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Biomedical subjects

David R Mehr

Publications and source records attributed to David R Mehr.

At least 19 recordsLinked to original sources
PubMed2006

Predictors of mortality for lower respiratory infections in nursing home residents with dementia were validated transnationally.

BACKGROUND AND OBJECTIVE: Generalizability of clinical predictors for mortality from lower respiratory infection (LRI) in nursing home residents has not been assessed for residents with dementia. STUDY DESIGN AND SETTING: In prospective cohort studies of LRI in 61 nursing homes in the Netherlands (n = 541) and 36 nursing homes in Missouri, USA (n = 564), we examined 14-day and 1- and 3-month mortality in residents with dementia who were treated with antibiotics. RESULTS: A logistic model predicting 14-day mortality derived from Dutch data included eating dependency, elevated pulse, decreased alertness, respiratory difficulty, insufficient fluid intake, high respiratory rate, male gender, and pressure sores. After adjusting coefficients with the heuristic shrinkage factor, the 14-day model showed good discrimination and calibration in both datasets. The apparent c-statistic for the original Dutch model was 0.80 (after correction for optimism, it was 0.75); the c-statistic was 0.74 in the U.S. validation population. The models predicting 1- and 3-month mortality showed moderate performance. A scoring system for estimating 14-day mortality performed equally well as the original model. CONCLUSION: We identified a set of credible clinical predictors that are easily assessed and demonstrated validity in identifying residents at low risk of dying from LRI across different nursing home populations. This tool should inform decision-making for families and doctors.

Aged↗
PubMed2006

Defining severe dementia with the Minimum Data Set.

BACKGROUND: Accurately defining severe dementia is important for care and prognosis, but is not explicitly included in the Minimum Data Set (MDS). OBJECTIVE: To define severe dementia using the MDS, we used data for nursing home residents with moderate to severe dementia. METHODS: Two cross-sectional studies enrolled 175 residents; 89 residents from one US Veterans Affairs nursing home, and 86 residents from nine Dutch nursing homes. Measurements included the Cognitive Performance Scale (CPS; range: 0-6), activities of daily living (ADL) dependency, and the Bedford Alzheimer Nursing Severity-Scale (BANS-S; range: 7-28), a staging instrument specific for severe dementia. RESULTS: Half of the residents received CPS scores of 5, and their BANS-S scores varied widely. There was fair agreement (kappa=0.36) between severe cognitive impairment as defined by the CPS (scores 5 and 6) and the BANS-S (score 17 or higher). Addition of an ADL dependency requirement to the CPS definition improved agreement (kappa=0.75). The observed patterns were similar but more obvious for US residents than for Dutch residents. CONCLUSION: Cognitively impaired residents comprise a heterogeneous group with a wide variety of function. Restriction with respect to ADL dependency allows for distinction between moderate and severe dementia. We propose the following MDS-based definition of severe dementia: a CPS score of 5 or 6 with a minimum score of at least 10 points on the MDS ADL-Short Form.

Activities of Daily Living↗
PubMed2006

Changes in the use of postacute care during the initial Medicare payment reforms.

OBJECTIVE: To examine changes in postacute care (PAC) use during the initial Medicare payment reforms enacted by the Balanced Budget Act of 1997. DATA SOURCES: We used claims data from the 5 percent Medicare beneficiary sample in 1996, 1998, and 2000. Linked data from the Denominator file, Provider of Service file, and Area Resource File provided additional patient, hospital, and market-area characteristics. STUDY DESIGN: Six disease groups with high PAC use were selected for analysis. We used multinomial logit regression to examine how PAC use differed by year of service, controlling for patient, hospital, and market-area characteristics. PRINCIPAL FINDINGS: There were major changes in PAC use, and a portion of services shifted to settings where reimbursement remained cost-based. During the first reform, the home health agency interim payment system, home health use decreased consistently across disease groups. This decrease was accompanied by increased use in skilled nursing facilities (SNFs). Following the implementation of the prospective payment system for SNFs, the use of inpatient rehabilitation facilities increased. CONCLUSIONS: The shift in usage among settings occurred in two stages that corresponded to the timing of payment reforms for home health agencies and SNFs. Evidence strongly suggests the substitutability between PAC settings. Financial incentives, in addition to clinical needs and individual preferences, play a major role in PAC use.

Acute Disease↗
PubMed2006

Entrepreneurial program of research and service to improve nursing home care.

