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Biomedical subjects

Vincent Mor

Publications and source records attributed to Vincent Mor.

At least 37 records · Page 2Linked to original sources
PubMed2005

End-of-life care in black and white: race matters for medical care of dying patients and their families.

OBJECTIVES: To compare the end-of-life medical care experienced by African-American and white decedents and their families. DESIGN: Cross-sectional, retrospective survey with weighted results based on a two-stage probability sampling design. SETTING: Hospitals, nursing homes, and home-based medical services across the United States. PARTICIPANTS: Surrogates (N=1,447; primarily family members) for decedents from 22 states. MEASUREMENTS: Validated end-of-life care outcomes concerning symptom management, decision-making, informing and supporting families, individualized care, coordination, service utilization, and financial impact. RESULTS: Family members of African-American decedents were less likely than those of white decedents to rate the care received as excellent or very good (odds ratio (OR)=0.4). They were more likely to report absent (OR=2.4) or problematic (OR=1.9) physician communication, concerns with being informed (OR=2.5), and concerns with family support (OR=2.6). Family members of African Americans were less likely than those of whites to report that the decedent had treatment wishes (OR=0.3) or written advance care planning documents (OR=0.4). These differences persist when limiting the sample to respondents whose expectations for life-sustaining treatments matched treatments received. Family members of African-American decedents also were more likely to report financial hardship due to savings depletion (OR=2.1) or difficulty paying for care (OR=2.0) and that family/friends (OR=2.0) or home health workers (OR=1.9) provided home care. CONCLUSION: This national study brings evidence that racial disparities persist into end-of-life care, particularly regarding communication and family needs. Results also suggest different home care patterns and levels of financial impact.

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PubMed2005

The compression of morbidity hypothesis: a review of research and prospects for the future.

Cross-national evidence for the validity of the compression of morbidity hypothesis originally proposed by Fries is generally accepted. Generational improvements in education and the increased availability of adaptive technologies and even medical treatments that enhance quality of life have facilitated continued independence of older persons in the industrialized world. Whether this trend continues may depend upon the effect of the obesity epidemic on the next generation of older people.

Aging↗
PubMed2005

Bereaved family member perceptions of quality of end-of-life care in U.S. regions with high and low usage of intensive care unit care.

OBJECTIVES: To compare the quality of end-of-life care of persons dying in regions of differing practice intensity. DESIGN: Mortality follow-back survey. SETTING: Geographic regions in the highest and lowest deciles of intensive care unit (ICU) use. PARTICIPANTS: Bereaved family member or other knowledgeable informants. MEASUREMENTS: Unmet needs, concerns, and rating of quality of end-of-life care in five domains (physical comfort and emotional support of the decedent, shared decision-making, treatment of the dying person with respect, providing information and emotional support to family members). RESULTS: Decedents in high- (n=365) and low-intensity (n=413) hospital service areas (HSAs) did not differ in age, sex, education, marital status, leading causes of death, or the degree to which death was expected, but those in the high-intensity ICU HSAs were more likely to be black and to live in nonrural areas. Respondents in high-intensity HSAs were more likely to report that care was of lower quality in each domain, and these differences were statistically significant in three of five domains. Respondents from high-intensity HSAs were more likely to report inadequate emotional support for the decedent (relative risk (RR)=1.2, 95% confidence interval (CI)=1.0-1.4), concerns with shared decision-making (RR=1.8, 95% CI=1.0-2.9), inadequate information about what to expect (RR=1.5, 95% CI=1.3-1.8), and failure to treat the decedent with respect (RR=1.4, 95% CI=1.0-1.9). Overall ratings of the quality of end-of-life care were also significantly lower in high-intensity HSAs. CONCLUSION: Dying in regions with a higher use of ICU care is not associated with improved perceptions of quality of end-of-life care.

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PubMed2005

Cerebrovascular events among elderly nursing home patients treated with conventional or atypical antipsychotics.

