Impact of legislation on nursing home care in the United States: lessons for the United Kingdom.
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Biomedical subjects
V Mor
Publications and source records attributed to V Mor.
Gender differences in the relation between comorbidity and mortality of patients with Alzheimer's disease. Systematic Assessment of Geriatric drug use via Epidemiology (SAGE) Study Group.
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.
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Tacrine use in nursing homes: implications for prescribing new cholinesterase inhibitors. SAGE Study Group. Systematic Assessment of Geriatric Drug Use via Epidemiology.
OBJECTIVE: To describe the use of tacrine in nursing home residents using data from a clinically based resident assessment instrument used by all US nursing homes. METHODS: Data were from the Systematic Assessment of Geriatric Drug Use via Epidemiology (SAGE) database, a population-based data set with information on 329,520 patients admitted to all Medicare/Medicaid certified nursing homes in four US states (Maine, Mississippi, New York, and South Dakota) from 1992 through 1995. The SAGE database combines information from the Minimum Data Set (MDS) and the On-Line Survey and Certification Automated Record. We identified all residents receiving tacrine and up to five control residents per case matched on state, date of tacrine use, cognitive function, and dementia diagnosis. RESULTS: A total of 1,640 (0.5%) nursing home residents received tacrine at least once. Only 38% of these residents had a diagnosis of AD documented on the MDS; regardless of dementia diagnosis, 25% had severe cognitive impairment, 35% were severely dependent in activities of daily living (ADL), and 17% had both severe cognitive and ADL impairment. Only 8% achieved a therapeutic dose of at least 120 mg/d. After adjusting for confounding variables, wandering and being physically abusive were the strongest predictors of tacrine use. CONCLUSIONS: A minority of nursing home residents received tacrine. Of those who did, a significant proportion were unlikely to benefit from its use because of their level of cognitive and ADL impairment, or because low doses were used. As new medications become available for dementia, MDS data can be used by nursing homes to monitor the use of these therapies.
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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.
Canada↗
Characteristics of the SAGE database: a new resource for research on outcomes in long-term care. SAGE (Systematic Assessment of Geriatric drug use via Epidemiology) Study Group.
BACKGROUND: Because there is a lack of databases specific to long-term care, standardized assessments of nursing home residents are seen as a potential new resource for studying an important but neglected population. We describe the design and principal population characteristics of the first integrated database combining detailed clinical information and administrative claims data. METHODS: We studied nearly 300,000 residents admitted between 1992 and 1994 to all Medicare/Medicaid certified nursing homes of five U.S. states (Kansas, Maine, Mississippi, New York, and South Dakota). The database crosslinks: (a) Resident Data: over 350 items (demographic, diagnostic, clinical, and treatments) collected with the Minimum Data Set; (b) Drug Data: brand name, dosage route, and frequency of administration for all drugs consumed by each resident; (c) Medicare Data: eligibility and inpatient hospital claims; (d) Facilities Data: structural and staffing information on nursing homes; and (e) Country Data: information on population, health professions and facility data, and economic parameters. RESULTS: Ninety-two percent of the residents were aged 65 years and older. Residents were predominantly white (85%) and female (72%). The average number of medical diagnoses was above three, and residents were receiving an average of six medications. Sixty-five percent of residents had at least one hospital claim following the initial assessment, most commonly related to cardiovascular diseases and metabolic disorders. Fifty-five percent of the facilities were for-profit and 33% were of small size. Quality indicators and staffing level varied significantly by state. CONCLUSIONS: The SAGE (Systematic Assessment of Geriatric drug use via Epidemiology) database provides a unique resource to study the relation between treatments received and outcomes experienced, particularly functional and health services outcomes, that have not been possible before in very old, frail people.
Activities of Daily Living↗
Hospice in nursing homes: a facility-level analysis of the distribution of hospice beneficiaries.
Since 1989, the Medicare hospice benefit has been available to terminally ill individuals residing in nursing homes. We first describe the evolution and nature of hospice care for nursing home residents. We then utilize recent On-line Survey and Certification of Automated Records data on a national sample of Medicare/Medicaid certified nursing homes, merged with hospice Provider of Service and Area Resource File information, to examine the distribution of hospice beneficiaries in nursing homes. Bivariate analyses provide descriptive comparisons of homes with 0%, 0.1-4.9%, and 5%+ residents on the hospice benefit. Multinomial logistic regression reveals the influence of organizational, market, and environmental factors on the proportion of beneficiaries in nursing homes. Results indicate that significant numbers of homes have hospice patients and that these institutions may have strong incentives to convert residents to the Medicare hospice benefit.