This is a methodological article intended to demonstrate the integration of multiple goals, multiple projects with diverse foci, and multiple funding sources to develop an entrepreneurial program of research and service to directly affect and improve the quality of care of older adults, particularly nursing home residents. Examples that illustrate how clinical ideas build on one another and how the research ideas and results build on one another are provided. Results from one study are applied to the next and are also applied to the development of service delivery initiatives to test results in the real world. Descriptions of the Quality Improvement Program for Missouri and the Aging in Place Project are detailed to illustrate real-world application of research to practice.

Aged↗
PubMed2006

Field testing, refinement, and psychometric evaluation of a new measure of nursing home care quality.

The primary aim of this NINR-NIH-funded field test in 407 nursing homes in 3 states was to complete the development of and conduct psychometric testing for the Observable Indicators of Nursing Home Care Quality Instrument (Observable Indicators, OIQ). The development of the OIQ was based on extensive qualitative and iterative quantitative work that described nursing home care quality and did initial validity and reliability field testing of the instrument in 123 nursing homes in 1 state. The scale is meant for researchers, consumers, and regulators interested in directly observing and quickly evaluating (within 30 minutes of observation) the multiple dimensions of care quality in nursing homes. After extensive testing in this study, the Observable Indicators instrument has been reduced to 30 reliable and discriminating items that have a conceptually coherent hierarchical factor structure that describes nursing home care quality. Seven first-order factors group together into two second-order factors of Structure (includes Environment: Basics and Odors) and Process (includes Care Delivery, Grooming, Interpersonal Communication, Environment: Access, and Environment: Homelike) that are classic constructs of Quality, which was the third-order factor. Internal consistency reliability for the 7 first-order factors ranged from .77 to .93. Construct validity analyses revealed an association between survey citations and every subscale as well as the total score of the OIQ instrument. Known groups analysis revealed expected trends in the OIQ scores. The Observable Indicators instrument as a whole shows acceptable interrater and test-retest reliabilities, and strong internal consistency. Scale subscales show acceptable reliability as well. Generalizability Theory analyses revealed that dependability of scores can be improved by including a second site observer, or by revisiting a site. There is a small additional benefit from increasing observers or visits beyond two.

Communication↗
PubMed2005

Measuring pain presence and intensity in nursing home residents.

OBJECTIVES: To examine the extent of agreement between nursing home residents' (or their proxies') reports of pain presence and intensity as derived from an interview questionnaire and the Minimum Data Set (MDS) nearest to the interview date. DESIGN: Cross-sectional comparison of the 2 data sources on pain measurements. SETTING: Nursing homes included in evaluation projects of EverCare program and Minnesota Senior Health Options. PARTICIPANTS: Nursing home residents (n = 3100) were grouped based on the type of respondent answering the interview questionnaire: resident, family proxy, or staff proxy. MEASUREMENTS: We used kappa statistics and multinomial logit regression to examine agreement between the interview questionnaire and the MDS on pain presence and intensity. RESULTS: Presence of pain was reported 1.3 to 1.8 times more often on the questionnaire, depending on the respondent group. Agreement on the presence of pain was slight to fair (kappa = 0.17 to 0.28) between the MDS and the questionnaire. There was slight agreement on pain intensity (kappa = 0.13 to 0.18). The family proxy respondent group showed the largest discrepancy between questionnaire and the MDS in reporting of pain presence and intensity. The staff proxy respondent group had better agreement on pain intensity than did the other respondent groups, but it achieved only slight agreement (kappa = 0.18). CONCLUSIONS: Detecting and quantifying pain in nursing home residents is complex. Pain information is best obtained directly from residents; observations should be standardized. The MDS should be revised accordingly.

Aged, 80 and over↗
PubMed2005

Comorbidity and 1-year mortality risks in nursing home residents.