OBJECTIVE: Concern exists about a possible increased risk of cerebrovascular events (CVEs) among elderly patients receiving risperidone or olanzapine. We estimated the effect of atypical and conventional antipsychotics on the risk of CVEs among elderly nursing home patients with dementia. METHOD: We conducted a case-control study on residents of nursing homes in 6 U.S. states by using the Systematic Assessment of Geriatric drug use via Epidemiology database, which includes data from the Minimum Data Set linked to Medicare inpatient claims. Participants were diagnosed with Alzheimer's disease or other forms of dementia on the basis of clinical criteria and medical history (including medical records and neuroradiologic documentation). Cases included patients hospitalized for stroke or transient ischemic attack between June 30, 1998, and December 27, 1999. For each case, we identified up to 5 controls hospitalized for septicemia or urinary tract infection residing in the same facility during the same time period. The sample consisted of 1130 cases and 3658 controls. RESULTS: After controlling for potential confounders, the odds ratio of being hospitalized for CVEs was 0.87 (95% CI = 0.67 to 1.12) for risperidone users, 1.32 (95% CI = 0.83 to 2.11) for olanzapine users, 1.57 (95% CI = 0.65 to 3.82) for users of other atypical agents, and 1.24 (95% CI = 0.95 to 1.63) for conventional antipsychotic users compared to nonusers of antipsychotics. A history of CVEs appeared to modify the effect of atypical antipsychotics other than risperidone on the risk of new events. CONCLUSION: Overall, no increased risk of CVEs seems to be conferred by atypical or conventional antipsychotics. Preexisting cerebrovascular risk factors might interact with some atypical antipsychotics to increase the risk of events. These results should be interpreted in light of the limitations of the study and need to be confirmed.

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PubMed2004

Family perspectives on end-of-life care at the last place of care.

CONTEXT: Over the past century, nursing homes and hospitals increasingly have become the site of death, yet no national studies have examined the adequacy or quality of end-of-life care in institutional settings compared with deaths at home. OBJECTIVE: To evaluate the US dying experience at home and in institutional settings. DESIGN, SETTING, AND PARTICIPANTS: Mortality follow-back survey of family members or other knowledgeable informants representing 1578 decedents, with a 2-stage probability sample used to estimate end-of-life care outcomes for 1.97 million deaths from chronic illness in the United States in 2000. Informants were asked via telephone about the patient's experience at the last place of care at which the patient spent more than 48 hours. MAIN OUTCOME MEASURES: Patient- and family-centered end-of-life care outcomes, including whether health care workers (1) provided the desired physical comfort and emotional support to the dying person, (2) supported shared decision making, (3) treated the dying person with respect, (4) attended to the emotional needs of the family, and (5) provided coordinated care. RESULTS: For 1059 of 1578 decedents (67.1%), the last place of care was an institution. Of 519 (32.9%) patients dying at home represented by this sample, 198 (38.2%) did not receive nursing services; 65 (12.5%) had home nursing services, and 256 (49.3%) had home hospice services. About one quarter of all patients with pain or dyspnea did not receive adequate treatment, and one quarter reported concerns with physician communication. More than one third of respondents cared for by a home health agency, nursing home, or hospital reported insufficient emotional support for the patient and/or 1 or more concerns with family emotional support, compared with about one fifth of those receiving home hospice services. Nursing home residents were less likely than those cared for in a hospital or by home hospice services to always have been treated with respect at the end of life (68.2% vs 79.6% and 96.2%, respectively). Family members of patients receiving hospice services were more satisfied with overall quality of care: 70.7% rated care as "excellent" compared with less than 50% of those dying in an institutional setting or with home health services (P<.001). CONCLUSIONS: Many people dying in institutions have unmet needs for symptom amelioration, physician communication, emotional support, and being treated with respect. Family members of decedents who received care at home with hospice services were more likely to report a favorable dying experience.

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PubMed2004

Principles for modeling propensity scores in medical research: a systematic literature review.

