Examining Nursing Home Information Technology Maturity and Antibiotic Use Among Long-Term Care Residents.

OBJECTIVES: Up to 15% of the 1.4 million US nursing home (NH) residents receive antibiotics daily. Antibiotic use in NHs is often inappropriate, contributing to quality and safety concerns as well as antibiotic resistance. Information technology (IT) maturity-defined as the extent to which facilities possess and use diverse technological devices and software that are integrated across resident care, clinical support, and administrative activities-may improve the tracking and reporting of antibiotic use in NH residents. Thus, this research explores trends in IT maturity over time and associations with antibiotic use in US NHs. DESIGN: Repeated cross-sectional study. SETTING AND PARTICIPANTS: Long-term resident assessments from a random sample of Medicare-certified US NHs over 4 consecutive years (2013-2017). METHODS: Three data sources were used: (1) 4 annual surveys measuring IT maturity, (2) Minimum Data Set (MDS) 3.0 assessments for resident characteristics, and (3) Certification and Survey Provider Enhanced Reporting data for facility characteristics. Nonadmission MDS assessments that were within a 90-day window of the IT survey were eligible. Descriptive statistics were examined. Bivariate and multivariate regressions using NH fixed effects were conducted controlling for resident and NH characteristics. RESULTS: There were 219,461 MDS assessments from 80,237 long-stay residents aged ≥65 years, living in 817 NHs. Trends in IT maturity increased significantly over 4 years. IT integration in administrative processes was positively associated with antibiotic use (AOR 1.072, 95% CI 1.025, 1.122). CONCLUSIONS AND IMPLICATIONS: IT components that integrate administrative activities, which can provide greater access to data sources across the organization as a whole, was associated with changes in antibiotic use. Further evaluation is needed to determine if antibiotic use is more appropriate with higher maturity such that policy makers can encourage IT with these capabilities to promote antibiotic stewardship.

Excluding Pulmonary Embolism with End-tidal Carbon Dioxide: Accuracy, Cost, and Harm Avoidance.

A non-randomized single center prospective, descriptive, correlational design was used to determine what end-tidal carbon dioxide (EtCO2) level provided the best sensitivity, specificity, and negative predictive value to exclude pulmonary embolism (PE) diagnosis in hemodynamically stable hospitalized adults (n = 111). The financial impact and harm avoidance of adding EtCO2 to the PE diagnostic process also were examined. PE diagnosis was determined by computed tomography pulmonary angiography (CTPA). PE prevalence was 18.9%. Mean±SD EtCO2 was lower for PE positive than negative participants (28 ± 7.8 to 33 ± 8.1 mmHg respectively 95% CI: 1.22-8.96; P = .01). For PE exclusion, an EtCO2 cutoff ≥42 mmHg yielded 100% sensitivity, 12.2% specificity, and 100% negative predictive value. For every six inpatients assessed with EtCO2, one could be saved from unnecessary CTPA. Eliminating unnecessary CTPA removes the potential harm associated with radiation and intravenous contrast exposure. Additionally, an EtCO2 cutoff ≥42 mmHg could eliminate ~$88,000/year in healthcare waste at this institution.

Ternary Trends in Nursing Home Information Technology and Quality Measures in the United States.

Nursing home information technology (NH IT) adoption trends are not measured regularly. Evidence indicates digital footprints are growing, but gaps about NH IT adoption and quality impacts remain. We hypothesize as NH IT adoption grows, quality improves. This research assessed ternary (2014-2017) trends in IT and quality measures using a primary survey of U.S. NHs. Survey measures included nine dimensions/domains and total IT sophistication. Administrators completed 815 Year 1 surveys. Each year mean total IT sophistication scores in nine dimensions/domains consistently increased. Eighteen significant correlations (r > .13, absolute value) between IT sophistication and quality measures existed. Regression shows that for every 10 units increase in administrative activity extent of IT use, a decrease of 1.3% occurs in the percentage of low-risk long-stay residents with bowel or bladder incontinence. Increases in NH IT sophistication positively impact quality. Estimating ongoing trends in NH IT sophistication provides new information that should be consistently available.

Building consensus toward a national nursing home information technology maturity model.

