A Postacute Care Function Process Quality Measure for the Collection of Standardized Self-Care and Mobility Data: Development, Implementation, and Quality Measure Scores.

OBJECTIVE: To describe the development of and quality measure scores for the cross-setting postacute care function process quality measure that requires the collection of standardized self-care and mobility data at admission and discharge and at least 1 function goal. DESIGN: Description of the development and implementation of the quality measure and the associated standardized self-care and mobility data elements. Descriptive analyses of quality measure scores for the first calendar year using data from the Minimum Data Set, the Inpatient Rehabilitation Facility Patient Assessment Instrument, the Long-Term Care Hospitals (LTCH) Continuity Assessment Record and Evaluation Data Set, and Outcome and Assessment Information Set. SETTING: 15,127 skilled nursing facilities (SNFs), 1129 inpatient rehabilitation facilities (IRFs), 414 LTCHs, and 10,352 home health agencies (HHAs) in the United States. PARTICIPANTS: In total there were 9,216,943 stays/quality episodes (N = 9,216,943), including 2,084,774 SNF Medicare fee-for-service patient stays, 493,209 IRF Medicare patient stays, 161,714 patient stays, and 6,477,246 Medicare and Medicaid quality episodes. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Scores for the cross-setting postacute care function process quality measure. RESULTS: The mean process quality measure scores for SNFs, IRFs, LTCHs, and HHAs were 95.5%, 99.7%, 99.1%, and 95.8, respectively. The 10th percentile scores for SNFs, IRFs, LTCHs, and HHAs were 88.5%, 99.3%, 98.4%, and 89.4, respectively, indicating that at least 90% of postacute care providers submitted the standardized data for a large proportion of their patients. Mean quality measure scores did not vary by provider characteristics. CONCLUSIONS: Most SNFs, IRFs, LTCHs, and HHAs submitted the self-care and mobility data, resulting in high quality measure scores during the first year of implementation. The availability of the standardized self-care and mobility data across postacute care settings offers the opportunity to compare the characteristics and functional outcomes of patients treated in postacute care.

Opportunities to Improve Informed Consent with AHRQ Training Modules.

BACKGROUND: Informed consent is a process of communication between clinician and patient that results in the patient's decision about whether to undergo a specific intervention. However, patients often do not understand the risks, benefits, and alternatives, even after signing a consent form. METHODS: Mixed-methods pilot test of two Agency for Healthcare Research and Quality (AHRQ) informed consent training modules implemented in four hospitals. Methods included staff and patient surveys, interviews, site visits, and pre- and posttests of the modules. RESULTS: A low proportion of clinicians reported using teach-back (40.0%) or high-quality decision aids (55.0%). Patients reported limited use of best practices, including being asked to teach-back (58.4%), having other options described (54.9%), viewing decision aids (37.4%), and finding the form very easy to understand (66.8%). Content of the training modules aligned well with identified deficiencies. Barriers to completing the modules included staff turnover, competing demands, and lack of accountability. Facilitators included committed champions with available time, motivation, and release time for staff to take modules. Knowledge increased for leaders (p <0.05) and staff (p <0.001) who completed the training modules. Hospitals reported the effects of piloting the modules included fostering dialogue and identifying opportunities for improvements, identifying and rectifying policy ambiguity and noncompliance, reinforcing the use of interpreter services, and using modules' strategies and tools to improve informed consent. CONCLUSION: Many opportunities exist for hospitals to improve their informed consent practices. AHRQ's two training modules, have face validity, addressed demonstrated deficiencies in hospitals' informed consent policies and processes, and stimulated improvement activity in motivated hospitals.

When genomic and standard test results diverge: implications for breast cancer patients' preference for chemotherapy.