PURPOSE: To document which established criteria for logistic regression modeling researchers consider when using propensity scores in observational studies. METHODS: We performed a systematic review searching Medline and Science Citation to identify observational studies published in 2001 that addressed clinical questions using propensity score methods to adjust for treatment assignment. We abstracted aspects of propensity score model development (e.g. variable selection criteria, continuous variables included in correct functional form, interaction inclusion criteria), model discrimination and goodness of fit for 47 studies meeting inclusion criteria. RESULTS: We found few studies reporting on the propensity score model development or evaluation of model fit. CONCLUSIONS: Reporting of aspects related to propensity score model development is limited and raises questions about the value of these principles in developing propensity scores from which unbiased treatment effects are estimated.

Bias↗
PubMed2004

Hospice and palliative care in nursing homes.

This article reviews the challenges inherent in providing high-quality palliative care to dying nursing home residents and summarizes the efforts to address these challenges. It is suggested that a stronger physician presence and oversight of physicians knowledgeable in palliative care in nursing homes are needed to improve the quality of end-of-life care in nursing homes.

Hospice Care↗
PubMed2004

The opportunity for collaborative care provision: the presence of nursing home/hospice collaborations in the U.S. states.

This study estimated the proportion of U.S. nursing homes (NHs) collaborating with Medicare hospices and identified state-level factors associated with this collaboration. Collaboration was classified as present when at least one of a NH's residents dying in July through December, 2000 received hospice. Seventy-six percent of NHs (n=12,174) had hospice collaborations, with proportions ranging from 37% in Wyoming to 96% in Florida. State-level factors associated with greater collaboration included having a lower proportion of persons 65+ residing in rural areas, lower NH occupancy and larger hospices, and Medicaid NH reimbursement which was not case-mixed and was paid directly to NHs (not to hospices) for hospice-enrolled residents. Considering the high amount of estimated NH/hospice collaboration, care provision by both NHs and hospices appears to be a potentially viable approach for providing comprehensive end-of-life care in the majority of U.S. NHs. Findings suggest the rural composition of a state as well as its policies and healthcare market characteristics either foster or discourage NH/hospice collaboration.

Cooperative Behavior↗
PubMed2004

A comprehensive clinical assessment tool to inform policy and practice: applications of the minimum data set.

The Minimum Data Set (MDS) for nursing home (NH) resident assessment, designed to assess elders functional status and care needs, exemplifies how the information needs of clinical practice are congruent with those of research. Building on a review of the published literature, this article describes the development of the MDS, its reliability and validity testing, as well as the variety of different policy and research uses to which it has been applied. Interrater reliability of items and internal consistency of MDS summary scales is generally good to excellent. Validation studies reveal good correspondence to research quality instruments for cognition, activities of daily living, and diagnoses with more variable results for vision, pain, mood, and behavior scales. To date, no consistent evidence suggests that applications of MDS data for case-mix reimbursement and quality indicator monitoring systematically bias the data. Although facility variation in data quality could compromise some applications, creation of the MDS as a clinical tool for care planning provides an example of how assessment tools with clinical use can be used in administrative databases for research and policy applications.

Activities of Daily Living↗
PubMed2004

Driven to tiers: socioeconomic and racial disparities in the quality of nursing home care.

Nursing home care is currently a two-tiered system. The lower tier consists of facilities housing mainly Medicaid residents and, as a result, has very limited resources. The nearly 15 percent of U.S. nonhospital-based nursing homes that serve predominantly Medicaid residents have fewer nurses, lower occupancy rates, and more health-related deficiencies. They are more likely to be terminated from the Medicaid/Medicare program, are disproportionately located in the poorest counties, and are more likely to serve African-American residents than are other facilities. The public reporting of quality indicators, intended to improve quality through market mechanisms, may result in driving poor homes out of business and will disproportionately affect nonwhite residents living in poor communities. This article recommends a proactive policy stance to mitigate these consequences of quality competition.

Black or African American↗
PubMed2004

Effect of state Medicaid reimbursement rates on hospitalizations from nursing homes.