OBJECTIVES: We describe the development of a nursing home information technology (IT) maturity model designed to capture stages of IT maturity. MATERIALS AND METHODS: This study had 2 phases. The purpose of phase I was to develop a preliminary nursing home IT maturity model. Phase II involved 3 rounds of questionnaires administered to a Delphi panel of expert nursing home administrators to evaluate the validity of the nursing home IT maturity model proposed in phase I. RESULTS: All participants (n = 31) completed Delphi rounds 1-3. Over the 3 Delphi rounds, the nursing home IT maturity staging model evolved from a preliminary, 5-stage model (stages 1-5) to a 7-stage model (stages 0-6). DISCUSSION: Using innovative IT to improve patient outcomes has become a broad goal across healthcare settings, including nursing homes. Understanding the relationship between IT sophistication and quality performance in nursing homes relies on recognizing the spectrum of nursing home IT maturity that exists and how IT matures over time. Currently, no universally accepted nursing home IT maturity model exists to trend IT adoption and determine the impact of increasing IT maturity on quality. CONCLUSIONS: A 7-stage nursing home IT maturity staging model was successfully developed with input from a nationally representative sample of U.S. based nursing home experts. The model incorporates 7-stages of IT maturity ranging from stage 0 (nonexistent IT solutions or electronic medical record) to stage 6 (use of data by resident or resident representative to generate clinical data and drive self-management).

A longitudinal assessment of adherence to breast and cervical cancer screening recommendations among women with and without intellectual disability.

Each year in the United States, about 4000 deaths are attributed to cervical cancer, and over 40,000 deaths are attributed to breast cancer (U.S. Cancer Statistics Working Group, 2015). The purpose of this study was to identify predictors of full, partial, and no screening for breast and cervical cancer among women with and without intellectual disability (ID) who are within the age group for screening recommended by the U.S. Preventive Service Task Force (USPSTF), while accounting for changes in recommendations over the study period. Women with ID and an age matched comparison group of women without ID were identified using merged South Carolina Medicaid and Medicare files from 2000 to 2010. The sample consisted of 9406 and 16,806 women for mammography screening and Papanicolaou (Pap) testing adherence, respectively. We estimated multinomial logistic regression models and determined that women with ID were significantly less likely than women without ID to be fully adherent compared to no screening with mammography recommendations (adjusted odds ratio [AOR]: 0.63, 95% confidence interval [CI] 0.55-0.72), and Pap testing recommendations (AOR: 0.17, 95% CI 0.16-0.19). For the 70% of women with ID for whom we had residential information, those who lived in a group home, medical facility, or supervised community living setting were more likely to be fully adherent with both preventive services than those living alone or with family members. For both outcomes, women residing in a supervised nonmedical community living setting had the highest odds of full adherence, adjusting for other covariates.

Pharmacotherapy effectiveness for clinical subgroups among children and adolescents with early onset schizophrenia.

OBJECTIVE: This study aims to determine the effectiveness of pharmacotherapies among children and adolescents diagnosed with early onset schizophrenia subgrouped according to their co-occurring psychiatric disorders. METHODS: A retrospective cohort design was employed, using South Carolina's (USA) Medicaid claims dataset covering outpatient and inpatient medical services, between January, 1999 and December, 2013 to identify patients ≤17 years of age. Random effects regression analyses assessed differential changes in acute psychiatric service utilization over time across the 3 subgroups associated with antipsychotic, mood stabilizer, psychostimulant, or antidepressant pharmacotherapy. RESULTS: For patients with schizophrenia and comorbid mood disorders or emotional dysregulation (Cluster 1), or schizophrenia and severe cognitive impairments (Cluster 2), those treated with monotherapy second-generation antipsychotics (SGAs) over time demonstrated consistently lower use of acute psychiatric treatment services as did those coprescribed mood stabilizers, primarily lithium, or anticonvulsants. In all clusters, including the relatively homogenous subgroup of patients with early onset schizophrenia and few comorbid disorders, acute psychiatric service utilization was significantly higher and more variable over time for those prescribed multiple SGAs. CONCLUSIONS: Regardless of the specific constellation of symptoms and comorbid disorders targeted, the coprescription of multiple SGAs was not effective over time in stabilizing children and adolescents outside of acute care settings.

Diagnostic clusters associated with an early onset schizophrenia diagnosis among children and adolescents.

