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Biomedical subjects

Dan Osterweil

Publications and source records attributed to Dan Osterweil.

18 recordsLinked to original sources
PubMed2006

A standardized quality assessment system to evaluate pain detection and management in the nursing home.

CONTEXT: Assessment and management of pain for nursing home residents is frequently reported to be inadequate, yet few studies have used objective criteria to measure the quality of care related to pain. OBJECTIVE: Field test a standardized resident interview and medical record review protocol to assess and score quality indicators relevant to pain. DESIGN: Descriptive. SETTING: Thirty nursing homes (NHs). PARTICIPANTS: Seven hundred ninety-four residents met overall eligibility criteria. Quality indicators were scored for those residents who met specific eligibility requirements for each pain indicator. MEASUREMENTS: Medical record reviews were completed for 542 participants, and data were used to score 12 indicators related to pain assessment, management, and response to treatment. A seven-item pain interview was attempted with all 794 participants and completed with 478 participants who were rated by NH staff as cognitively aware. RESULTS: Quality indicators could be reliably scored. Physicians scored low on assessment of pain, performing targeted history and physical examinations, documenting risk factors for use of analgesics, and documenting response to treatment. Forty-eight percent of participants (227/478) reported symptoms of chronic pain during the interview, and 81% of this group reported a preference for a pain medication. However, nearly half had no physician assessment of pain in the past year and only 42% were receiving pain medication. Licensed nurse assessments of pain were documented weekly; but, more than 50% of those reporting symptoms of chronic pain on interview had nurse pain scores of 0 for 4 consecutive weeks prior to interview. CONCLUSIONS: Infrequent or incomplete physician pain assessment and treatment and inaccurate documentation by licensed nurses limits evaluation of pain care quality based on medical record review alone. A brief resident interview identified participants reporting symptoms of chronic pain not documented in the medical record and those with a preference for medication. Initial targeting of residents with self-reported pain maximizes the efficiency of the standardized scoring system described in this study. Focusing on explicit process measures clearly identifies areas for improvement and represents an important step in assessing the quality of pain care in the NH.

Journal Article↗
PubMed2005

Improving the quality of nursing home care and medical-record accuracy with direct observational technologies.

Nursing home medical-record documentation of daily-care occurrence may be inaccurate, and information is not documented about important quality-of-life domains. The inadequacy of medical record data creates a barrier to improving care quality, because it supports an illusion of care consistent with regulations, which reduces the motivation and ability of providers to identify areas for improvement. Observational protocols designed for use by survey and quality-assurance staff can provide the independent information necessary for improving both medical record accuracy and residents' quality of life. Unfortunately, observational protocols currently used in survey and quality-assurance activities are not designed in a manner that is consistent with the scientific principles that guide observational measurement. The purpose of this article is to describe the steps to develop a standardized and scientifically defensible observational system to assess nursing home care quality.

Aged↗
PubMed2003

Does an exercise and incontinence intervention save healthcare costs in a nursing home population?

OBJECTIVES: To determine whether an intervention that combines low-intensity exercise and incontinence care offsets some of its costs by reducing the incidence of selected health conditions in nursing home residents. DESIGN: Randomized, controlled trial with the incidence and costs of selected, acute conditions compared between a 6-month baseline and an 8-month intervention phase. SETTING: Four nursing homes. PARTICIPANTS: One hundred ninety incontinent, long-stay nursing home residents. INTERVENTION: Low-intensity, functionally oriented exercise and incontinence care were provided every 2 hours from 8:00 a.m. to 4:00 p.m. for 5 days a week for 8 months. MEASUREMENTS: Predefined acute conditions hypothesized to be related to physical inactivity, incontinence, or immobility were abstracted from residents' medical records by blinded observers during a 6-month baseline period and throughout the 8-month intervention. Conditions included those in the dermatological, genitourinary, gastrointestinal, respiratory and cardiovascular systems; falls; pain; and psychiatric and nutritional disturbances. Costs were determined using Current Procedural Terminology Center and Medicare allowable cost reimbursement at a rate of 80%. RESULTS: The intervention group had significantly better functional outcomes than the control group (strength, mobility endurance, urinary and fecal incontinence) and a reduction of 10% in the incidence of the acute conditions, which was not significant. There were no significant differences between groups in the cost of assessing and treating these acute conditions between baseline and intervention. CONCLUSION: The intervention, which is consistent with federal and clinical practice guidelines, significantly improved functional outcomes but did not reduce the incidence and costs of selected acute health conditions. The cost of implementing these labor-intensive interventions for frail nursing home residents will have to be justified based on functional and quality-of-life outcomes and are unlikely to be offset by savings in medical care costs in this population.