OBJECTIVES: To investigate the effect of chronic diseases and disease combinations on 1-year mortality in nursing home residents. DESIGN: Retrospective cohort study using electronically submitted Minimum Data Set (MDS) information and Missouri death certificate data. SETTING: Five hundred twenty-two nursing homes in Missouri. PARTICIPANTS: Forty-three thousand five hundred ten nursing home residents with a full MDS assessment in 1999. MEASUREMENTS: Information about chronic diseases, age, sex, and performance in activities of daily living (ADLs) available from the first full MDS 2.0 assessment in 1999; death within 1 year after the first full MDS-assessment in 1999. RESULTS: After adjustment for age and sex, eight variables were predictive for 1-year mortality: seven chronic diseases (dementia, cancer, heart failure, renal failure, emphysema/chronic obstructive pulmonary disease, diabetes mellitus, and anemia) and an interaction variable containing age and cancer. Adding terms for disease combinations (e.g., diabetes mellitus and heart failure) did not enhance survival prediction. When there was also adjustment for ADL performance as measured using the MDS-ADL Short Form, dementia and anemia were not included, because they had no prognostic value above that of the other variables. CONCLUSION: Several chronic diseases were associated with 1-year mortality in the institutionalized elderly after adjustment for ADL performance, age, and sex. Evidence of a synergistic effect of disease combinations on mortality is lacking.

Activities of Daily Living↗
PubMed2005

Home-based comprehensive assessment of rural elderly persons: the CARE project.

CONTEXT: Home-based comprehensive geriatric assessment (CGA) has been effective in urban areas but has had little study in rural areas. CGA involves medical history taking, a physical exam, and evaluation of functional status, mental status, cognitive status, gait and balance, medications, vision, extent of social supports, and home safety. We sought to develop and pilot a model of rural home-based CGA to determine whether successful urban models can be adapted to rural areas. METHODS: This study was a developmental demonstration project with qualitative and quantitative evaluation components of a home-based CGA model using a home health agency and a geriatrician participating from a remote location by teleconference. Findings and recommendations were relayed to patients, caregivers, and primary physicians. The population studied was elderly volunteers (N = 51) aged 75 years and older who did not have a terminal diagnosis or immediate plans to enter a long-term care facility. Survey instruments and focus groups were used with subjects, family members or caregivers, and physicians to generate refinements and outcome measures for the model. FINDINGS: Among the 51 patients undergoing CGA, Instrumental Activities of Daily Living dependency and balance and gait problems were highly prevalent. Means of 1.1 major problems and 4.9 nonmajor problems were identified per patient. Recommendations were implemented for 32% of major problems and for 35% of nonmajor problems. Primary physicians found recommendations for vaccination and home safety change helpful but were skeptical of physical examination findings by the nurse. Practitioners noted that this study resulted in several positive outcomes: (1) some subjects initiated regular clinic visits; (2) several visually impaired elders began services for the blind; (3) identification of gait and balance problems resulted in physical therapy treatment; and (4) identification of caregiver stress was addressed by social-work intervention. Potential further refinements of the model for rural home-based CGA were identified. CONCLUSIONS: Home-based CGA identifies important problems of rural older adults. However, modifications are still needed to create a truly effective process.

Activities of Daily Living↗
PubMed2004

Nursing home quality, cost, staffing, and staff mix.

PURPOSE: The purpose of this study was to describe the processes of care, organizational attributes, cost of care, staffing level, and staff mix in a sample of Missouri homes with good, average, and poor resident outcomes. DESIGN AND METHODS: A three-group exploratory study design was used, with 92 nursing homes randomly selected from all nursing homes in Missouri and classified into resident outcome groups. Resident outcomes were measured by use of quality indicators derived from nursing home Minimum Data Set resident assessment data. Cost and staffing information were derived from Medicaid cost reports. Participant observation methods were used to describe the care delivery processes. RESULTS: In facilities with good resident outcomes, there are basics of care and processes surrounding each that staff consistently do: helping residents with ambulation, nutrition and hydration, and toileting and bowel regularity; preventing skin breakdown; and managing pain. The analysis revealed necessary organizational attributes that must be in place in order for those basics of care to be accomplished: consistent nursing and administrative leadership, the use of team and group processes, and an active quality improvement program. The only facility characteristic across the outcome groups that was significantly different was the number of licensed beds, with smaller facilities having better outcomes. No significant differences in costs, staffing, or staff mix were detected across the groups. A trend in higher total costs of 13.58 dollars per resident per day was detected in the poor-outcome group compared with the good-outcome group. IMPLICATIONS: For nursing homes to achieve good resident outcomes, they must have leadership that is willing to embrace quality improvement and group process and see that the basics of care delivery are done for residents. Good quality care may not cost more than poor quality care; there is some evidence that good quality care may cost less. Small facilities of 60 beds were more likely to have good resident outcomes. Strategies have to be considered so larger facilities can be organized into smaller clusters of units that could function as small nursing homes within the larger whole.

