Biomedical subjects

Vincent Mor

Publications and source records attributed to Vincent Mor.

At least 19 recordsLinked to original sources

PubMed2006

Facility and county effects on racial differences in nursing home quality indicators.

This study's goal was to examine the effects of nursing home (NH) and county racial mix on quality of care in NHs. We examined quality indicator (QI) outcomes for residents in 408 urban New York NHs in July through September, 1995. The QI outcomes studied were restraint and antipsychotic drug use (for low and high-risk residents), and at study commencement, these QIs were being used by the Centers for Medicare and Medicaid Services to monitor the quality of care in USA Medicare and/or Medicaid-certified NHs. A hierarchical modeling approach was used to properly reflect the nesting of both residents within NHs and NHs within counties. Separate regression models were fit to the two strata of interest (Urban Non-Hispanic Whites and Urban African Americans) to test, for each race group, the effect on quality of residing in NHs and counties with higher proportions of African Americans (than state medians). Descriptive analyses found that, compared to Whites, the unadjusted restraint rate was lower for African Americans while the antipsychotic drug rate was higher. For both race groups, multi-level analyses showed residence in for-profit NHs was associated with higher likelihoods of being restrained, and of receiving antipsychotic drugs. Also, for both race groups, residence in NHs with higher proportions of African-Americans was associated with lower likelihoods of being restrained and with higher, statistically nonsignificant, likelihoods of receiving antipsychotic drugs. Higher NH nurse staffing ratios were associated with higher likelihoods of being restrained and with lower likelihoods of antipsychotic drug use (statistically significant for low-risk African-Americans). Findings support the notion that differential care is provided in USA NHs caring for higher proportions of African-American residents and thereby suggest intervention at the organizational level is warranted to improve QI outcomes for both race groups.

Black or African American↗

PubMed2006

Effect of educational level and minority status on nursing home choice after hospital discharge.

OBJECTIVES: The movement to publicly report data on provider quality to inform consumer choices is predicated on assumptions of equal access and knowledge. We examine the validity of this assumption by testing whether minority/less educated Medicare patients are at greater risk of being discharged from a hospital to the lowest-quality nursing homes in a geographic area. METHODS: We used the 2002 national Minimum Data Set to identify 62601 new Medicare admissions to nursing homes in 95 hospital service areas with at least 4 freestanding nursing homes and at least 50 African Americans aged 65 years or older with Medicare admissions to nursing homes. RESULTS: The probability of African Americans' being admitted to nursing homes in the lowest-quality quartile in the area was greater (relative risk [RR]=1.26; 95% confidence interval [CI]=1.0, 8.45) in comparison with Whites. Individuals without a high-school degree were also more likely to be admitted to a low-quality nursing home (RR=1.22; 95% CI=1.0, 1.46). CONCLUSIONS: African American and poorly educated patients enter the worst-quality nursing facilities. This finding raises concerns about the usefulness of the current public reporting model for certain consumers.

Black or African American↗

PubMed2006

Defining and measuring quality outcomes in long-term care.

The US health care industry increasingly agrees that sharing information about quality of care is necessary to stimulate providers' efforts to improve the quality of health care. The availability of mandated, uniform clinical data in all nursing homes and home health agencies has facilitated the rapid adoption of public reporting of comparative quality data. This paper examines the conceptual and technical challenges underlying the application of information about long-term care provider quality to judge and compare the quality of care provided by nursing homes and home health agencies. In general, the impetus to apply the emerging set of quality "tools" based on mandated clinical assessments may have outstripped the evidence for their valid application in selecting top providers or for rewarding their superior performance.

Home Care Agencies↗

PubMed2006

The effect of state medicaid case-mix payment on nursing home resident acuity.

