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PubMed2004

Black/White differences in pressure ulcer incidence in nursing home residents.

OBJECTIVES: To compare black and white nursing home residents with respect to the incidence of nursing home (NH)-acquired pressure ulcers (PUs) and to examine the role of resident characteristics and facility characteristics in explaining differences between the racial groups. DESIGN: Prospective cohort study conducted between 1992 and 1995. SETTING: Fifty-nine Maryland NHs. PARTICIPANTS: A total of 1,938 residents (301 black, 1,637 white) aged 65 and older newly admitted to participating NHs. MEASUREMENTS: The outcome variable was the first occurrence of a Stage 2, 3, or 4 PU as determined based on medical record review. The predictor variable was race (black, white). Eight resident characteristics (age, sex, number of activity of daily living dependencies, bedfast, PU on admission to facility, incontinence, dementia, and whether the resident was on Medicaid) and three facility characteristics (number of beds, for-profit ownership status, and urban/nonurban location) were considered as possible confounding variables. RESULTS: The incidence of PUs was 0.38 per person-year in the NH. The rate for blacks was significantly higher than for whites (0.56 vs 0.35 per person-year) (P<.001). In multivariate analysis, controlling for eight resident characteristics and three facility characteristics, race was significantly associated with PU incidence (hazard ratio comparing blacks with whites=1.31, 95% confidence interval=1.02-1.66). CONCLUSION: Blacks have a higher incidence of NH-acquired PUs than whites; resident characteristics appear to mediate the higher risk. Future research should aim to identify modifiable factors that explain differences between racial groups in PU risk and to develop solutions to prevent the suffering and cost associated with PUs.

Activities of Daily Living↗
PubMed2005

Quality management systems and clinical outcomes in Dutch nursing homes.

The objective of the article is to explore the impact quality management systems and quality assurance activities in nursing homes have on clinical outcomes. The results are based on a cross-sectional study in 65 Dutch nursing homes. The management of the nursing homes as well as the residents (N = 12,377) participated in the study. Primary survey-data about the implementation of quality management systems and quality assurance activities were collected in 1994/1995 and in 1998, and were combined with information on resident characteristics and the prevalence of undesirable clinical outcomes. The results demonstrate that there are differences between nursing homes in the prevalence of undesirable clinical outcomes. In the nursing homes with the lowest scores, undesirable outcomes occur approximately 10 times less often than in nursing homes with the highest scores. The multi-level analysis has demonstrated that the differences in outcomes are mainly caused by differences between residents and, to some extent, also by differences between nursing homes. Resident characteristics explain 48% of the differences between residents and 72% of the differences between nursing homes. The size of the nursing home, the involvement of a client council and the implementation of a quality management system could explain a small part of the remaining variation in the number of undesirable outcomes. It seems that the implementation of a quality management system and the involvement of a client council had significant influence on the number of undesirable outcomes. Approximately 50% of the undesirable outcomes cannot be explained by the selected resident characteristics, the size of the nursing home and the implementation of quality management systems or quality assurance activities.

Aged↗
PubMedDate not supplied

Resident behaviors and characteristics as determinants of quality of residential care: an observational study.

The effects of resident behaviors and resident characteristics on the quantity and quality of care they receive from direct-care staff was examined. Four hundred and fifty-two residents with severe and profound mental retardation and 416 direct care staff members were involved. Naturalistic observations were conducted on direct-care staff behavior, that is, staff-resident initiatives, staff affection, staff communicative behavior, on resident behaviors (i.e., maladaptive, stereotypic, and adaptive behavior, position, attending, and communicative behavior), and on resident characteristics (i.e., gender, age, ambulancy, sensory handicaps, and seizure disorder). By importance, residents' ambulancy/motoric skills, their communicative behavior, and attending behavior accounted for the greatest differences in the quality and quantity of the care they receive from direct-care staff. Given that certain resident characteristics can be ameliorated through training, residents themselves may control, to a certain extent, the care they receive from direct-care staff in residential facilities.

Adult↗
PubMed2002

Predictors of shoulder and back injuries in nursing home workers: a prospective study.