Costs and Cost Analysis↗
PubMed2004

Does hospitalization impact survival after lower respiratory infection in nursing home residents?

BACKGROUND: Lower respiratory infection (LRI) is the leading cause of hospitalization for nursing home residents, but hospitalization is costly and may cause complications. OBJECTIVE: We sought to compare mortality and cost between episodes of LRI initially treated in the hospital versus the nursing home after controlling for illness severity and the probability of hospitalization. DESIGN: This was a prospective cohort study of nursing home residents with LRIs. SUBJECTS: We identified 1406 episodes of LRI in 36 nursing homes in central Missouri and the St. Louis area between August 15, 1995, and September 30, 1998. Economic analysis was restricted to 1033 episodes identified after March 31, 1997. MEASURES: We adjusted for the higher probability of initial hospitalization in sicker residents using measures of illness severity and a hospitalization propensity score. The propensity score was derived from a logistic regression model that included patient, physician, and facility variables. Estimated costs were attributed to initial treatment setting. RESULTS: After controlling for the probability of hospitalization and illness severity, hospitalization was not a significant mortality predictor (odds ratio 0.89, 95% confidence interval 0.52-1.52). Mean daily cost was $138.24 for initial nursing home treatment and $419.75 for the hospital. CONCLUSIONS: After controlling for illness severity and propensity for hospitalization, hospital treatment is not associated with either increased or decreased risk for mortality for nursing home residents with LRIs. For residents with low and medium mortality risk, nursing home treatment is likely to be safe and less costly.

Aged↗
PubMed2004

Effect of do-not-resuscitate orders on hospitalization of nursing home residents evaluated for lower respiratory infections.

OBJECTIVES: To determine resident and facility characteristics associated with do-not-resuscitate (DNR) orders and to test the effect of DNR orders on hospitalization of acutely ill nursing home (NH) residents with lower respiratory tract infections (LRIs). DESIGN: Prospective cohort. SETTING: Thirty-six NHs (almost 4,000 residents) in central and eastern Missouri in the Missouri Lower Respiratory Infection study. PARTICIPANTS: NH residents with a LRI (n=1031). MEASUREMENTS: Data were obtained from new Minimum Data Set evaluations, resident examination, and chart review. Associations between resident, physician, and facility characteristics and the presence of a DNR order and hospitalization within 30 days from evaluation for an LRI were analyzed. RESULTS: Sixty percent of subjects had a DNR order, and 2% had a do-not-hospitalize order. Resident characteristics associated with a DNR order included older age, white race, having a surrogate decision-maker, NH residence for longer than 3 years, and more-impaired cognition. Residents with DNR orders were more likely to live in facilities with more licensed beds, a lower proportion of Medicaid recipients, and a higher prevalence of influenza vaccination. After controlling for potential confounders, residents with a DNR order before the acute illness episode were significantly less likely to be hospitalized (adjusted odds ratio=0.69, 95% confidence interval=0.49-0.97). CONCLUSION: DNR orders independently reduce the risk of hospitalization for LRI and may function as a marker for undocumented care limitations or as a mandate to limit care (unrelated to resuscitation) in NH residents with LRI.

Acute Disease↗
PubMed2004

Treatment of nursing home residents with dementia and lower respiratory tract infection in the United States and The Netherlands: an ocean apart.

OBJECTIVES: To compare treatment of nursing home residents with dementia and lower respiratory tract infection (LRI) in Missouri and the Netherlands. DESIGN: Two separate but simultaneous prospective cohort studies. SETTING: Nursing homes in Missouri (n=36) and the Netherlands (n=61). PARTICIPANTS: Selected residents (701 from Missouri and 551 from the Netherlands) diagnosed with LRI and dementia. MEASUREMENTS: Treatment, dementia severity, symptoms and signs of LRI, and general health condition were recorded at the time of diagnosis of LRI. Death was monitored at follow-up. Treatment and mortality, stratified for dementia severity, are reported. RESULTS: Treatment of nursing home-acquired LRI in Missouri residents involved a larger number of antibiotics, more frequent hospitalization, and greater use of intravenous antibiotics and rehydration therapy than in Dutch residents of equal dementia severity. Furthermore, for Missouri residents, intensive interventions were more often provided irrespective of severe dementia. By contrast, in both countries, treatments to relieve symptoms of LRI were provided for only a minority of residents. Dutch mortality rates were higher overall. CONCLUSION: Care for U.S. nursing home residents with LRI and dementia is more aggressive than care for Dutch residents, particularly in residents with severe dementia. These results are relevant to the debate on optimal care in relation to curative or palliative treatment goals.