OBJECTIVE: To examine the relationship between Medicaid case-mix payment and nursing home resident acuity. DATA SOURCES: Longitudinal Minimum Data Set (MDS) resident assessments from 1999 to 2002 and Online Survey Certification and Reporting (OSCAR) data from 1996 to 2002, for all freestanding nursing homes in the 48 contiguous U.S. states. STUDY DESIGN: We used a facility fixed-effects model to examine the effect of introducing state case-mix payment on changes in nursing home case-mix acuity. Facility acuity was measured by aggregating the nursing case-mix index (NCMI) from the MDS using the Resource Utilization Group (Version III) resident classification system, separately for new admits and long-stay residents, and by an OSCAR-derived index combining a range of activity of daily living dependencies and special treatment measures. DATA COLLECTION/EXTRACTION METHODS: We followed facilities over the study period to create a longitudinal data file based on the MDS and OSCAR, respectively, and linked facilities with longitudinal data on state case-mix payment policies for the same period. PRINCIPAL FINDINGS: Across three acuity measures and two data sources, we found that states shifting to case-mix payment increased nursing home acuity levels over the study period. Specifically, we observed a 2.5 percent increase in the average acuity of new admits and a 1.3 to 1.4 percent increase in the acuity of long-stay residents, following the introduction of case-mix payment. CONCLUSIONS: The adoption of case-mix payment increased access to care for higher acuity Medicaid residents.

Diagnosis-Related Groups↗

PubMed2006

The use of contract licensed nursing staff in U.S. nursing homes.

The extent to which nursing homes rely on the use of contracted licensed staff, factors associated with this staffing practice, and the resultant effect on the quality of resident care has received little public attention. Merging the On-line Survey Certification and Reporting System database with the Area Resource File from 1992 through 2002, the authors regressed organizational and market-level variables on the use of 5 percent or more contract full-time equivalent registered nurses and licensed practical nurses. Since 1997, the proportion of facilities using 5 percent or more contract licensed staff more than tripled. Use of contract nurses was associated with more deficiency citations, characteristics of poorer facilities, and tight labor markets. Nursing homes increasingly rely on contract nurses. The failure of nursing homes to attract and retain a competent, stable workforce creates a vicious cycle of staffing practices, which may lead to decline in quality of care.

Contracts↗

PubMed2005

The effect of provider-level ascertainment bias on profiling nursing homes.

Profiling health care providers for the purpose of public reporting and quality improvement has become commonplace. Recently, the Centers for Medicare and Medicaid Services (CMS) began publishing measures of quality for every Medicare/Medicaid-certified nursing home in the country. The facility-specific quality indicators (QIs) reported by CMS are based on quarterly measures from the minimum data set (MDS). However, some QIs from the MDS are potentially subject to ascertainment bias. Ascertainment bias would occur if there was variation in the way items that make up QIs are measured by nurses from each facility. This is potentially a problem for difficult-to-measure items such as pain and pressure ulcers. To assess the impact of ascertainment bias on profiling, we utilize data from a reliability study of nursing homes from six states. We develop methods for profiling providers in situations where the data consist of a response variable for each subject based on assessments from an internal rater, and, for a subset of subjects in each facility, a response variable based on assessments from an independent (external) rater. The internal assessments are potentially subject to provider-level ascertainment bias, whereas the independent assessments are considered the 'gold standard'. Our methods extend popular Bayesian approaches for profiling by using the paired observations from the subset of subjects with error-prone and error-free assessments to adjust for ascertainment bias. We apply the methods to MDS merged with the reliability data, and compare the bias-corrected profiles with those of standard approaches.

Aged↗

PubMed2005

Functional significance of low-intensity polyparasite helminth infections in anemia.

BACKGROUND: We wanted to quantify the impact that polyparasite infections, including multiple concurrent low-intensity infections, have on anemia. METHODS: Three stool samples were collected and read in duplicate by the Kato-Katz method in a cross-sectional sample of 507 children from Leyte, The Philippines. The number of eggs per gram of stool was used to define 3 infection intensity categories--uninfected, low, and moderate/high (M+)--for 3 geohelminth species and Schistosomiasis japonicum. Four polyparasite infection profiles were defined in addition to a reference profile that consisted of either no infections or low-intensity infection with only 1 parasite. Logistic regression models were used to quantify the effect that polyparasitism has on anemia (hemoglobin level <11 g/dL). RESULTS: The odds of having anemia in children with low-intensity polyparasite infections were nearly 5-fold higher (P = .052) than those in children with the reference profile. The odds of having anemia in children infected with 3 or 4 parasite species at M+ intensity were 8-fold greater than those in children with the reference profile (P < .001). CONCLUSION: Low-intensity polyparasite infections were associated with increased odds of having anemia. In most parts of the developing world, concurrent infection with multiple parasite species is more common than single-species infections. This study suggests that concurrent low-intensity infections with multiple parasite species result in clinically significant morbidity.