BACKGROUND: Nursing assistants (NAs) working in nursing homes have among the highest back and shoulder injury rates in the US. Incidence, severity, and cost of non-traumatic soft tissue musculoskeletal disorders in the nursing home industry in Washington State are quite high. METHODS: To determine whether resident characteristics data reported on the Health Care Financing Administration Minimum Data Set (MDS) could be used as a surrogate measure of cumulative exposure to physical loads, we conducted an 18-month prospective study in one nursing home. RESULTS: The combined NA injury incidence rate (IR) was 45.8 self-reported back and shoulder injuries per 100 [FTE] workers per year. In general, MDS reported resident characteristics failed to predict risk with the exception of exposure to loss of voluntary leg mobility (OR = 1.11 per person-shifts of exposure, 95% CI [0.97-1.27]), with the highest risk on the day shift (OR = 1.15, 95% CI [0.95-1.40]). CONCLUSIONS: These findings suggest social integration and work organization issues may be more important predictors of back and shoulder injuries in nursing assistants than reported resident characteristics as measured by the MDS.

Adult↗
PubMed2002

Nursing homes with persistent deficiency citations for physical restraint use.

OBJECTIVES: This paper examines the organizational and aggregate resident characteristics of nursing homes associated with persistent poor quality in the use of physical restraints. Deficiency citations for physical restraint use in two and three consecutive certification survey inspections are used as our measures of poor quality. MATERIALS AND METHODS: Nationally representative data from the 1996, 1997, 1998, and 1999 Online Survey, Certification, and Reporting system are used, first, to provide descriptive analyses. Second, multinomial logistic regression analyses are used to examine organizational and aggregate resident characteristics associated with deficiency citations for restraint use on any survey inspection, on two consecutive inspections, and deficiencies for physical restraint use in three consecutive inspections. RESULTS: It is shown that 729 (5.2%) nursing homes had deficiency citations for restraint use on two consecutive inspections and 317 (2.3%) on three consecutive inspections. Persistent poor quality in the use of physical restraints in nursing homes is negatively associated to higher staffing levels of care givers, and positively associated to higher Medicaid census, and higher average activities of daily living (ADL) levels. CONCLUSION: The Nursing Home Reform Act has been extremely influential in reducing the overall prevalence of physical restraint use in nursing homes, but the number of facilities with persistent quality problems in their use of restraints in the face of this legislation is surprising. The organizational and aggregate resident characteristics of these nursing homes, especially RN staffing levels, Medicaid census, and average ADL levels differ from those that did not receive any deficiency citations for use of physical restraints.

Activities of Daily Living↗
PubMedDate not supplied

Characteristics of combined family practice-psychiatry residency programs.

OBJECTIVE: To evaluate how family practice-psychiatry residency programs meet the challenges of rigorous accreditation demands, clinical supervision, and boundaries of practice. METHOD: A 54-question survey of program directors of family practice-psychiatry residency programs outlining program demographic data, curricula, coordination, resident characteristics, integration, and overall satisfaction was mailed to 11 combined family practice psychiatry-residency programs. RESULTS: Programs surveyed were meeting residency review committee (RRC) requirements, and a majority of the program directors believe that the training is as good as or better than categorical programs, and categorical residents benefited from training alongside combined residents. CONCLUSIONS: Training programs are growing in size and producing quality physicians.

Education↗
PubMed1993

Quality of care and outcomes of chronic mentally ill patients in hospitals and nursing homes.

OBJECTIVE: Quality of care in three types of facilities in which chronic mentally ill patients reside was examined to determine how it was related to patient functioning and to determine how patients' dependency on others for self-care moderated relationships between quality of care and patient functioning. METHODS: Discriminant function analyses and multiple regression analyses were used to examine 12-month follow-up data from a Department of Veterans Affairs (VA) study of 294 chronic mentally ill patients in 52 community nursing homes, nine VA nursing home care units, and 43 VA hospital psychiatric units. RESULTS: The three types of facilities were best differentiated by staff and resident characteristics and facility policies. Residents of community nursing homes were more impaired, and staff were less well trained, than in the VA facilities. The community nursing homes had less restrictive policies. Patients who lived in facilities that gave them more control over their daily lives and that had larger proportions of high-functioning patients reported more life satisfaction and vigor. Patients in facilities with more social and recreational activities reported less life satisfaction. The extent to which facility features were beneficial or harmful was related to patients' self-care dependency. Supportive physical features and living-assistance services tended to aid impaired residents, whereas more experienced staff and policies that promoted control by residents tended to aid independent residents. CONCLUSIONS: Program managers may need to tailor facility environments to patients' level of functioning to maximize beneficial effects.