Hospice Care↗
Facility characteristics associated with hospitalization of nursing home residents: results of a national study.
OBJECTIVES: To test the effect of facility characteristics on the probability of hospitalization of nursing home residents, controlling for resident characteristics and the competing risk of death. RESEARCH DESIGN: Study data were derived from the evaluation of the implementation of the Resident Assessment Instrument, the Minimum Data Set (MDS) in 1993. The data consisted of 2080 residents in 253 NHs as well as the annual On-Line Survey Certification of Automated Records (OSCAR). MEASURES: Multinomial logistic regression was used to determine the effects of selected resident and facility characteristics on hospitalization or death within 6 months of baseline, adjusting for the complex sampling design (using SUDAAN). RESULTS: By controlling for resident demographics, advance directives, diagnoses, selected clinical signs, and type of payer, we found that homes with special care units, more physicians (above the median 0.08 FTE physicians on staff or contract), and any physician extenders (nurse practitioners or physician assistants) were less likely to hospitalize their residents. Homes in which over 3.6% of the residents received respiratory treatment were more likely to hospitalize their residents. CONCLUSIONS: Findings suggest that Medicare HMOs should consider the capacity of nursing facilities, especially in terms of medical care capacity and clinical resources, to limit hospital admissions.
Advance Directives↗
Correlates and management of nonmalignant pain in the nursing home. SAGE Study Group. Systematic Assessment of Geriatric drug use via Epidemiology.
OBJECTIVE: 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. DESIGN: A cross-sectional study. SETTING: Nursing Home in four US states. PARTICIPANTS: A total of 49,971 nursing home residents from 1992 to 1995. MEASUREMENTS: We used the SAGE database (Systematic Assessment of Geriatric drug use via Epidemiology), which linked information from the Minimum Data Set and nursing home drug utilization data. The MDS items measured included pain, activities of daily living (ADL) function, mood, and time involved in activities. The use of analgesics, anxiolytics, and antidepressants was also documented. RESULTS: Daily pain was reported in 26% of nursing home residents. The prevalence was lower among men, persons more than age 85, and racial minorities. Persons suffering pain daily were more likely to have severe ADL impairment, odds ratio (OR) (2.47 (95% CI, 2.34-2.60)), more depressive signs and symptoms (OR 1.66 (95% CI, 1.57-1.75)), and less frequent involvement in activities (OR 1.35 (95% CI, 1.29-1.40)). Approximately 25% of persons with daily pain received no analgesics. Residents who were more than 85 years old (OR 1.15 (95% CI 1.02-1.28)), cognitively impaired, (OR 1.44 (95% CI, 1.29-1.61)), of male gender (OR 1.17 (95% CI, 1.06-1.29)), or a racial minority (OR 1.69 (95% CI, 1.40-2.05) and OR 1.56 (95% CI, 0.70-1.04) for blacks and Hispanics, respectively) were at greater risk of not receiving analgesics. Approximately 50% of those in pain used physical and occupational therapies, which was more than two times higher (OR 2.44 (95% CI, 2.34-2.54)), than use for those not in pain. CONCLUSIONS: Daily nonmalignant pain is prevalent among nursing home residents and is often associated with impairments in ADL, mood, and decreased activity involvement. Even when pain was recognized, men, racial minorities, and cognitively impaired residents were at increased risk for undertreatment. More education and research is necessary to improve the recognition and management of pain in the nursing home, remembering that attention should be paid to populations at increased risk for underrecognition and undertreatment.
Activities of Daily Living↗
Predictors of mortality in patients with Alzheimer's disease living in nursing homes.