Acute Disease↗
PubMed2003

The minimum data set pressure ulcer indicator: does it reflect differences in care processes related to pressure ulcer prevention and treatment in nursing homes?

OBJECTIVES: To determine whether nursing homes (NHs) that score in the extreme quartiles of pressure ulcer (PU) prevalence as reported on the Minimum Data Set (MDS) PU quality indicator provide different PU care. DESIGN: Descriptive, cohort. SETTING: Sixteen NHs. PARTICIPANTS: Three hundred twenty-nine NH residents at risk for PU development as determined by the PU Resident Assessment Protocol of the MDS. MEASUREMENTS: : Sixteen care process quality indicators (10 specific to PU care processes, five related to nutrition, and one related to incontinence management) were scored using medical record data, direct human observation, interviews, and data from wireless thigh movement monitors. RESULTS: There were no differences between homes with low- and high-PU prevalence rates reported on the MDS PU quality indicator on most care processes. NHs with high PU prevalence rates used pressure-reduction surfaces more frequently and were better at documentation of four wound characteristics when PUs were present. No measure of PU care processes was better in low-PU NHs. Neither low- nor high-PU prevalence NHs routinely repositioned residents every 2 hours, even though 2-hour repositioning was documented in the medical record for nearly all residents. CONCLUSION: The assumption that homes with fewer PUs and thus low PU prevalence according to the MDS PU quality indicator are providing better PU care was not supported in this sample. NHs that scored low on the MDS PU quality indicator did not provide significantly better care than NHs that scored high. All NHs could improve PU prevention, as evidenced by the poor performance on prevention care processes by low- and high-PU NHs. The MDS PU quality indicator is not a useful measure of the quality of PU care in NHs and can be misleading if not presented with an explanation of the meaning of the indicator.

Aged↗
PubMed2003

The minimum data set weight-loss quality indicator: does it reflect differences in care processes related to weight loss?

OBJECTIVES: To determine whether nursing homes (NHs) that score differently on prevalence of weight loss, according to a Minimum Data Set (MDS) quality indicator, also provide different processes of care related to weight loss. DESIGN: Cross-sectional. SETTING: Sixteen skilled nursing facilities: 11 NHs in the lower (25th percentile-low prevalence) quartile and five NHs in the upper (75th percentile-high prevalence) quartile on the MDS weight-loss quality indicator. PARTICIPANTS: Four hundred long-term residents. MEASUREMENTS: Sixteen care processes related to weight loss were defined and operationalized into clinical indicators. Trained research staff conducted measurement of NH staff implementation of each care process during assessments on three consecutive 12-hour days (7 a.m. to 7 p.m.), which included direct observations during meals, resident interviews, and medical record abstraction using standardized protocols. RESULTS: The prevalence of weight loss was significantly higher in the participants in the upper quartile NHs than in participants in the lower quartile NHs based on MDS and monthly weight data documented in the medical record. NHs with a higher prevalence of weight loss had a significantly larger proportion of residents with risk factors for weight loss, namely low oral food and fluid intake. There were few significant differences on care process measures between low- and high-weight-loss NHs. Staff in low-weight-loss NHs consistently provided verbal prompting and social interaction during meals to a greater proportion of residents, including those most at risk for weight loss. CONCLUSION: The MDS weight-loss quality indicator reflects differences in the prevalence of weight loss between NHs. NHs with a lower prevalence of weight loss have fewer residents at risk for weight loss and staff who provide verbal prompting and social interaction to more residents during meals, but the adequacy and quality of feeding assistance care needs improvement in all NHs.