Aged↗
PubMed2003

Predictors of short-term functional decline in survivors of nursing home-acquired lower respiratory tract infection.

BACKGROUND: Scant information exists about the risk of functional decline following treatment of acute illness in the nursing home (NH) setting. The aim of this study was to determine the incidence of short-term (30-day) functional decline among survivors of NH-acquired lower respiratory tract infection (LRI) and the factors that predict such decline, including the role of initial hospitalization. METHODS: We used a prospective cohort design to study 781 episodes of LRI in 1044 NH residents in 36 NHs in central Missouri and the St. Louis metropolitan area. Functional decline was defined as a 3-point increase on the Minimum Data Set (MDS) activities of daily living (ADL) long form scale. RESULTS: Of 781 LRI cases who survived to 30 days, the incidence of ADL decline was 28.8%. In a logistic regression model that used generalized estimating equations to adjust for clustering, variables associated with ADL decline included the following: chronic feeding tube use (AOR = 4.54, 95% confidence interval, or CI, 1.61, 12.80), decubitus ulcer (adjusted odds ratio [AOR] = 2.29, 95% CI 1.35, 3.90), shortness of breath (AOR = 2.18, 95% CI 1.44, 3.30), short-term memory problems (AOR = 2.07, 95% CI 1.33, 3.23), decline in self-performance of toilet use in the 24 hours prior to evaluation (AOR = 1.65, 95% CI 1.29, 2.12), age (AOR = 1.02, 95% CI 1.00, 1.05), and baseline ADL score. Addition of treatment variables to the model showed that initial hospitalization was also associated with ADL decline (AOR = 1.90, 95% CI 1.20, 3.00). Residents with ADL decline at 30 days were less likely to recover to their baseline ADL status at 90 days. CONCLUSIONS: Many NH residents who survive to 30 days following LRI develop new functional limitations, and such individuals are at risk for ADL decline at 90 days. A limited number of clinical variables may predict short-term functional decline. Initial hospitalization for acute treatment of LRI may increase the risk of subsequent ADL decline among individuals who survive to 30 days.

Activities of Daily Living↗
PubMed2003

Statewide strategy to improve quality of care in nursing facilities.

PURPOSE: We describe the development of a statewide strategy to improve resident outcomes in nursing facilities, and we present some evaluative data from this strategy. DESIGN AND METHODS: Key components of the strategy include (a) a partnership between the state agency responsible for the nursing home survey and certification and the school of nursing in an academic health sciences center; and (b) on-site clinical expert technical assistance and support to facilities throughout the state. RESULTS: The partnership has resulted in state agency staff having information from analyses about resident needs and outcomes in the state and facilities having access to the quarterly electronic "Show-Me Quality Indicator Report." On-site clinical expert technical assistance is now used widely across the state, with 569 site visits conducted in 286 different facilities to help them interpret their quality indicator (QI) reports and implement quality improvement programs; statewide improvements in QI scores have been measured in several key QIs. IMPLICATIONS: Other states should consider building partnerships with schools of nursing in an academic health sciences center. Programs using on-site clinical consultation can facilitate improving quality of care in nursing facilities.

Aged↗
PubMed2003

Lower respiratory infections in nursing home residents with dementia: a tale of two countries.

PURPOSE: A focus on palliative care for residents with dementia is much more common in Dutch nursing homes than in the United States. We compared treatment and mortality in U.S. and Dutch nursing home residents with lower respiratory infections (LRI), which are often the immediate cause of death in dementia. DESIGN AND METHODS: We studied two prospective cohorts--a study of pneumonia (n = 706) conducted in 61 psychogeriatric nursing homes throughout the Netherlands and 701 subjects with likely dementia from a study of LRIs in 36 nursing homes in Missouri. RESULTS: Nursing home residents with dementia were more often treated without antibiotics in the Netherlands (23%) than in Missouri (15%). Indicators of severe illness operate in opposite directions: more severe illness is associated with antibiotic treatment in the United States, but with palliative treatment without antibiotics in the Netherlands. IMPLICATIONS: Our findings are consistent with others in indicating problems with transition to palliative care for U.S. nursing home residents with dementia.

Aged↗