OBJECTIVES: To identify factors associated with mortality in patients with Alzheimer's disease, and to evaluate whether these factors vary according to severity of cognitive impairment. METHODS: Data were from the SAGE database which includes information on all residents admitted between 1992 and 1995 to all Medicare/ Medicaid certified nursing homes of five US states. We conducted a longitudinal follow up study (median 23 months) on 9264 patients aged 65 years and above with a diagnosis of Alzheimer's disease. Patient data including demographic characteristics, dementia severity, comorbidity, and other clinical and treatment variables were collected with the Minimum Data Set. Information on death was derived through linkage to Medicare files. Baseline characteristics were used to predict survival in univariate and multivariate Cox proportional hazard models. RESULTS: Overall mortality rate was 50%, with a first year rate of 25.7%. Increased age (risk ratio (RR) 1. 83; 95% confidence interval (95% CI) 1.65-2.03, for patients 85+ years), male sex (RR 1.81; 95% CI 1.70-1.94), limitation in physical function (RR 1.45; 95% CI 1.27-1.66), a condition of malnutrition (RR 1.31; 95%CI 1.23-1.39), the presence of pressure ulcers (RR 1.24; 95% CI 1.13-1.36), a diagnosis of diabetes mellitus (RR 1.32; 95% CI 1.21-1.43), and of cardiovascular diseases (RR 1.22; 95% CI 1. 14-1.30) were independent predictors of death, regardless of the severity of baseline dementia. Sensory problems (hearing and vision) and urinary incontinence were associated with increased mortality only among patients with less severe dementia. The presence of disruptive behaviour, aphasia, and a diagnosis of Parkinson's disease were not related to survival. African-Americans and other minority groups were less likely to die relative to white people. CONCLUSIONS: Age, sex, functional limitation, and malnutrition seem to be the strongest predictors of death for patients with Alzheimer's disease in nursing homes. Altogether, severity of dementia has no influence on survival, yet the predictive role of certain variables depends on the degree of impairment. Minority groups have a reduced risk of death relative to white people.
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Is drug use by the elderly with cognitive impairment influenced by type of dementia?
Patterns of drug use among the elderly vary greatly depending on level of cognitive function, yet no systematic evaluation of drug use by type of dementia has been performed. We compared patterns of drug use among patients with Alzheimer's disease (AD) and vascular dementia (VaD) to examine their relation to cognitive impairment. We used a population-based data set with over 350,000 residents admitted between 1992 and 1995 to all Medicare-Medicaid-certified nursing homes in five states. After excluding patients with a history of mental disorders or retardation, we identified 23,073 patients age 65 years and over with a diagnosis of AD and 76,087 with VaD. We examined over 350 resident data items (demographic, diagnostic, clinical, treatment) collected with the federally mandated Minimum Data Set, drug data (brand name, dosage, route and frequency of administration for all drugs), and Medicare hospital claims. Cognitive status was measured with a 7-point cognitive performance scale. Estimates of drug use were adjusted for age, gender, race, and prevalence of respective disease. Patients with AD were younger and had more severe cognitive impairment than those with VaD. The latter had more comorbid clinical conditions (3.1 +/- 1.9 vs 2.3 +/- 1.7 for patients with AD) and received a greater number of total drugs (6.1 +/- 4.6 vs 5.3 +/- 4.3). Overall use of cardiovascular, anti-Parkinson, pulmonary, antineoplastic, and nutritional agents was less frequent among patients with AD than those with VaD. Results were consistent across different levels of cognitive impairment. Thus, patients with AD have fewer associated diseases and appear to be less intensively medically treated.
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Organizational and environmental factors associated with nursing home participation in managed care.
OBJECTIVE: To develop and test a model, based on resource dependence theory, that identifies the organizational and environmental characteristics associated with nursing home participation in managed care. DATA SOURCES AND STUDY SETTING: Data for statistical analysis derived from a survey of Directors of Nursing in a sample of nursing homes in eight states (n = 308). These data were merged with data from the On-line Survey Certification and Reporting System, the Medicare Managed Care State/County Data File, and the 1995 Area Resource File. STUDY DESIGN: Since the dependent variable is dichotomous, the logistic procedure was used to fit the regression. The analysis was weighted using SUDAAN. FINDINGS: Participation in a provider network, higher proportions of resident care covered by Medicare, providing IV therapy, greater availability of RNs and physical therapists, and Medicare HMO market penetration are associated with a greater likelihood of having a managed care contract. CONCLUSION: As more Medicare recipients enroll in HMOs, nursing home involvement in managed care is likely to increase. Interorganizational linkages enhance the likelihood of managed care participation. Nursing homes interested in managed care should consider upgrading staffing and providing at least some subacute services.
Contract Services↗
Prevalence, clinical correlates, and treatment of hypertension in elderly nursing home residents. SAGE (Systematic Assessment of Geriatric Drug Use via Epidemiology) Study Group.