Aged↗
PubMed2003

A standardized quality assessment system to evaluate incontinence care in the nursing home.

OBJECTIVES: To demonstrate the reliability and feasibility of a standardized protocol to assess and score urinary incontinence care in nursing homes. DESIGN: Descriptive. SETTING: Eighteen nursing homes (NHs). PARTICIPANTS: Four hundred twenty-six incontinent residents. MEASUREMENTS: Resident interview data were used to score three quality indicators, and usable data were retrieved from 117 (27%) of 426 incontinent residents in 18 homes who were selected for interview based on evidence that they could accurately describe the care they received. Medical record data were used to score six quality indicators for a subset of 58 participants in five homes. RESULTS: Zero to 98% of the participants were scored as receiving care consistent with the intent of the indicator across the nine indicators. All NHs failed to provide chart documentation of an assessment to determine an incontinent resident's appropriateness for a scheduled toileting program (0% passed). The absence of an assessment to determine a resident's potential responsiveness to toileting assistance may explain why 103 incontinent residents who were documented on the Minimum Data Set as being on a scheduled toileting program reported that they received the same number of toileting assists per day (1.3) as the group of 114 incontinent residents who were not on a scheduled toileting program (1.0). The received toileting assistance frequencies reported by both groups were too low to maintain continence. CONCLUSION: The standardized quality assessment system generated scores for nine incontinence quality indicators with good interrater reliability and provided explicit scoring rules that can facilitate replication. The focus of the indicators on care processes that are under the control of NH staff make the protocol useful for external survey and internal quality improvement purposes.

Aged↗
PubMed2003

The minimum data set urinary incontinence quality indicators: do they reflect differences in care processes related to incontinence?

PURPOSE: To determine if nursing homes that score in the lower 25th percentile (low prevalence) versus the upper 75th percentile (high prevalence) on each of two Minimum Data Set (MDS) incontinence quality indicators provide different incontinence care processes DESIGN: Cross-sectional. SUBJECTS: 347 long-term residents in 14 skilled nursing facilities for the MDS "prevalence of incontinence" indicator and 432 residents in 16 skilled nursing facilities for the MDS "prevalence of incontinence without a toileting plan" indicator. MEASURES: Nine care processes related to incontinence were defined and operationalized into clinical indicators. Research staff assessed implementation of each care process on 3 consecutive 12-hour days (7 am to 7 pm ). The assessment included resident interviews, physical performance evaluations, and chart abstraction using standardized protocols. RESULTS: Homes with lower prevalence rates on both MDS incontinence quality indicators (good outcomes) had a significantly higher proportion of participants with chart documentation of two relevant care processes: 1 an evaluation of the resident's incontinence history and 2 toileting assistance rendered by staff. However, interviews with incontinent residents capable of accurately reporting care activity occurrence showed no difference in toileting assistance frequency between homes in the upper and lower quartiles for either MDS incontinence indicator. Participants reported an average of 1.8 toileting assists per day across all homes with a narrow average frequency range between homes (1.6-2.0). These frequencies of toileting assistance are not sufficient to improve urinary incontinence. There was also no difference in the frequency of toileting assistance received by incontinent participants rated on the MDS as receiving scheduled toileting (n = 75, mean = 1.9 +/- 1.24) compared to incontinent residents rated on the MDS as not receiving scheduled toileting (n = 131, mean = 1.8 +/- 1.22). None of the homes provided chart documentation that supported staff decisions to place or not place a resident on a scheduled toileting program. CONCLUSIONS: The quality of incontinence assessment and treatment as documented by scheduled toileting interventions was poor across all homes, and the MDS incontinence quality indicators were not associated with clinically important differences in related care processes. Chart documentation that a resident was on a scheduled toileting program or received toileting assistance was not related to resident reports of the frequency of received assistance.

