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Biomedical subjects

Vincent Mor

Publications and source records attributed to Vincent Mor.

At least 55 records · Page 3Linked to original sources
PubMed2003

Clinical and organizational factors associated with feeding tube use among nursing home residents with advanced cognitive impairment.

CONTEXT: Empiric data and expert opinion suggest that use of feeding tubes is not beneficial for older persons with advanced dementia. Previous research has shown a 10-fold variation in this practice across the United States. OBJECTIVE: To identify the facility and resident characteristics associated with feeding tube use among US nursing homes residents with severe cognitive impairment. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional study of all residents with advanced cognitive impairment who had Minimum Data Set assessments within 60 days of April 1, 1999, (N = 186,835) and who resided in Medicare- or Medicaid-certified US nursing homes. Main Outcomes Measures Facility and resident characteristics described in the 1999 On-line Survey Certification of Automated Records and the 1999 Minimum Data Set. Multivariate analysis using generalized estimating equations determined the facility and resident factors independently associated with feeding tube use. RESULTS: Thirty-four percent of residents with advanced cognitive impairment had feeding tubes (N = 63,101). Resident characteristics associated with a greater likelihood of feeding tube use included younger age, nonwhite race, male sex, divorced marital status, lack of advance directives, a recent decline in functional status, and no diagnosis of Alzheimer disease. Controlling for these patient factors, residents living in facilities that were for profit (adjusted odds ratio [OR], 1.09; 95% confidence interval [CI], 1.06-1.12); located in an urban area (OR, 1.14; 95% CI, 1.11-1.16); having more than 100 beds (OR, 1.04; 95% CI, 1.01-1.07); and lacking a special dementia care unit (OR, 1.11; 95% CI, 1.07-1.15) had a higher likelihood of having a feeding tube. Additionally, feeding tube use was more likely among residents living in facilities that had a smaller proportion of residents with do-not-resuscitate orders, had a higher prevalence of nonwhite residents, and lacked a nurse practitioner or physician assistant on staff. CONCLUSIONS: More than one third of severely cognitively impaired residents in US nursing homes have feeding tubes. Feeding tube use is independently associated with both the residents' clinical characteristics and the nursing homes' fiscal, organizational, and demographic features.

Advance Directives↗
PubMed2003

Benchmarking and quality in residential and nursing homes: lessons from the US.

BACKGROUND: Performance measurement and benchmarking are common concerns in the delivery of long term care. It is common to measure the performance of providers and to publicly report these data. This paper examines selected technical challenges facing those who design, implement and disseminate health care quality performance measures. METHOD: Review of the application of measures of performance in the US nursing home sector. RESULTS: Using examples drawn from the skilled nursing home arena, problems ranging from data reliability and validity, the multi-dimensional nature of quality measures and selection bias as well as differential measurement abilities are discussed. CONCLUSIONS: Benchmarking of performance is an inherently complex issue. However, to ensure that such comparisons are both fair and valid requires measures to be more technically sophisticated and sensitive to real changes attributable to changes in care.

Benchmarking↗
PubMed2003

Hospice enrollment and pain assessment and management in nursing homes.

This study compared pain assessment and management in the last 48 hours of life for hospice and nonhospice nursing home residents. Included were 209 hospice and 172 nonhospice residents in 28 nursing homes in six geographic areas. Hospice patients were considered short-stay (seven days or less) (n=51), or longer-stay (over seven days) (n=158). Of residents not in a hospital or a coma (n=265), 33% of nonhospice residents, 6% of short-stay and 7% of longer-stay hospice residents had no documented pain assessment (P<0.05). For those with pain documented (n=93), longer-stay hospice residents, compared to nonhospice residents, had a significantly greater likelihood of having received an opioid (adjusted odds ratio [AOR] 5.4; 95% CI 1.3, 21.7), and an opioid at least twice a day (AOR 2.7; 95% CI 0.9, 7.7; P=0.07). Study results suggest that hospice enrollment improves pain assessment and management for nursing home residents; they also document the need for continued improvement of pain management in nursing homes.

Aged↗
PubMed2003

Admission and continued-stay criteria for assisted living facilities.

As residents in assisted living facilities (ALFs) try to "age in place" but decline in health, the facilities, families, and residents must find a balance between protecting the health and safety of residents in ALFs and maintaining their desire to live independently. The assisted living industry incorporates resident autonomy into its goals, but with regard to resident health and safety, recent reports have found that ALF staff are struggling to provide adequate care for residents with increasingly complex needs. Moreover, state regulations are not consistent in obligating ALFs to prioritize adequate health care and protection for residents over resident autonomy, or vice versa. A set of admission and continued stay criteria for individuals residing in assisted living that could serve as a guideline for state regulations in addressing the balance between safety and autonomy in ALFs is recommended.