Activities of Daily Living↗
PubMed1995

Characteristics of residents with do-not-resuscitate orders in nursing homes.

We determined patient characteristics associated with do-not-resuscitate (DNR) status in nursing homes using cross-sectional analysis of secondary data derived from Minimum Data Set documents in 14 nursing homes from one state in the upper Midwest. The primary outcome variable was DNR status. Bivariate analysis was first carried out on all variables. Variables associated with DNR status at this stage were then included in a stepwise logistic regression to determine variables independently associated with DNR status. Overall, 71% of patients had DNR orders. Variables found to be independently associated with a higher probability of DNR status were increasing age, female gender, worse cognitive function, durable power of attorney, being self-paying, or having commercial insurance. Lack of daily contact with relatives and friends and lack of involvement with others were associated with lower probability of DNR status. A higher prevalence of DNR status in nursing homes was seen than in prior literature. The patient characteristics shown to be associated with DNR status may give important insight into the reasons that such decisions are made.

Age Factors↗
PubMedDate not supplied

Board certification among preventive medicine residency graduates: characteristics, advantages, and barriers.

In 1991, a mail survey was conducted of graduates (1979-1989) of general preventive medicine/public health (GPM/PH) residency programs to obtain information about the graduates' demographic characteristics, training, and present professional work. Specifically, we evaluated the survey data for percentage of graduates with board certification, advantages of board certification, and barriers to board certification in preventive medicine (PM). The survey response rate was 74% (797 of 1,070 graduates). Only 45% of the respondents were board certified in PM as of 1991. The percentage of respondents board certified in PM was highest among military PM residency graduates and lowest among those from the Centers for Disease Control (CDC) PM residency. Reasons for not taking the board examination included the perception of limited benefit of board certification in current employment or professional endeavors, previous board certification in a clinical specialty, lack of a master of public health (MPH) degree, high cost and time commitment for the examination, and uncertainty about examination admission requirements. PM residency graduates with board certification in PM were more likely to be involved in public health and preventive medicine programs, devoted more time to administration and management, and earned more income than those PM residency graduates without PM board certification. Increasing the percentage of residency graduates who pursue PM board certification will require increasing the advantages of certification for practice, encouraging all residents to identify themselves as practicing the specialty of PM, and addressing the unique concerns of physicians who train both in PM and in a purely or primarily clinical specialty.

Attitude of Health Personnel↗
PubMed1996

HIV-2 infection in 12 European residents: virus characteristics and disease progression.

OBJECTIVE: To assess the disease progression rate among 12 HIV-2-infected West European residents (nine of West African descent), compared with the disease progression rate among HIV-1-infected individuals of the same population, and the characteristics of the HIV-2 strains involved. METHODS: HIV-2-infected individuals were identified by commercially available serological assays, their clinical status and CD4+ cell counts were monitored, and HIV-2 was isolated from their peripheral blood mononuclear cells. T-cell-line tropism and syncytium-inducing capacities of the isolated viruses were determined and their phylogenetic relationships were analysed by comparing polymerase chain reaction-amplified nucleotide sequences of reverse transcriptase (RT) gene segments. RESULTS: Eight of the 12 HIV-2-infected individuals presented with progressive disease and one of them progressed from Centers for Disease Control and Prevention group A1 to A3 within 36 months after seroconversion. The ratios of asymptomatic versus symptomatic individuals among residents of the Rotterdam region of West African descent were 2:7 for HIV-2 and 8:9 for HIV-1-infected individuals. HIV-2 was isolated from six of the nine individuals with progressive disease. The time required for virus isolation correlated inversely with the individuals' CD4+ cell counts. Five of the HIV-2 isolates replicated in immortalized T-cell lines, and two isolates from patients with AIDS were syncytium-inducing. Five HIV-2 isolates from patients born in the Cape Verdian Isles grouped together within subtype A. The HIV-2 isolate from a patient of Ghanese origin belonged to subtype B. Mutations were identified in the RT genes from HIV-2 isolates of two zidovudine-treated patients, one of which has also been shown to be involved in zidovudine resistance in HIV-1. CONCLUSION: Disease progression in HIV-2 infection may be as rapid as in HIV-1. HIV-2 isolation and viral phenotype were related to disease status, and mutations identical to those observed in HIV-1 zidovudine resistance were observed in patients treated with zidovudine.

Adult↗
PubMed1997

A survey of United States general psychiatry residency programs: program characteristics and relationship to the 1994 National Residency Matching Program results.