Aged↗
PubMedDate not supplied

A standardized quality assessment system to evaluate pain detection and management in the nursing home.

CONTEXT: Assessment and management of pain for nursing home residents is frequently reported to be inadequate, yet few studies have used objective criteria to measure the quality of care related to pain. OBJECTIVE: Field test a standardized resident interview and medical record review protocol to assess and score quality indicators relevant to pain. DESIGN: Descriptive. SETTING: Thirty nursing homes (NHs). PARTICIPANTS: Seven hundred ninety-four residents met overall eligibility criteria. Quality indicators were scored for those residents who met specific eligibility requirements for each pain indicator. MEASUREMENTS: Medical record reviews were completed for 542 participants, and data were used to score 12 indicators related to pain assessment, management, and response to treatment. A seven-item pain interview was attempted with all 794 participants and completed with 478 participants who were rated by NH staff as cognitively aware. RESULTS: Quality indicators could be reliably scored. Physicians scored low on assessment of pain, performing targeted history and physical examinations, documenting risk factors for use of analgesics, and documenting response to treatment. Forty-eight percent of participants (227/478) reported symptoms of chronic pain during the interview, and 81% of this group reported a preference for a pain medication. However, nearly half had no physician assessment of pain in the past year and only 42% were receiving pain medication. Licensed nurse assessments of pain were documented weekly; but, more than 50% of those reporting symptoms of chronic pain on interview had nurse pain scores of 0 for 4 consecutive weeks prior to interview. CONCLUSIONS: Infrequent or incomplete physician pain assessment and treatment and inaccurate documentation by licensed nurses limits evaluation of pain care quality based on medical record review alone. A brief resident interview identified participants reporting symptoms of chronic pain not documented in the medical record and those with a preference for medication. Initial targeting of residents with self-reported pain maximizes the efficiency of the standardized scoring system described in this study. Focusing on explicit process measures clearly identifies areas for improvement and represents an important step in assessing the quality of pain care in the NH.

Aged↗
PubMedDate not supplied

The effect of megestrol acetate on oral food and fluid intake in nursing home residents: a pilot study.

OBJECTIVES: The objective of this study was to evaluate the effect of megestrol acetate (Megace OS; Bristol-Myers Squibb, Princeton, NJ) on the oral food and fluid intake of nursing home (NH) residents under two conditions: usual NH care and optimal mealtime feeding assistance. DESIGN AND SETTING: We conducted a prospective, preliminary trial in four NHs. PARTICIPANTS: Participants (n = 17) were recruited from a larger study designed to assess nutritional care quality. Eligibility for the Megace OS trial required participants to consistently eat less than 75% of most meals under both usual NH care and optimal feeding assistance conditions at baseline. INTERVENTION: Megace OS, an oral liquid suspension of megestrol acetate, was given daily in a 400-mg dose for 63 days. MEASUREMENTS: Each participant's oral food and fluid intake was monitored weekly for 1 day (three meals) during which research staff conducted direct observations of usual NH care (weeks 1, 3, and 5 and day 63) or provided optimal feeding assistance (weeks 2, 4, and 6). Average total percent intake was compared from baseline across the assessment weeks of the trial under the two mealtime care conditions. RESULTS: Megace OS had a significant effect on oral food and fluid intake only under the optimal mealtime feeding assistance condition, in which average total percent eaten increased from 50% (+/-15%) at baseline to 63% (+/-14%) post-63 days of the trial. There was no change in participants' oral food and fluid intake under the usual NH care condition (average total percent intake at baseline 43% +/- 12% vs. 43% +/- 20% post-63 days). CONCLUSION: The results of this preliminary study suggest that Megace OS is not an effective nutritional intervention to increase oral intake under usual NH care conditions, which is often characterized by inadequate feeding assistance. However, Megace OS in combination with optimal mealtime feeding assistance does significantly increase oral intake in a frail NH sample at high risk for weight loss.