Aged↗
PubMed2003

The quality of quality measurement in U.S. nursing homes.

PURPOSE: This article examines various technical challenges inherent in the design, implementation, and dissemination of health care quality performance measures. DESIGN AND METHODS: Using national and state-specific Minimum Data Set data from 1999, we examined sample size, measure stability, creation of ordinal ranks, and risk adjustment as applied to aggregated facility quality indicators. RESULTS: Nursing home Quality Indicators now in use are multidimensional and quarterly estimates of incidence-based measures can be relatively unstable, suggesting the need for some averaging of measures over time. IMPLICATIONS: Current public reports benchmarking nursing homes' performances may require additional technical modifications to avoid compromising the fairness of comparisons.

Nursing Homes↗
PubMed2003

Oversight of nursing homes: pruning the tree or just spotting bad apples?

PURPOSE: This study investigated whether higher rates of nursing home quality citations are associated with increased risk of voluntary and involuntary facility terminations from the Medicare/Medicaid certification process. DESIGN AND METHODS: We examined nationwide Online Survey Certification and Reporting (OSCAR) data from 1992 through 2000 and used a multinomial logistic regression model with time-varying covariates to estimate the relationship between nursing home deficiencies and terminations. RESULTS: In the study period, 8.7% of nursing homes voluntarily terminated and 2.4% of facilities were involuntarily terminated. Deficiencies significantly predicted both types of termination, controlling for state and market characteristics. Low occupancy and very high Medicaid mix were strongly related to voluntary and involuntary terminations (p <.05). IMPLICATIONS: Nursing homes that receive a high number of deficiencies exit the Medicare/Medicaid market and have lower occupancy rates before termination, although the relationship varies considerably across states. If competition on the basis of quality is increased because of public reporting efforts, our analyses suggest that terminations, both voluntary and involuntary, will likely increase.

Certification↗
PubMed2003

Factors associated with site of death: a national study of where people die.

OBJECTIVES: Recent public attention has focused on quality of care for the dying. Where one dies is an important individual and public health concern. MATERIALS AND METHODS: The 1993 National Mortality Followback Survey (NMFS) was used to estimate the proportion of deaths occurring at home, in a hospital, or in a nursing home. Sociodemographic variables, underlying cause of death, geographic region, hospice use, social support, health insurance, patients' physical limitations, and physical decline were considered as possible predictors of site of death. The relationship between these predictors and site death with multinomial logistic regression methods was analyzed. RESULTS: Nearly 60% of deaths occurred in hospitals, and approximately 20% of deaths took place at home or in nursing homes. Decedents, who were black, less educated, and enrolled in an HMO were more likely to die in the hospital. After adjustment, functional decline in the last 5 months of life was an important predictor of dying at home (for loss of 3 or more ADLs [OR, 1.57; 95% CI, 1.11-2.21]). Having functional limitations 1 year before death, and experiencing functional decline in the last 5 months of life were both associated with dying in a nursing home. CONCLUSIONS: Rapid physical decline during the last 5 months was associated with dying at home or in a nursing home, whereas earlier functional loss was associated with dying in a nursing home.

Activities of Daily Living↗
PubMed2003

The impact of the prospective payment system for skilled nursing facilities on therapy service provision: a transaction cost approach.

OBJECTIVE: To examine skilled nursing facilities (SNFs) "make-or-buy" decisions with respect to rehabilitation therapy service provision in the 1990s, both before and after implementation of Medicare's Prospective Payment System (PPS) for SNFs. DATA SOURCES: Longitudinal On-line Survey Certification and Reporting (OSCAR) data (1992-2001) on a sample of 10,241 freestanding urban SNFs. STUDY DESIGN: We estimated a longitudinal multinomial logistic regression model derived from transaction cost economic theory to predict the probability of the outcome in each of four service provision categories (all employed staff, all contract, mixed, and no services provided). PRINCIPAL FINDINGS: Transaction frequency, uncertainty, and complexity result in greater control over therapy services through employment as opposed to outside contracting. For-profit status and chain affiliation were associated with greater control over therapy services. Following PPS, nursing homes acted to limit transaction costs by either exiting the rehabilitation market or exerting greater control over therapy services by managing rehabilitation services in-house. CONCLUSIONS: The financial incentives associated with changes in reimbursement methodology have implications that extend beyond the boundaries of the health care industry segment directly affected. Unintended quality and access consequences need to be carefully monitored by the Medicare program.

Contract Services↗
PubMed2003

The use of atypical antipsychotics in nursing homes.