We developed a questionnaire regarding issues in psychiatric residency training and distributed it to the chief residents at all United States general psychiatry residency training programs. We hoped to examine psychiatry residency program characteristics and see if any particular characteristics had a significant relationship to improved success in the 1994 National Residency Matching Program (NRMP) results. We found that those programs with six or more PGY-1 positions available in the NRMP, those programs with an associated child and adolescent psychiatry residency training program, and those programs offering a research elective had a higher PGY-1 match through the NRMP than programs without these features.

Adolescent↗
PubMed2003

[Resource use of the elderly in long-term care hospital using RUG-III].

PURPOSE: This study was to classify elderly in long-term care hospitals for using Resource Utilization Group(RUG-III) and to consider feasibility of payment method based on RUG-III classification system in Korea. METHOD: This study designed by measuring resident characteristics using the Resident Assessment Instrument-Minimum Data Set(RAI-MDS) and staff time. The data were collected from 382 elderly over sixty-year old, inpatient in the five long-term care hospitals. Staff time was converted into standard time based on the average wage of nurse and aids. RESULT: The subjects were classified into 4 groups. The group of Clinically Complex was the largest(46.3%), Reduced Physical Function(27.2%), Behavior Problem(17.0%), and Impaired Cognition(9.4%). The average resource use for one resident in terms of care time(nurses, aids) was 183.7 minutes a day. Relative resource use was expressed as a case mix index(CMI) calculated as a proportion of mean resource use. The CMI of Clinically Complex group was the largest(1.10), and then Reduced Physical Function(0.93), Behavior Problem(0.93), and Impaired Cognition(0.83) followed. The difference of the resource use showed statistical significance between major groups(p<0.0001). CONCLUSION: The results of this study showed that the RUG-III classification system differentiates resources provided to elderly in long-term care hospitals in Korea.

English Abstract↗
PubMed2004

[On the feasibility of a RUG-III based payment system for long-term care facilities in Korea].

PURPOSE: The purpose of this study was to classify the elderly in long-term care facilities using the Resource Utilization Group(RUG-III) and to examine the feasibility of a payment method based on the RUG-III classification system in Korea. METHOD: This study measured resident characteristics using a Resident Assessment Instrument-Minimum Data Set(RAI-MDS) and staff time. Data was collected from 530 elderly residents over sixty, residing in long-term care facilities. Resource use for individual patients was measured by a wage-weighted sum of staff time and the total time spent with the patient by nurses, aides, and physiotherapists. RESULT: The subjects were classified into 4 groups out of 7 major groups. The group of Clinically Complex was the largest (46.3%), and then Reduced Physical Function(27.2%), Behavior Problems (17.0%), and Impaired Cognition (9.4%) followed. Homogeneity of the RUG-III groups was examined by total coefficient of variation of resource use. The results showed homogeneity of resource use within RUG-III groups. Also, the difference in resource use among RUG major groups was statistically significant (p<0.001), and it also showed a hierarchy pattern as resource use increases in the same RUG group with an increase of severity levels(ADL). CONCLUSION: The results of this study showed that the RUG-III classification system differentiates resources provided to elderly in long-term care facilities in Korea.

Aged↗
PubMed1995

Pressure ulcers in the nursing home.

OBJECTIVE: To review the literature on the causes, epidemiology, prevention, and treatment of pressure ulcers in nursing homes and to summarize this information for clinicians caring for nursing home residents. DATA SOURCES: A MEDLINE search of English-language articles published between 1980 and October 1994 using the terms decubitus ulcer and elderly. References from identified articles were also examined. STUDY SELECTION: Articles were excluded if the title indicated that patients were not nursing home residents (unless data from nursing homes were limited or unavailable), that patients were not elderly, or that the ulcers were related to peripheral vascular disease or neuropathy. DATA EXTRACTION: Selected studies either contained original data or were meta-analyses. Prevalence studies were required to have an identifiable denominator; risk factor and incidence studies were required to have an identifiable cohort and a specified duration of follow-up. Preference was given to risk factors identified through multivariate analyses. Studies of preventive and therapeutic interventions were required to have an identifiable control group; preference was given to randomized controlled trials. DATA SYNTHESIS: Seventeen percent to 35% of patients have pressure ulcers at the time of admission to a nursing home, and the prevalence of pressure ulcers among nursing home residents ranges from 7% to 23%. Among high-risk patients, the incidence of pressure ulcers is estimated to be 14/1000 patient-days. Residents at higher risk for developing ulcers are those who have limited ability to reposition themselves, cannot sense the need to reposition, have fecal incontinence, or cannot feed themselves. Occlusive dressings are as effective and less costly than traditional wet-to-dry saline dressings for treating earlier stages of pressure ulcers. There is no consensus on the use of specialized beds in the nursing home for promoting the healing of advanced-stage ulcers or for reducing the incidence of ulcers in high-risk patients. Specific interventions should not detract from careful, total assessment and management of the patient. CONCLUSIONS: Pressure ulcers in the nursing home are common problems associated with significant morbidity and mortality. Because resident characteristics can identify residents likely to develop ulcers, preventive measures can be implemented early. Therapy for advanced stages of pressure ulcers is expensive and prolonged. Involvement of the physician with the multidisciplinary nursing home team is essential for prevention and therapy.