PURPOSE: We examined how women incorporate potentially differing genomic and standard assessments of breast cancer recurrence risk into chemotherapy decisions. METHODS: 165 women previously treated for early-stage breast cancer indicated their interest in chemotherapy regimens to prevent recurrence of breast cancer in response to six hypothetical vignettes that presented breast cancer recurrence risk estimates from standard criteria and a genomic test, some of which were discordant. RESULTS: Standard and genomic test results each elicited greater interest in chemotherapy when they indicated high rather than low risk for recurrence (89% vs. 26%, and 87% vs. 22%, respectively, Ps < 0.001). Genomic test results had a larger impact on chemotherapy preferences than standard measures to predict recurrence. CONCLUSIONS: Some women may be reluctant to forgo chemotherapy when genomic tests indicate low recurrence risk but standard criteria suggest high risk. Additional research including replication of the findings of this small, vignette-based study is needed.

Health literacy and cancer risk perception: implications for genomic risk communication.

BACKGROUND: As new genomic technology expands the number of medical tests available to physicians and patients, identifying gaps in our understanding of how best to communicate risk is increasingly important. We examined how health literacy informs breast cancer survivors' understanding of and meaning assigned to recurrence risks yielded by genomic tests. METHODS: Study participants were posttreatment female breast cancer survivors (N =163) recruited at a university breast cancer clinic. We assessed their health literacy (using REALM) and their interpretation of hypothetical recurrence risk results from a genomic test, presented in several verbal and numerical formats. Analyses controlled for women's objective recurrence risk, age, income, and race. RESULTS: Women with lower health literacy gave higher mean estimates of recurrence risk for a hypothetical group of women with early-stage breast cancer than did women with higher health literacy (52% v. 30%, P < 0:001). Women with lower health literacy also gave more variable estimates in this and several other tasks. When making chemotherapy decisions using risks presented in verbal formats, decisions by women with lower health literacy were less sensitive to the difference between low and high recurrence risk. Ease of understanding of risk formats differed by health literacy. CONCLUSIONS: Health literacy affected the meanings women assigned to recurrence risk when presented in certain formats. The greater variability in responding by women with lower health literacy supports the hypothesis that they have less precise mental representations of risk, but more research is needed to rule out other possible explanations.

Successfully reducing antibiotic prescribing in nursing homes.

OBJECTIVES: To determine whether antibiotic prescribing can be reduced in nursing homes using a quality improvement (QI) program that involves providers, staff, residents, and families. DESIGN: A 9-month quasi-experimental trial of a QI program in 12 nursing homes (6 comparison, 6 intervention) conducted from March to November 2011. SETTING: Nursing homes in two regions of North Carolina, roughly half of whose residents received care from a single practice of long-term care providers. PARTICIPANTS: All residents, including 1,497 who were prescribed antibiotics. INTERVENTION: In the intervention sites, providers in the single practice and nursing home nurses received training related to prescribing guidelines, including situations for which antibiotics are generally not indicated, and nursing home residents and their families were sensitized to matters related to antibiotic prescribing. Feedback on prescribing was shared with providers and nursing home staff monthly. MEASUREMENTS: Rates of antibiotic prescribing for presumed urinary tract, skin and soft tissue, and respiratory infections. RESULTS: The QI program reduced the number of prescriptions ordered between baseline and follow-up more in intervention than in comparison nursing homes (adjusted incidence rate ratio = 0.86, 95% confidence interval = 0.79-0.95). Based on baseline prescribing rates of 12.95 prescriptions per 1,000 resident-days, this estimated adjusted incidence rate ratio implies 1.8 prescriptions avoided per 1,000 resident-days. CONCLUSION: This magnitude of effect is unusual in efforts to reduce antibiotic use in nursing homes. Outcomes could be attributed to the commitment of the providers; outreach to providers and staff; and a focus on common clinical situations in which antibiotics are generally not indicated; and suggest that similar results can be achieved on a wider scale if similar commitment is obtained and education provided.

Role of body temperature in diagnosing bacterial infection in nursing home residents.

