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B Kader

Publications and source records attributed to B Kader.

8 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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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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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

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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