BACKGROUND: Use of atypical antipsychotics for "off-label" indications, such as behavioral and psychological symptoms of dementia, depression, and bipolar disorder, have been frequently reported, although not systematically studied. We describe the pattern of atypical antipsychotic use among nursing home residents and identify demographic and clinical correlates. METHOD: We conducted a cross-sectional study on 139,714 nursing home residents living in 1732 nursing homes in 5 U.S. states from Jan. 1, 1999, to Jan. 31, 2000. Data were obtained from the computerized Minimum Data Set (MDS) assessment records. RESULTS: Behavior problems associated with cognitive impairment were manifest in 86,514 residents, and, of these, 18.2% received an antipsychotic. Approximately 11% received an atypical antipsychotic, while 6.8% received a conventional agent. Clinical correlates of atypical antipsychotic use were Parkinson's disease (adjusted odds ratio [OR] = 1.57, 95% confidence interval [CI] = 1.34 to 1.84), depression (OR = 1.35, 95% CI = 1.24 to 1.46), antidepressant use (OR = 1.38, 95% CI = 1.27 to 1.49), Alzheimer's disease (OR = 1.21, 95% CI = 1.12 to 1.32), non-Alzheimer dementia (OR = 1.15, 95% CI = 1.07 to 1.24), and cholinesterase inhibitor use (OR = 1.74, 95% CI = 1.52 to 1.98). Severe functional impairment was inversely related to atypical antipsychotic use (OR = 0.76, 95% CI = 0.65 to 0.89). CONCLUSION: Atypical antipsychotics are now used more than conventional antipsychotic agents in U.S. nursing homes. Indications and dosages seem appropriate relative to labeling. Clinical and demographic differences between atypical and conventional antipsychotic users tend to be relatively small, suggesting that other factors may explain the choice of prescribing physicians. The impact of facility factors, economic forces, and physician characteristics needs to be investigated.

Activities of Daily Living↗
PubMed2002

A problem-solving approach to stress reduction among younger women with breast carcinoma: a randomized controlled trial.

BACKGROUND: Previous research indicates that younger women (i.e., 50) and that coping style is significantly related to the psychosocial adjustment of women with this disease. The purpose of this study was to evaluate through a randomized controlled trial the effectiveness of a problem-solving training intervention designed to empower women with breast carcinoma to cope with a range of difficulties when diagnosed in mid-life. METHODS: The study population consisted of women aged 50 years or younger who had no prior history of breast carcinoma, were diagnosed with Stage I-IIIA tumors, and for whom a first course of chemotherapy had been initiated recently. The intervention consisted of two in-person and four telephone sessions with an oncology nurse who provided problem-solving skills training and informational materials to the women over a 12-week period. All subjects were assessed for physical and psychosocial adjustment through telephone and mailed surveys at baseline, at 4 -months, and at 8 months. RESULTS: Of 183 eligible women, 164 participated (a 90% participation rate), 149 of whom completed the study (a 91% completion rate). The subjects had significantly lower unmet needs and better mental health at the 4-month assessment. The intervention significantly decreased the number and severity of difficulties experienced by women with average or good problem-solving skills at 8 months, but was not effective in alleviating or resolving the problems encountered by women with poor problem-solving skills, relative to the control group. CONCLUSIONS: We conclude that this problem-solving therapy-based home care training intervention is an effective method of helping the majority of women with breast carcinoma to reduce the stresses associated with the diagnosis and treatment of cancer in mid-life.

Adult↗
PubMed2002

Adjuvant tamoxifen prescription in women 65 years and older with primary breast cancer.

PURPOSE: We examined patterns of adjuvant tamoxifen discussion and prescription among breast cancer patients age 65 years and older. METHODS: We selected from women diagnosed with primary breast cancer those with (1) stage I (tumor diameter > or = 1 cm), stage II, or stage IIIa disease; (2) age 65 years or older on the date of diagnosis; and (3) permission from the attending physician to contact. Data were collected from consenting patients' medical records, telephone interviews with patients, and mailed questionnaires completed by their physicians. RESULTS: We obtained medical record and interview data for 698 patients. The oldest patients (odds ratio [OR], 0.45; 95% confidence interval [CI], 0.23 to 0.87 for those aged 80+ relative to those aged 65 to 69 years old), those with more comorbid conditions (each additional comorbid condition reduced the odds of discussion by 0.84; 95% CI, 0.73 to 0.96), and those who were estrogen receptor-negative (OR, 0.56; 95% CI, 0.32 to 0.99) were less likely to report discussion of tamoxifen therapy with a physician. Older patients (OR, 2.17; 95% CI, 1.18 to 4.01 for 70- to 79-year-olds relative to 65- to 69-year-olds; OR, 2.44; 95% CI, 1.11 to 5.34 for those aged 80+ relative to those aged 65 to 69 years old), those who reported a greater influence of information about tamoxifen on decision-making (an increase in 1 SD increased the odds by 7.43; 95% CI, 4.36 to 12.65), and those whose physicians believed that the benefits of tamoxifen outweighed its risks (an increase in 1 SD increased the odds by 1.87; 95% CI, 1.34 to 2.62) were more likely to be prescribed tamoxifen. CONCLUSION: These findings highlight the key role of communication in the care of older women with breast cancer and its ultimate influence on the receipt of therapy.