BACKGROUND: Hypertension is prevalent in the elderly, but an information gap remains regarding the old, frail, individuals with complex conditions living in long-term care. OBJECTIVE: To analyze the patterns of antihypertensive drug therapy among elderly patients living in nursing homes to elucidate their conformity with consensus guidelines. SUBJECTS AND METHODS: We used a long-term care database that merged sociodemographic, functional, clinical, and treatment information on nearly 300000 patients admitted to the facilities of 5 US states between 1992 and 1994. RESULTS: Hypertension was diagnosed in 80206 patients (mean age, 82.7+/-7.8 years). The prevalence was higher among women and among blacks. About one fourth of patients had 6 or more comorbid conditions; 26%, 22%, and 29% had concomitant diagnoses of coronary heart disease, congestive heart failure, and cerebrovascular disease, respectively. Seventy percent of patients were treated pharmacologically. Calcium channel blockers were the most common agents (26%), followed by diuretics (25%), angiotensin-converting enzyme inhibitors (22%), and beta-blockers (8%). The relative use of these drugs changed according to the presence of other cardiovascular conditions. Adjusting for potential confounders, the relative odds of receiving antihypertensive therapy were significantly decreased for the oldest subjects (> or =85 years old: odds ratio, 0.85; 95% confidence interval, 0.81-0.89) and those with marked impairment of physical (odds ratio, 0.77; 95% confidence interval, 0.73-0.81) and cognitive (odds ratio, 0.67; 95% confidence interval, 0.64-0.70) function. CONCLUSIONS: Among very old, frail hypertensive patients living in nursing homes, the pattern of treatment seems not to follow recommended guidelines; age, functional status, and comorbidity appear to be important determinants of treatment choice.
Adrenergic beta-Antagonists↗
Management of pain in elderly patients with cancer. SAGE Study Group. Systematic Assessment of Geriatric Drug Use via Epidemiology.
CONTEXT: Cancer pain can be relieved with pharmacological agents as indicated by the World Health Organization (WHO). All too frequently pain management is reported to be poor. OBJECTIVE: To evaluate the adequacy of pain management in elderly and minority cancer patients admitted to nursing homes. DESIGN: Retrospective, cross-sectional study. SETTING: A total of 1492 Medicare-certified and/or Medicaid-certified nursing homes in 5 states participating in the Health Care Financing Administration's demonstration project, which evaluated the implementation of the Resident Assessment Instrument and its Minimum Data Set. STUDY POPULATION: A group of 13 625 cancer patients aged 65 years and older discharged from the hospital to any of the facilities from 1992 to 1995. Data were from the multilinked Systematic Assessment of Geriatric Drug Use via Epidemiology (SAGE) database. MAIN OUTCOME MEASURES: Prevalence and predictors of daily pain and of analgesic treatment. Pain assessment was based on patients' report and was completed by a multidisciplinary team of nursing home personnel that observed, over a 7-day period, whether each resident complained or showed evidence of pain daily. RESULTS: A total of 4003 patients (24%, 29%, and 38% of those aged > or =85 years, 75 to 84 years, and 65 to 74 years, respectively) reported daily pain. Age, gender, race, marital status, physical function, depression, and cognitive status were all independently associated with the presence of pain. Of patients with daily pain, 16% received a WHO level 1 drug, 32% a WHO level 2 drug, and only 26% received morphine. Patients aged 85 years and older were less likely to receive morphine or other strong opiates [corrected] than those aged 65 to 74 years (13% vs 38%, respectively). More than a quarter of patients (26%) in daily pain did not receive any analgesic agent. Patients older than 85 years in daily pain were also more likely to receive no analgesia (odds ratio [OR], 1.40; 95% confidence interval [CI], 1.13-1.73). Other independent predictors of failing to receive any analgesic agent were minority race (OR, 1.63; 95% CI, 1.18-2.26 for African Americans), low cognitive performance (OR, 1.23; 95% CI, 1.05-1.44), and the number of other medications received (OR, 0.65; 95% CI, 0.5-0.84 for 11 or more medications). CONCLUSIONS: Daily pain is prevalent among nursing home residents with cancer and is often untreated, particularly among older and minority patients.
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Randomised trial of impact of model of integrated care and case management for older people living in the community.