Aged↗
PubMed2001

Outcome trajectories for assisted living and nursing facility residents in Oregon.

OBJECTIVE: To compare assisted living residents and nursing home residents on outcome trajectories for three outcomes: ability to perform activities of daily living (ADLs), psychological well-being, and pain and discomfort. DATA SOURCES/STUDY SETTING: A representative sample of one-third of the census from 38 participating assisted living facilities (N = 605) and two-fifths of the census from 31 participating nursing facilities (N = 610). STUDY DESIGN: A longitudinal design using hierarchical linear models to examine how setting (being in an assisted living setting or in a nursing home) affected growth trajectories for each outcome studied when adjusting for other resident characteristics. DATA COLLECTION: Residents or their proxies were interviewed and chart reviews done at baseline, six months, and one year. All baseline data were collected between August 1995 and May 1996. PRINCIPAL FINDINGS: We found differences in case mix between assisted living and nursing facility residents but no differences in outcome trajectories for ADLs, psychological well-being, and pain and discomfort. For ADLs and pain and discomfort on average, residents in both settings experienced change over the study period. For psychological well-being, residents experienced no change on average. CONCLUSIONS: The lack of difference in growth trajectories for ADLs, pain and discomfort, and psychological well-being between the two settings was noteworthy.

Activities of Daily Living↗
PubMed2000

Nursing home staffing and its relationship to deficiencies.

OBJECTIVES: The authors examined the relationships between different types of nursing home staffing and nursing home deficiencies to test the hypothesis that fewer staff hours would be associated with higher numbers of deficiencies. METHODS: Data were from the On-Line Survey, Certification, and Reporting System for all certified nursing homes in the United States. Regression models examined total deficiencies, quality of care, quality of life, and other deficiencies. RESULTS: Fewer registered nurse hours and nursing assistant hours were associated with total deficiencies and quality of care deficiencies, when other variables were controlled. Fewer nursing assistant staff and other care staff hours were associated with quality of life deficiencies. Fewer administrative staff hours were associated with other deficiencies. Facilities that had more depressed and demented residents, that were smaller, and that were nonprofit or government-owned had fewer deficiencies. Facilities with more residents with urinary incontinence and pressure sores and with higher percentages of Medicaid residents had more deficiencies, when staffing and resident characteristics were controlled. DISCUSSION: Facility characteristics and states were stronger predictors of deficiencies than were staffing hours and resident characteristics. Because only a small portion of the total variance in deficiencies could be explained, much work remains to explore factors that influence deficiencies.

Aged↗
PubMed2005

A comparison of three methods of measuring dementia-specific quality of life: perspectives of residents, staff, and observers.

PURPOSE: This exploratory study compared three methods of assessing dementia specific quality of life, corresponding to the perspectives of residents, staff members, and trained observers. DESIGN AND METHODS: We collected data on 172 residents with dementia in four special care nursing facilities and three assisted living facilities. Analyses assessed the relationship of each quality-of-life method or perspective to the others and to resident characteristics such as cognitive and functional status. RESULTS: The relationship of staff quality-of-life measures to resident characteristics varied by care setting while no significant relationships were found for resident quality-of-life measures. Staff and observational measures were moderately correlated in both settings. Moderate correlations of resident measures with staff and observational measures were found in the assisted living sample. IMPLICATIONS: Each perspective is relatively independent and somewhat unique. Measures that focus on specific aspects of quality of life may be more appropriate to use with assisted living residents than with residents of special care facilities.

Aged, 80 and over↗