OBJECTIVES: To estimate the effect of state Medicaid nursing home reimbursement rates on hospitalizations of nursing home residents. DESIGN: Cross-sectional sample of nongovernment-owned nursing homes with 25 beds or more in one Metropolitan Statistical Area in each of 10 states in 1993, with 6 months follow-up on mortality and hospitalizations. SETTING: Two hundred fifty-three nursing homes. PARTICIPANTS: Eight to 16 randomly selected residents from each facility, totaling 2,080. MEASUREMENTS: Minimum Data Set assessments conducted by research nurses at baseline. A three-category 6-month outcome was defined as (1) any hospitalization; for those not hospitalized, (2) death versus (3) alive in the facility. RESULTS: Using multinomial logistic regression, adjusted to survey design, controlling for resident and facility characteristics, a 10 dollar increase in 1993 Medicaid reimbursement rate above the mean rate of approximately 75 dollars resulted in a 9% reduction in a resident's risk of hospitalization (P<.05). CONCLUSION: State Medicaid reimbursement rates appear to affect clinical decisions regarding the need for hospital admission and thresholds for nursing home use. The findings from this study reemphasize the importance of properly aligning state Medicaid and federal Medicare long-term care policies because, currently, states have no incentive to increase reimbursement rates to avoid hospitalization.

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PubMed2004

Daily pain that was excruciating at some time in the previous week: prevalence, characteristics, and outcomes in nursing home residents.

OBJECTIVES: To examine the prevalence, correlates, and consequences of nursing home (NH) staff reports of "excruciating" level of pain at some time in the previous week in persons with daily pain reported on the Minimum Data Set (MDS). DESIGN: Cross-sectional study. SETTING: NHs in the United States. PARTICIPANTS: A total 2,138,442 persons who resided in 15,745 nursing homes in the United States. MEASUREMENTS: Pain reported as daily and at its most excruciating in the previous week on the MDS at initial and follow-up assessment. Associations were examined with demographic characteristics, functioning, and measures of disease burden reported on the MDS. RESULTS: NH staff noted that 80,512 (3.7%) of residents had daily pain that was at one or more times excruciating in the previous week. This level of pain was more prevalent in younger residents. Nearly two-thirds (62.1%) of persons with this level of pain were no longer independent in activities of daily living, but 48.8% were rated to have normal cognitive status. In contrast, those without daily pain that was sometimes excruciating were less likely to be cognitively intact (25.7%P<.001) and less likely to have declined in their functioning (30.1%, P=.001). More than one in five with daily pain that was excruciating at times had a cancer diagnosis, and 21.5% experienced weight loss. Of the 24,300 persons with a second assessment, 10,284 (42.3%) still had excruciating pain at some time in the previous week. CONCLUSION: NH residents with daily pain that was sometimes excruciating were younger and seriously ill with functional decline and weight loss. Too often, persons remain in this level of pain.

Activities of Daily Living↗
PubMed2004

Government expenditures at the end of life for short- and long-stay nursing home residents: differences by hospice enrollment status.

OBJECTIVES: To examine end-of-life government expenditures for short- and long-stay Medicare- and Medicaid-eligible (dual-eligible) nursing home (NH) hospice and nonhospice residents. DESIGN: A retrospective cohort study. SETTING: Six hundred fifty-seven Florida NHs. PARTICIPANTS: Dual-eligible NH residents who died in Florida NHs between July and December 1999 (N=5,774). MEASUREMENTS: Nursing home stays of 90 days or less were considered short stays (n=1,739), and those over 90 days were long stays (n=4,035). Three diagnosis groups were studied: cancer without Alzheimer's disease or dementia, Alzheimer's disease or dementia, and other diagnoses. Eligibility and expenditure claims data for 1998 and 1999 were merged with vital statistics and NH resident assessment data to determine diagnoses, location of death, hospice enrollment, eligibility, and expenditures. RESULTS: Twenty percent of short-stay (n=350) and 26% of long-stay (n=958) NH decedents elected hospice; of these, 73% of short-stay and 58% of long-stay NH residents had hospice stays of 30 days or less. Overall, mean government expenditures in the last month of life were significantly less for hospice than nonhospice residents (7,365 dollars; 95% confidence interval (CI)=7,144-7586 dollars vs 8,134 dollars; 95% CI=7,896-8,372 dollars), but 1-month expenditures were only significantly lower for hospice residents with short NH stays, not for those with long NH stays. CONCLUSION: Overall, hospice care in NHs does not appear to increase government expenditures. Because significantly lower expenditures are observed for short-stay NH hospice residents, policy restricting access to Medicare hospice for Medicare skilled nursing facility residents may represent a missed opportunity for savings.