Aged↗
PubMedDate not supplied

Inhaled zanamivir versus rimantadine for the control of influenza in a highly vaccinated long-term care population.

BACKGROUND: Despite vaccination, influenza commonly causes morbidity and mortality in institutional settings. Influenza control with rimantadine and amantadine is limited by emergence and transmission of drug-resistant influenza A variants, ineffectiveness against influenza B, and toxicity. This study evaluated the efficacy and tolerability of zanamivir versus rimantadine for influenza outbreak control in long-term care facilities. METHODS: This double-blind, randomized, controlled study prospectively enrolled nursing home residents for 3 influenza seasons (1997 to 2000). Vaccine was offered to all subjects. Following influenza outbreak declaration, subjects were randomized to inhaled zanamivir 10 mg or standard of care (rimantadine 100 mg for influenza A or placebo for influenza B) once daily for 14 days. The proportion of randomized subjects developing symptomatic, laboratory-confirmed influenza during prophylaxis was the primary endpoint. RESULTS: Of 482 randomizations (238 zanamivir, 231 rimantadine, 13 placebo), 96% of subjects were elderly or had high-risk conditions; over 90% were vaccinated. Symptomatic, laboratory-confirmed influenza occurred in 3% of zanamivir subjects and 8% of rimantadine subjects during chemoprophylaxis (P = .038; additional protective efficacy for zanamivir over rimantadine = 61%). Since only 25 subjects were randomized during 2 influenza B outbreaks and none developed influenza, the influenza B data were excluded from further analysis. Zanamivir was well tolerated and unassociated with emergence of resistant virus; rimantadine-resistant variants were common. CONCLUSIONS: This is the first prospective, controlled study demonstrating effectiveness of chemoprophylaxis for influenza outbreak control. Zanamivir prevents symptomatic, laboratory-confirmed influenza more effectively than rimantadine, is unassociated with resistant virus, and has a favorable safety profile. Zanamivir is an appropriate alternative for influenza outbreak control among institutionalized vaccinated elderly.

Administration, Inhalation↗
PubMedDate not supplied

Incidence and costs of acute medical conditions in long-stay incontinent nursing home residents.

OBJECTIVES: To determine the incidence of acute medical conditions in incontinent nursing home residents, and associated costs of diagnostic testing and treatment DESIGN: Prospective, cohort study. SETTING: Three community nursing homes. PARTICIPANTS: 161 long-stay residents with urinary incontinence in (mean age 86 years, 77% female, 92% white). MEASUREMENTS: Acute medical conditions were identified prospectively through medical record review based on standardized criteria. All diagnostic testing and treatment provided for these conditions were recorded, and related costs in the nursing home were assigned based on 1997-1998 Medicare and Medicaid reimbursement. RESULTS: The highest incidences of illness were for dermatological conditions (107 episodes per 1000 patient-weeks, involving 70% of subjects), respiratory illnesses (29 per 1000 patient-weeks, 47% of subjects) and gas-trointestinal illnesses (24 per 1000 patient-weeks, 36% of subjects). Among episodes with an incidence of at least 5 per 1000 patient-weeks, the illness events with the highest median diagnostic testing and treatment costs per episode were pneumonia, acute bronchitis, and depression. Only 42 out of the total 1071 episodes identified resulted in a hospitalization. Significant predictors of higher illness incidence included greater baseline comorbidity and higher number of routine medications (model adjusted R-square = 0.319, P = 0.021). CONCLUSION: Acute illness is very common among incontinent nursing home residents, and is generally diagnosed and treated at the nursing home site, with variation among conditions in associated costs. Important policy implications include resource allocation (including appropriate staffing patterns), educational and quality improvement activities, and future research and guideline development for the optimal management of medical conditions in the nursing home setting.