Adolescent↗

PubMed2005

Conventional and atypical antipsychotics and the risk of hospitalization for ventricular arrhythmias or cardiac arrest.

BACKGROUND: Conventional antipsychotic drugs have been implicated as a cause of ventricular arrhythmias and cardiac arrest, but no definitive information is available regarding atypical antipsychotics. We compared the effect of conventional and atypical antipsychotics on the risk of hospitalization for ventricular arrhythmias and cardiac arrest. METHODS: We conducted a case-control study on residents of nursing homes in 6 US states by using data from the Minimum Data Set linked to Medicare inpatient claims. Cases were residents hospitalized for ventricular arrhythmias or cardiac arrest between July 4, 1998, and December 30, 1999. For each case, we identified up to 5 controls residing in the same facility during the same period. The sample consisted of 649 cases and 2962 controls. RESULTS: Use of conventional antipsychotics was associated with a nearly 2-fold increase in risk of hospitalization for ventricular arrhythmias or cardiac arrest (adjusted odds ratio, 1.86; 95% confidence interval, 1.27-2.74). There was no increased risk associated with the use of atypical antipsychotics (odds ratio, 0.87; 95% confidence interval, 0.58-1.32). The risk of hospitalization for ventricular arrhythmias or cardiac arrest was highest among conventional users with cardiac disease (odds ratio, 3.27; 95% confidence interval, 1.95-5.47). However, cardiac disease and conventional antipsychotics did not show a synergistic effect (synergy index, 1.19). CONCLUSIONS: Conventional but not atypical antipsychotics are associated with an increased risk of hospitalization for ventricular arrhythmias and cardiac arrest. The prescription of conventional antipsychotics in patients with cardiac disease should be carefully weighed.

Aged↗

PubMed2005

Weaknesses of goodness-of-fit tests for evaluating propensity score models: the case of the omitted confounder.

PURPOSE: Propensity scores are used in observational studies to adjust for confounding, although they do not provide control for confounders omitted from the propensity score model. We sought to determine if tests used to evaluate logistic model fit and discrimination would be helpful in detecting the omission of an important confounder in the propensity score. METHODS: Using simulated data, we estimated propensity scores under two scenarios: (1) including all confounders and (2) omitting the binary confounder. We compared the propensity score model fit and discrimination under each scenario, using the Hosmer-Lemeshow goodness-of-fit (GOF) test and the c-statistic. We measured residual confounding in treatment effect estimates adjusted by the propensity score omitting the confounder. RESULTS: The GOF statistic and discrimination of propensity score models were the same for models excluding an important predictor of treatment compared to the full propensity score model. The GOF test failed to detect poor model fit for the propensity score model omitting the confounder. C-statistics under both scenarios were similar. Residual confounding was observed from using the propensity score excluding the confounder (range: 1-30%). CONCLUSIONS: Omission of important confounders from the propensity score leads to residual confounding in estimates of treatment effect. However, tests of GOF and discrimination do not provide information to detect missing confounders in propensity score models. Our findings suggest that it may not be necessary to compute GOF statistics or model discrimination when developing propensity score models.

Confounding Factors, Epidemiologic↗

PubMed2005

Use of comprehensive geriatric assessment in older cancer patients: recommendations from the task force on CGA of the International Society of Geriatric Oncology (SIOG).