OBJECTIVE: To evaluate the impact of a programme of integrated social and medical care among frail elderly people living in the community. DESIGN: Randomised study with 1 year follow up. SETTING: Town in northern Italy (Rovereto). SUBJECTS: 200 older people already receiving conventional community care services. INTERVENTION: Random allocation to an intervention group receiving integrated social and medical care and case management or to a control group receiving conventional care. MAIN OUTCOME MEASURES: Admission to an institution, use and costs of health services, variations in functional status. RESULTS: Survival analysis showed that admission to hospital or nursing home in the intervention group occurred later and was less common than in controls (hazard ratio 0.69; 95% confidence interval 0.53 to 0.91). Health services were used to the same extent, but control subjects received more frequent home visits by general practitioners. In the intervention group the estimated financial savings were in the order of 1125 ($1800) per year of follow up. The intervention group had improved physical function (activities of daily living score improved by 5.1% v 13.0% loss in controls; P<0.001). Decline of cognitive status (measured by the short portable mental status questionnaire) was also reduced (3.8% v 9.4%; P<0.05). CONCLUSION: Integrated social and medical care with case management programmes may provide a cost effective approach to reduce admission to institutions and functional decline in older people living in the community.
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Validity of diagnostic and drug data in standardized nursing home resident assessments: potential for geriatric pharmacoepidemiology. SAGE Study Group. Systematic Assessment of Geriatric drug use via Epidemiology.
OBJECTIVES: The Health Care Financing Administration requires that patients admitted to certified nursing homes be assessed with the Minimum Data Set, a data collection instrument containing more than 300 demographic, diagnostic, clinical, and treatment variables. Long-term care databases potentially may be used to assess the outcomes of specific treatments as well as drug effectiveness. The authors sought to ascertain reliability and validity of diagnostic and drug data in a database obtained by merging the Minimum Data Set with detailed information on drugs consumed by each resident. METHODS: A population of 296,379 residents of 1,492 nursing homes in Kansas, Maine, Mississippi, New York, and South Dakota participated in the study between 1992 and 1994. Minimum Data Set clinical diagnoses were contrasted with selected resident characteristics and a variety of symptoms and treatments. Limited to individuals who had been hospitalized in the 6 months preceding the first assessment, Minimum Data Set diagnoses were compared with those on the hospital discharge claims maintained in the Medicare Provider Analysis and Review database. Finally, the probability that the use of selected drugs predicted the correspondent gender-specific, age-specific, or unique labeled indication was estimated. RESULTS: The positive predictive value for Minimum Data Set diagnoses compared with gender or function measures exceeded 0.9, and it was 0.8 for specific symptoms and 0.6 for virtually all other comparisons. The positive predictive value for Minimum Data Set diagnoses compared with those from hospital claims was approximately 0.7 for all chronic medical conditions, except for depression and asthma/chronic obstructive pulmonary disease/emphysema. The positive predictive value for acute/subacute diagnoses (ie, pneumonia, urinary tract infection, anemia) that may resolve during hospital stay was less than 0.5. The positive predictive value for selected drugs, except estrogens, compared with age and gender was close to 1.0 in all cases. When compared to their labeled indication, the positive predictive value was more than 0.6 for all drugs considered, with 0.97, 0.91, and 0.87 for tacrine and Alzheimer's disease, antidiabetics and diabetes mellitus, and L-dopa and Parkinson's disease, respectively. CONCLUSIONS: These findings point to the overall validity of the drug and clinical data in this Minimum Data Set-based data set. Additional validation efforts will determine whether this data set can be used for studies of geriatric pharmacoepidemiology and for analyses of the influence of different policies and practices on residents' outcomes.
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Physical restraints in nursing homes: a review of the literature since the Nursing Home Reform Act of 1987.
The use of physical restraints is one of the most negative features of nursing home care. Their use significantly affects the quality of life of residents. In an attempt to limit the use of restraints, the Nursing Home Reform Act (NHRA) of 1987 contained provisions regulating their use. In this article, the authors review the literature on the use and consequences of physical restraints in nursing homes since the passage of the NHRA. First, they describe the history behind the use of restraints and define what is considered to be a physical restraint. Second, they examine the four most common justifications for restraint use. Third, they describe the incidence and prevalence of restraint use. Fourth, they address demographic and clinical characteristics of residents that have been found to be associated with restraint use. Fifth, they examine negative outcomes of restraining residents. Finally, they describe alternatives to using restraints.
Activities of Daily Living↗
Opportunities and dangers in the changing health care system.
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Managed Care Programs↗
The emergence of Medicare managed care: Implications for the post-acute sector.
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Home Care Agencies↗