Age Factors↗
PubMed2002

Does receipt of hospice care in nursing homes improve the management of pain at the end of life?

OBJECTIVES: To compare analgesic management of daily pain for dying nursing home residents enrolled and not enrolled in Medicare hospice. DESIGN: Retrospective, comparative cohort study. SETTING: Over 800 nursing homes in Kansas, Maine, Mississippi, New York, and South Dakota. PARTICIPANTS: A subset of residents with daily pain near the end of life taken from a matched cohort of hospice (2,644) and nonhospice (7,929) nursing home residents who had at least two resident assessments (Minimum Data Sets (MDSs)) completed, their last between 1992 and 1996, and who died before April 1997. The daily pain subset consisted of 709 hospice and 1,326 nonhospice residents. MEASUREMENTS: Detailed drug use data contained on the last MDS before death were used to examine analgesic management of daily pain. Guidelines from the American Medical Directors Association (AMDA) were used to identify analgesics not recommended for use in managing chronic pain in long-term care settings. The study outcome, regular treatment of daily pain, examined whether patients received any analgesic, other than those not recommended by AMDA, at least twice a day for each day of documented daily pain (i.e., 7 days before date of last MDS). RESULTS: Fifteen percent of hospice residents and 23% of nonhospice residents in daily pain received no analgesics (odds ratio (OR) = 0.57, 95% confidence interval (CI) = 0.45-0.74). A lower proportion of hospice residents (21%) than of nonhospice residents (29%) received analgesics not recommended by AMDA (OR = 0.65, 95% CI =0.52-0.80). Overall, acetaminophen (not in combination with other drugs) was used most frequently for nonhospice residents (25% of 1,673 prescriptions), whereas morphine derivatives were used most frequently for hospice residents (30% of 1,058 prescriptions). Fifty-one percent of hospice residents and 33% of nonhospice residents received regular treatment for daily pain. Controlling for clinical confounders, hospice residents were twice as likely as nonhospice residents to receive regular treatment for daily pain (adjusted odds ratio = 2.08, 95% CI = 1.68-2.56). CONCLUSION: Findings suggest that analgesic management of daily pain is better for nursing home residents enrolled in hospice than for those not enrolled in hospice.The prescribing practices portrayed by this study reveal that many dying nursing home residents in daily pain are receiving no analgesic treatment or are receiving analgesic treatment inconsistent with AMDA and other pain management guidelines. Improving the analgesic management of pain in nursing homes is essential if high-quality end-of-life care in nursing homes is to be achieved.

Aged↗
PubMed2002

An exploration of job, organizational, and environmental factors associated with high and low nursing assistant turnover.

PURPOSE: This article examines factors that distinguish nursing facilities with very high and very low nursing assistant turnover rates from a middle referent group, exploring the possibility that high and low turnover are discrete phenomena with different antecedents. DESIGN AND METHODS: Data from a stratified sample of facilities in eight states, with directors of nursing as respondents (N = 288), were merged with facility-level indicators from the On-Line Survey Certification of Automated Records and county-level data from the Area Resource File. Multinominal logistic regression was used to identify factors associated with low (less than 6.6% in 6 months) and high (more than 64% in 6 months) turnover rates. RESULTS: With the exception of registered nurse turnover rate, low turnover and high turnover were not associated with the same factors. IMPLICATIONS: Future studies of facility turnover should avoid modeling turnover as a linear function of a single set of predictors in order to provide clearer recommendations for practice.

Data Collection↗
PubMed2002

Identification and evaluation of existing nursing homes quality indicators.

We summarize work done to identify and evaluate existing quality indicators (QIs) for long-term care (LTC) settings. Indicators operationally defined using routinely collected and computerized patient assessments were identified and then aggregated to characterize the performance of the nursing facility over a specific period of time. Of 143 indicators reviewed, only 22 were recommended for use in comparing performance across facilities. Conceptual and technical issues influence the appropriateness of QIs for different audiences.

Aged↗