BACKGROUND: As more and more cancers occur in elderly people, oncologists are increasingly confronted with the necessity of integrating geriatric parameters in the treatment of their patients. METHODS: The International Society of Geriatric Oncology (SIOG) created a task force to review the evidence on the use of a comprehensive geriatric assessment (CGA) in cancer patients. A systematic review of the evidence was conducted. RESULTS: Several biological and clinical correlates of aging have been identified. Their relative weight and clinical usefulness is still poorly defined. There is strong evidence that a CGA detects many problems missed by a regular assessment in general geriatric and in cancer patients. There is also strong evidence that a CGA improves function and reduces hospitalization in the elderly. There is heterogeneous evidence that it improves survival and that it is cost-effective. There is corroborative evidence from a few studies conducted in cancer patients. Screening tools exist and were successfully used in settings such as the emergency room, but globally were poorly tested. The article contains recommendations for the use of CGA in research and clinical care for older cancer patients. CONCLUSIONS: A CGA, with or without screening, and with follow-up, should be used in older cancer patients, in order to detect unaddressed problems, improve their functional status, and possibly their survival. The task force cannot recommend any specific tool or approach above others at this point and general geriatric experience should be used.

Advisory Committees↗

PubMed2005

A multidimensional model for understanding cancer pain.

The experience of pain pervades the physical and psychosocial domains of a patient's existence. It has a concrete underpinning in the form of an injury or disease process, yet subjective responses to pain sensations are psychosocial processes that influence the experience of pain and the capacity to cope with it. Anticipation of pain is one of the key fears associated with cancer, and uncontrolled pain strips away morale and quality of life. The interacting biopsychosocial dimensions are important areas for consideration in the comprehensive, skillful approach to assessment and treatment of cancer pain. This article addresses the interactive relationships between pain and mood using the biopsychosocial model as a heuristic for assessment.

Anxiety↗

PubMed2005

Palliative care needs of cancer patients in U.S. nursing homes.

BACKGROUND: Increasingly, nursing homes are the place of care for older Americans with cancer. Yet, few studies has characterized the quality of care for this growing population. OBJECTIVE: Characterize the scope and quality of cancer care in U.S. nursing homes. DESIGN: Secondary analysis of the national repository of the Minimum Data Set (MDS) SETTING AND SUBJECTS: Nursing home residents noted to have cancer diagnosis on the MDS. RESULTS: Of the 190,769 New Hampshire residents (8.8%) with a cancer diagnosis, 1 in 4 had weight loss (23.4%), received intravenous medications (27.7%), or used oxygen (25.4%). Overall, 45.3% had a do-not-resuscitate (DNR) order, with state variations ranging from 17.8% (New Jersey) to 70.5% (Wisconsin). More than 1 in 10 (12.0%) were defined as terminally ill, although only 29.3% of these received hospice services. Among patients with pain, half of those who survived to a second assessment had persistent, severe pain (51.3%), which also varied by state, ranging from 43.3% (Iowa) to 65.8% (Nevada). Active treatment was rare; less than 5% received chemotherapy or radiotherapy. However, 15.5% had parenteral and/or tube feedings for nutrition. Approximately, 1 in 10 New Hampshire residents had advanced cancer. CONCLUSION: Our findings suggest important opportunities to improve the quality of cancer care for older adults.

Adolescent↗

PubMed2005

End-of-life hospitalization for African American and non-Latino white nursing home residents: variation by race and a facility's racial composition.

BACKGROUND: Hospitalization of nursing home residents at the end of life is common, more so among African Americans. Whether a nursing home's racial mix is associated with hospitalization is unknown. OBJECTIVE: This study examined the association between race, a nursing home's racial mix, and end-of-life hospitalization. DESIGN: This was a retrospective cohort study. SETTING/SUBJECTS: Studied were nursing home residents in New York (n = 14,159) and Mississippi (n = 1481) who died in 1995-1996 and had a minimum data set (MDS) assessment within 120 days of death. MEASUREMENTS: The outcome measure was the odds of hospitalization in the last 90 days of life. A variable reflecting a nursing home's proportion of African American residents (in 1995-1996) represented a nursing home's racial mix. RESULTS: Forty-six percent of African Americans and 32% of whites were hospitalized in the last 90 days of life. After controlling for demographics, diagnoses, function, patient preferences (do-not-resuscitate [DNR]), and facility resources, nursing home residents in facilities having higher proportions of African American residents had greater odds of hospitalization (adjusted odds ratio [AOR] 1.14; 95% confidence interval [CI] 1.10, 1.18 in New York and AOR 1.35; 95% CI 1.24, 1.46 in Mississippi). Age and frailty interacted with race; older African Americans had a 16% greater likelihood (95% CI 1.08, 1.24) of hospitalization, and African Americans with more functional limitations had a 37% (95% CI 1.24, 1.51) greater likelihood of hospitalization than did comparable whites. CONCLUSIONS: It appears higher end-of-life hospitalization rates for African American residents are attributable to the facilities where most reside, and to differential hospitalization of older or more functional limited residents.