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PubMed2004

Nursing home characteristics and potentially preventable hospitalizations of long-stay residents.

OBJECTIVES: To examine the association between having a nurse practitioner/physician assistant (NP/PA) on staff, other nursing home (NH) characteristics, and the rate of potentially preventable/avoidable hospitalizations of long-stay residents, as defined using a list of ambulatory care-sensitive (ACS) diagnoses. DESIGN: Cross-sectional prospective study using Minimum Data Set (MDS) assessments, Centers for Medicare and Medicaid Services inpatient claims and eligibility records, On-line Survey Certification Automated Records, (OSCAR) and Area Resource File (ARP). SETTING: Freestanding urban NHs in Maine, Kansas, New York, and South Dakota. PARTICIPANTS: Residents of 663 facilities with a quarterly or annual MDS assessment in the 2nd quarter of 1997, who had a prior MDS assessment at least 160 days before, and who were not health maintenance organization members throughout 1997 (N=54,631). MEASUREMENTS: A 180-day multinomial outcome was defined as having any hospitalization with primary ACS diagnosis, otherwise having been hospitalized, otherwise died, and otherwise remained in the facility. RESULTS: Multilevel models show that facilities with NP/PAs were associated with lower hospitalization rates for ACS conditions (adjusted odds ratio (AOR)=0.83), but not with other hospitalizations. Facilities with more physicians were associated with higher ACS hospitalizations (ACS, AOR=1.14, and non-ACS, AOR=1.10). Facilities providing intravenous therapy, and those that operate a nurses' aide training program were associated with fewer hospitalizations of both types. CONCLUSION: Employment of NP/PAs in NHs, the provision of intravenous therapy, and the operation of certified nurse assistant training programs appear to reduce ACS hospitalizations, and may be feasible cost-saving policy interventions.

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PubMed2003

Inter-rater reliability of nursing home quality indicators in the U.S.

BACKGROUND: In the US, Quality Indicators (QI's) profiling and comparing the performance of hospitals, health plans, nursing homes and physicians are routinely published for consumer review. We report the results of the largest study of inter-rater reliability done on nursing home assessments which generate the data used to derive publicly reported nursing home quality indicators. METHODS: We sampled nursing homes in 6 states, selecting up to 30 residents per facility who were observed and assessed by research nurses on 100 clinical assessment elements contained in the Minimum Data Set (MDS) and compared these with the most recent assessment in the record done by facility nurses. Kappa statistics were generated for all data items and derived for 22 QI's over the entire sample and for each facility. Finally, facilities with many QI's with poor Kappa levels were compared to those with many QI's with excellent Kappa levels on selected characteristics. RESULTS: A total of 462 facilities in 6 states were approached and 219 agreed to participate, yielding a response rate of 47.4%. A total of 5758 residents were included in the inter-rater reliability analyses, around 27.5 per facility. Patients resembled the traditional nursing home resident, only 43.9% were continent of urine and only 25.2% were rated as likely to be discharged within the next 30 days. Results of resident level comparative analyses reveal high inter-rater reliability levels (most items >.75). Using the research nurses as the "gold standard", we compared composite quality indicators based on their ratings with those based on facility nurses. All but two QI's have adequate Kappa levels and 4 QI's have average Kappa values in excess of.80. We found that 16% of participating facilities performed poorly (Kappa <.4) on more than 6 of the 22 QI's while 18% of facilities performed well (Kappa >.75) on 12 or more QI's. No facility characteristics were related to reliability of the data on which Qis are based. CONCLUSION: While a few QI's being used for public reporting have limited reliability as measured in US nursing homes today, the vast majority of QI's are measured reliably across the majority of nursing facilities. Although information about the average facility is reliable, how the public can identify those facilities whose data can be trusted and whose cannot remains a challenge.

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