Acute Disease↗
PubMedDate not supplied

Prescription analgesic and antidepressant utilization and cost among elderly Medicaid beneficiaries before and after nursing home admission.

OBJECTIVES: The objectives of this study were to describe changes in prescription analgesic and antidepressant medications and to track the costs associated with these medication changes when elderly Medicaid beneficiaries move from the community to a nursing home setting. DESIGN: Retrospective analysis of Medicaid long-term care and drugs claims data for fiscal year 2000 from three different states. SETTING: Long-term care facilities in three different states. PARTICIPANTS: We studied 1321 elderly Medicaid beneficiaries newly admitted to a nursing home during the study period. MEASUREMENTS: Pain medications were grouped into four different categories and all antidepressants were grouped into one category. For each medication category, we obtained the number of unique patients for whom it was prescribed, the number of days it was prescribed, and the amount paid by Medicaid. We then calculated the percentage of subjects prescribed and the amount paid per day for each medication class before and after nursing home admission. RESULTS: Except for skeletal muscle relaxants, 21% to 39% of beneficiaries already had claims linked to each medication class while still living in the community. After nursing home admission, the percentage of beneficiaries exposed to each medication class increased by 2% to 33%. Cost per day of therapy increased by 10% to 83%. There was significant variation among the states in utilization and cost per day of therapy. CONCLUSIONS: We draw three major conclusions: (1) community-dwelling elderly Medicaid beneficiaries in this study use more prescription analgesics and antidepressants than community-dwelling elders in prior studies; (2) there is a significant increase in medication utilization and cost on nursing home admission; and (3) significant variability in medication use and cost exists among the three states examined. Further investigation to elucidate the reasons for these differences could assist legislators in formulating sound public policy to contain Medicaid expenditures without sacrificing patient care.

Aged↗
PubMedDate not supplied

The effect of megestrol acetate on oral food and fluid intake in nursing home residents: a pilot study.

OBJECTIVES: The objective of this study was to evaluate the effect of megestrol acetate (Megace OS; Bristol-Myers Squibb, Princeton, NJ) on the oral food and fluid intake of nursing home (NH) residents under two conditions: usual NH care and optimal mealtime feeding assistance. DESIGN AND SETTING: We conducted a prospective, preliminary trial in four NHs. PARTICIPANTS: Participants (n = 17) were recruited from a larger study designed to assess nutritional care quality. Eligibility for the Megace OS trial required participants to consistently eat less than 75% of most meals under both usual NH care and optimal feeding assistance conditions at baseline. INTERVENTION: Megace OS, an oral liquid suspension of megestrol acetate, was given daily in a 400-mg dose for 63 days. MEASUREMENTS: Each participant's oral food and fluid intake was monitored weekly for 1 day (three meals) during which research staff conducted direct observations of usual NH care (weeks 1, 3, and 5 and day 63) or provided optimal feeding assistance (weeks 2, 4, and 6). Average total percent intake was compared from baseline across the assessment weeks of the trial under the two mealtime care conditions. RESULTS: Megace OS had a significant effect on oral food and fluid intake only under the optimal mealtime feeding assistance condition, in which average total percent eaten increased from 50% (+/- 15%) at baseline to 63% (+/- 14%) post-63 days of the trial. There was no change in participants' oral food and fluid intake under the usual NH care condition (average total percent intake at baseline 43% +/- 12% vs. 43% +/- 20% post-63 days). CONCLUSION: The results of this preliminary study suggest that Megace OS is not an effective nutritional intervention to increase oral intake under usual NH care conditions, which is often characterized by inadequate feeding assistance. However, Megace OS in combination with optimal mealtime feeding assistance does significantly increase oral intake in a frail NH sample at high risk for weight loss.

Activities of Daily Living↗