents at risk of dying. After adjusting for clinical and functional status, however, the independent risk associated with pressure ulcers declines considerably. The fact that larger ulcers are not associated with greater risk suggests that other unmeasured clinical conditions may also be contributing to the increased mortality associated with pressure ulcers.

Activities of Daily Living↗
PubMed1997

Predictors of pressure ulcer healing among long-term care residents.

OBJECTIVES: To identify predictors of pressure ulcer healing among long-term care residents. DESIGN: A retrospective cohort study. SETTING: Department of Veterans Affairs (VA) long-term care facilities. PARTICIPANTS: All long-term care residents with a pressure ulcer on April 1, 1993, who remained institutionalized as of October 1, 1993. Patients and pressure ulcer status were identified from the Patient Assessment File, a VA administrative database. MEASUREMENTS: Pressure ulcers were considered healed if patients were without an ulcer on October 1, 1993. Predictors of pressure ulcer healing were selected from among patient characteristics in the Patient Assessment File. RESULTS: Pressure ulcers were present in 7.7% of the long-term care residents institutionalized as of April 1, 1993. Among the 819 pressure ulcer patients remaining institutionalized as of October 1, 1993, ulcers had healed in 442 (54.0%). Seventy-two percent of patients with Stage 2 ulcers were ulcer-free at 6 months, compared with 45.2% of patients with Stage 3 ulcers and 30.6% of those with Stage 4 ulcers (P < .001). Significant (P < .05) independent predictors of healing included pressure ulcer size (Odds ratio (OR) = 5.2 for Stage 2 ulcers, OR = 1.5 for Stage 3 ulcers), older age (OR = 1.5), and receiving rehabilitation services (OR = 1.3 for each additional type of therapy). Both immobility (OR = .3) and incontinence (OR = .7) were associated with ulcers not healing. CONCLUSIONS: Most Stage 2 pressure ulcers, and many larger ulcers encountered in long-term care settings will heal. Baseline patient characteristics are important predictors of healing. Interventions may then be targeted at patients whose ulcers are unlikely to heal, and observed facility performance may be compared with expected outcomes.

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PubMed1996

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

OBJECTIVE: To determine the importance of case-mix adjustment in interpreting differences in rates of pressure ulcer development in Department of Veterans Affairs long- term care facilities. DESIGN: A sample assembled from the Patient Assessment File, a Veterans Affairs administrative database, was used to derive predictors of pressure ulcer development; the resulting model was validated in a separate sample. Facility-level rates of pressure ulcer development, both unadjusted and adjusted for case mix using the predictive model, were compared. SETTING: Department of Veterans Affairs long-term care facilities. PATIENTS: The derivation sample consisted of 31 150 intermediate medicine and nursing home residents who were initially free of pressure ulcers and were institutionalized between October 1991 and April 1993. The validation sample consisted of 17 946 residents institutionalized from April 1993 to October 1993. MEASUREMENT: Development of a stage 2 or greater pressure ulcer. RESULTS: 11 factors predicted pressure ulcer development. Validated performance properties of the resulting model were good. Model-predicted rates of pressure ulcer development at individual long-term care facilities varied from 1.9% to 6.3%, and observed rates ranged from 0% to 10.9%. Case-mix-adjusted rates and ranks of facilities differed considerably from unadjusted ratings. For example, among five facilities that were identified as high outliers on the basis of unadjusted rates, two remained as outliers after adjustment for case mix. CONCLUSIONS: Long-term care facilities differ in case mix. Adjustments for case mix result in different judgments about facility performance and should be used when facility incidence rates are compared.

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