Black or African American↗

PubMed2005

Nurse aide empowerment strategies and staff stability: effects on nursing home resident outcomes.

PURPOSE: This study examines the moderating effect of staff stability on the relationship between management practices used to empower nurse aides and resident outcomes in a multistate sample of nursing homes. An adaptation of Kanter's theory of structural power in organizations guided the framework for the model used in this study. DESIGN AND METHODS: Management practices and nurse aide staff stability measures were taken from a survey of directors of nursing (n = 156) and day-shift charge nurses (n = 430) in a stratified random sample of nursing facilities in Maine, Mississippi, New York, and Ohio (n = 156). Facility risk-adjusted pressure ulcer incidence rates and social engagement scores, taken from the Minimum Data Set, served as resident outcome measures. A hierarchical linear regression model was used to test the moderating effect of staff stability. RESULTS: The situation in which higher numbers of rewards were given to nurse aide staff was associated with lower incidence of pressure ulcers, whereas the situation in which nurse aides had more influence in resident care decisions was associated with higher aggregate social engagement scores. The inclusion of nurse aide staff stability in the regression model provided additional explanatory information for the relationship between management practices and resident outcomes. Facilities experiencing low turnover and high retention were associated with lower pressure ulcer incidence, whereas facilities with high turnover and high retention were associated with higher social engagement scores. IMPLICATIONS: This study suggests that certain management practices used to empower nurse aides can influence resident outcomes. Further, effects of nurse aide staff stability vary with respect to the physical versus psychosocial nature of the outcome.

Nursing Assistants↗

PubMed2005

Impact of cognitive function on assessments of nursing home residents' pain.

OBJECTIVES: We sought to examine the impact of residents' cognitive function on the quality of Minimum Data Set (MDS) pain data using the latent variable approach. RESEARCH DESIGN: Using the Resident Assessment Instrument (RAI) protocol, nursing home (NH) staff and well-trained study nurses independently assessed 3736 NH residents. MEASURES: Inter-rater agreement of pain ratings between NH staff and study nurses was quantified by weighted kappas and polychoric correlations and compared among groups of residents with no/mild, moderate, and severe cognitive impairment. Probit models were built to examine the effect of residents' cognitive function on thresholds raters used to rate pain. RESULTS: Of 3736 residents, 40.4% had no/mild, 35.9% moderate, and 23.7% severe cognitive impairment. Both NH staff and study nurses recorded less frequent and less severe pain for residents with more severe cognitive impairment. The inter-rater agreement on pain ratings between NH staff and study nurses was good-weighted kappas were greater than 0.5 and polychoric correlations greater than 0.7. The thresholds raters used to record pain were similar for NH staff and study nurses and progressively increased when raters recorded pain for residents with more severe cognitive impairment. CONCLUSIONS: Given the RAI protocols, the quality of MDS pain data collected by NH staff was similar to that of well-trained nurses regardless of residents' cognitive function. Our results strongly support the notion that specialized pain assessment instruments are needed to adequately detect pain for the large proportion of cognitive impaired NH residents.

Aged↗

PubMed2005

Improving the quality of long-term care with better information.

Publicly reporting information stimulates providers' efforts to improve the quality of health care. The availability of mandated, uniform clinical data in all nursing homes and home health agencies has facilitated the public reporting of comparative quality data. This article reviews the conceptual and technical challenges of applying information about the quality of long-term care providers and the evidence for the impact of information-based quality improvement. Quality "tools" have been used despite questions about the validity of the measures and their use in selecting providers or offering them bonus payments. Although the industry now realizes the importance of quality, research still is needed on how consumers use this information to select providers and monitor their performance and whether these efforts actually improve the outcomes of care.