OBJECTIVES: To provide empirically based recommendations for incorporating body temperature into clinical decision-making regarding diagnosing infection in nursing home (NH) residents. DESIGN: Retrospective. SETTING: Twelve North Carolina NHs. PARTICIPANTS: NH residents (N = 1,007) with 1,858 randomly selected antibiotic prescribing episodes. MEASUREMENTS: Maximum prescription-day temperature plus the three most recent nonillness temperatures were recorded for each prescribing episode. Two empirically based definitions of fever were developed: population-based (population mean nonillness temperature plus 2 population standard deviations (SDs)) and individualized (individual mean nonillness temperature plus 2 population SDs). These definitions were used along with previously published fever criteria and Infectious Diseases Society of America (IDSA) criteria to determine how often each prescribing episode was associated with a "fever" according to each definition. RESULTS: Mean population nonillness temperature was 97.7 ± 0.5 ºF. If "normal" were defined as less than 2 SDs above the mean, fever would be defined as any temperature above 98.7 ºF, and the previously published fever cutpoints and the IDSA criteria are 4.8 SDs above this mean. Between 30% and 32% of the 1,858 prescribing episodes examined were associated with temperatures more than 2 SDs above the population mean nonillness temperature, whereas only 10% to 11% of episodes met the previously published and IDSA fever definitions. CONCLUSION: Clinicians should apply empirically based definitions to assess fever in NH residents. Furthermore, low fever prevalence in residents treated with antibiotics according to all definitions suggests that some prescribing may not be associated with acute bacterial infection.

Does adherence to the Loeb minimum criteria reduce antibiotic prescribing rates in nursing homes?

OBJECTIVES: The Loeb minimum criteria (LMC), developed by a 2001 consensus conference, are minimum standards for initiation of antibiotics in long term care settings, intended to reduce inappropriate prescribing. This study examined the relationship between nursing home prescriber adherence to the LMC and antibiotic prescribing rates, overall and for each of three specific conditions (urinary tract infections, respiratory infections, and skin and soft tissue infections). DESIGN: We performed a cross-sectional analysis at the resident-day level. We estimated multivariate models adjusting for nursing home characteristics via multilevel Poisson regression, with robust standard errors to account for clustering of prescriptions within residents within nursing homes. SETTING: Data were collected through medical record abstraction in 12 North Carolina nursing homes between March and May 2011. PARTICIPANTS: In total, we identified 3381 antibiotic prescriptions across the 3-month observation period, representing 110,810 nursing home resident-days. In addition, we performed chart audits for a random sample of 653 prescriptions for urinary tract, respiratory, and skin and soft tissue infections to create measures of LMC adherence. MEASUREMENTS: The primary outcome was a count of prescriptions per resident per day, and the key explanatory variable was a nursing home-level estimate of the proportion of antibiotic prescriptions that adhered to the LMC. RESULTS: Only 12.7% of prescriptions were classified as LMC adherent, although there was substantial variation across study nursing homes (range: 4.8% to 22.0%) and by infection type (1.9% adherence for respiratory infections, 10.2% for urinary tract infections, and 42.7% for skin and soft tissue infections). We found no statistically significant relationship between adherence to the LMC and total prescribing rates (IRR 1.00, 95% CI 0.98-1.03; P = .84). Similarly, there was no significant relationship between LMC adherence and prescribing rates for treating urinary tract infections (IRR 0.99, 95% CI 0.96-1.02; P = .49), respiratory infections (IRR 0.91, 95% CI 0.76-1.08; P = .28), or skin and soft tissue infections (IRR 0.99, 95% CI 0.98-1.01; P = .39) considered alone. CONCLUSION: We found little evidence that prescribers in study nursing homes considered the LMC when making prescribing decisions. Further, we found no evidence that greater adherence to the LMC was associated with lower rates of antibiotic prescribing. Evidence-based guidelines for antibiotic initiation must be adopted more widely before any substantial gains from adherence are likely to be recognized.