OBJECTIVE: Given the greater severity and chronicity of psychiatric disorders that first declare in individuals under the age of 18, early onset schizophrenia (EOS) and its association with co-occurring psychiatric conditions deserve further investigation. METHODS: Cluster and discriminant analyses were used to examine the heterogeneity of children and adolescents diagnosed with schizophrenia in 1 statewide system of care. A retrospective cohort design was employed, using South Carolina's (USA) Medicaid claims dataset covering outpatient and inpatient medical services between January, 1999 and December, 2013 to identify patients ≤17 years of age. RESULTS: Among the 613 EOS patients selected, 3 main clusters of ICD-9 psychiatric diagnoses were identified: (1) older children with schizophrenia coaggregated with a spectrum of mood/emotional dysregulation conditions; (2) younger children with coaggregated schizophrenia, mental retardation/intellectual disability or autism spectrum disorders; and (3) older children with schizophrenia and significantly fewer diagnosed co-occurring conditions. Externalizing/disruptive behavior disorders (i.e., attention deficit hyperactivity disorder, conduct disorder, and oppositional defiant disorder) were significantly associated with Clusters 1 and 2. CONCLUSION: Symptom patterns plus age of first diagnosis are important differentiators of EOS subgroups in this cohort. Earlier recognition of psychiatric symptom/syndrome patterns that frequently co-occur may enable clinicians to stratify/tailor treatment interventions.

Colorectal Cancer Screening Adherence in Selected Disabilities Over 10 Years.

INTRODUCTION: Colorectal cancer (CRC) is the second leading cause of cancer mortality in the U.S.; however, if the population aged 50 years or older received routine screening, approximately 60% of these deaths could be eliminated. This study investigates whether adults, aged 50-75 years, with one of three disabilities (blind/low vision [BLV], intellectual disability [ID], spinal cord injury [SCI]) receive CRC screening at rates equivalent to adults without the three disabilities, by accounting for combinations of recommended CRC screenings during a 10-year period (colonoscopy, sigmoidoscopy, fecal occult blood test). METHODS: South Carolina Medicaid and Medicare, State Health Plan, and hospital discharge data (2000-2009) were analyzed (2013-2015) to estimate the proportion of adherence to and adjusted odds of CRC screening over time among adults with one of the three disabilities, BLV, ID, or SCI, versus adults without these conditions. RESULTS: The estimated proportion of adults who adhere to changing recommendations over time was lower for adults with ID (34.32%) or SCI (44.14%) compared with those without these disabilities (48.48%). All three case groups had significantly lower AORs of adherence versus those without (BLV: AOR=0.88, 95% CI=0.80, 0.96; ID: AOR=0.55, 95% CI=0.52, 0.59; SCI: AOR=0.88, 95% CI=0.82, 0.95). CONCLUSIONS: In this study, adults with BLV, ID, or SCI were less likely to receive and adhere to CRC screening recommendations than those without these disabilities. This method provides a thorough evaluation of adherence to CRC screening by considering levels of adherence during each month of Medicaid or Medicare coverage.

Women with Visual Impairment and Insured by Medicaid or Medicare Are Less Likely to Receive Recommended Screening for Breast and Cervical Cancers.

PURPOSE: To investigate whether women with visual impairment (VI) receive mammography and Pap testing to the same extent as women without VI among the low income population or those aged 65+ years. METHODS: We analyzed the 2000-2010 Medicaid and Medicare data for South Carolina women. Women with VI were identified on the basis of a qualifying diagnosis in billing data. We assessed women's adherence (full adherence, partial adherence and no screening) with two United States Preventive Services Task Force (USPSTF) cancer screening recommendations (mammography and Pap testing) throughout the course of the study period. Multinomial models were estimated to describe the association between VI and adherence to the two cancer screening recommendations. RESULTS: A total of 1308 women with VI and 2635 women without VI (mammography) and 1247 women with VI and 2483 women without VI (Pap testing) were included in the study. After adjusting for age, number of eligible enrollment years, insurance type (Medicare, Medicaid, or both), urban or rural residence and having a hysterectomy, women with VI were significantly less likely than those without VI to have full adherence to mammography recommendations (adjusted odds ratio, OR, 0.49, 95% confidence interval, CI, 0.40-0.60) and Pap testing recommendations (adjusted OR 0.32, 95% CI 0.27-0.39). CONCLUSION: We used a new approach to investigate adherence to USPSTF recommendations, accounting for both full and partial adherence. This approach identified disparities in mammography and Pap testing for women with VI. The findings of this study should facilitate the development of effective interventions to increase screening among women with VI.