Benchmarking↗

PubMed2005

The quality of the quality indicator of pain derived from the minimum data set.

OBJECTIVE: To examine facility variation in data quality of the level of pain documented in the minimum data set (MDS) as a function of level of hospice enrollment in nursing homes (NHs). DATA SOURCE: Clinical assessments on 3,469 nonhospice residents from 178 NHs were merged with On-line Survey Certification and Reporting data of 2000, Medicare Claims data of 2000 and the MDS of 2000-2002. STUDY DESIGN: Using the same assessment protocol, NH staff and study nurses independently assessed 3,469 nonhospice residents. Study nurses' assessments being gold standard, we quantified and compared quality of NH staff's pain rating across NHs with high, medium, or low hospice use. Multilevel models were built to assess the effect of NH hospice use levels on the occurrence of false positive (FP) and false negative (FN) errors in NH-rated "severe pain." PRINCIPAL FINDINGS: Of 178 NHs, 25 had medium and 41 high hospice use. NHs with higher hospice use had lower sensitivities. In multilevel analysis, we found a significant facility-level variation in the probability of FP and FN errors in facility-rated "severe pain." Resident characteristics only explained 4 and 0 percent of the facility variation in FP and FN, respectively; characteristics and locations (state) of NHs further explained 53 and 52 percent of the variance. After controlling for resident and NH characteristics, staff in NHs with medium or high hospice use were less likely to have FP or FN errors in their MDS documentation of pain than were staff in NHs with low or no hospice use. CONCLUSIONS: The examination of data quality of pooled MDS data from multiple NHs is insufficient. Multilevel analysis is needed to elucidate sources of heterogeneity in the quality of MDS data across NHs. Facility characteristics, e.g., hospice use or NH location, are systematically associated with overrated/underrated pain and may bias pain quality indicator (QI) comparisons. To ensure the integrity of QI comparison in the NH setting, the government may need to institute regular audits of MDS data quality.

Aged↗

PubMed2005

A national study of the location of death for older persons with dementia.

OBJECTIVES: To describe where older Americans with dementia die and to compare the state health system factors related to the location of dementia-related deaths with those of cancer and all other conditions in this population. DESIGN: Cross-sectional study. SETTING: United States in 2001. PARTICIPANTS: All persons aged 65 and older who died from nontraumatic causes in the United States during 2001. The underlying cause of death, as determined by the National Center for Health Statistics from death certificate data, was used to categorize subjects into three decedent groups: dementia (n=88,523, 5.1%), cancer (n=389,754, 22.4%), and all other conditions (n=1,256,873, 72.5%). MEASUREMENTS: Site of death was identified as the hospital, home, nursing home, or another location as recorded on the death certificate. In each state, the proportion of hospital deaths in the three decedent groups was categorized as high, medium, and low based on terciles of the national distribution. Using multivariate analyses, associations between state-level variables and the proportion of deaths occurring in the hospital in each state were examined. RESULTS: The majority of dementia-related deaths in the United States occurred in nursing homes (66.9%). In contrast, most older persons with cancer died at home (37.8%) or in the hospital (35.4%). The hospital was the most common site of death for all other conditions (52.2%). The state-specific proportion of dementia-related deaths occurring in hospitals varied from 5.0% to 37.0% across the nation and was in the highest tercile in 18 states. Hospital death rates related to cancer and all other conditions were in the highest tercile in 14 of these 18 states. After multivariate adjustment, states with a greater number of hospital beds per 1,000 persons and a lower percentage of decedents aged 85 and older were more likely to have a higher proportion of hospital deaths in all three decedent groups. Additionally, in the dementia cohort, states with fewer nursing home beds had a greater proportion of hospital deaths. CONCLUSION: The majority of older Americans whose underlying cause of death is attributable to dementia on their death certificate die in nursing homes. State-level factors, including the availability of hospital and nursing home beds and the age of decedents in the population, explain, in part, the wide state-to-state variability in the proportion of dementia-related deaths occurring in the hospital.

Age Distribution↗