Benefits and pitfalls of pooling datasets from comparable observational studies: combining US and Dutch nursing home studies.

Different research groups sometimes carry out comparable studies. Combining the data can make it possible to address additional research questions, particularly for small observational studies such as those frequently seen in palliative care research. We present a systematic approach to pool individual subject data from observational studies that addresses differences in research design, illustrating the approach with two prospective observational studies on treatment and outcomes of lower respiratory tract infection in US and Dutch nursing home residents. Benefits of pooling individual subject data include enhanced statistical power, the ability to compare outcomes and validate models across sites or settings, and opportunities to develop new measures. In our pooled dataset, we were able to evaluate treatments and end-of-life decisions for comparable patients across settings, which suggested opportunities to improve care. In addition, greater variation in participants and treatments in the combined dataset allowed for subgroup analyses and interaction hypotheses, but required more complex analytic methods. Pitfalls included the large amount of time required for equating study procedures and variables and the need for additional funding.

Dementia severity, decline and improvement after a lower respiratory tract infection.

OBJECTIVE: To assess decline and improvement in functional characteristics, cognition and restraint use after a lower respiratory tract infection (LRI) and describe variation by dementia severity. DESIGN: Two prospective cohort studies. SETTING: Nursing homes in the Netherlands and in Missouri, USA. PARTICIPANTS: 227 Dutch and 396 Missouri nursing home residents with dementia and LRI who were treated with antibiotics. MEASUREMENTS: We compared functional characteristics (Activities of Daily Living [ADL], bedfast status, pressure ulcers, incontinence), cognition and restraint use 3 months after an LRI with status 1 to 2 weeks before diagnosis. RESULTS: Residents with LRI frequently declined on all measures, but many also improved, including those with severe dementia. On the measures where residents could still decline further, residents with severe dementia showed higher variability than residents with less severe dementia. This was most obvious for bedfast status and restraint use. CONCLUSIONS: Compared with less severely demented residents, residents with severe dementia showed more decline on measures where they still had room for change. However, on these measures, residents with severe dementia also improved more often. LRI does not necessarily lead to deterioration even in individuals with severe dementia.

[Treatment of pneumonia in nursing home residents with severe dementia: for residents with poor prognosis, a more reserved approach in The Netherlands and more active treatment in the United States]. / Behandeling van pneumonie bij verpleeghuispatiënten met ernstige dementie: terughoudender beleid in Nederland en actiever beleid in de verenigde Staten naarmate de prognose ongunstiger is.

OBJECTIVE: To describe differences in the treatment of pneumonia and in the association of treatment with prognosis in Dutch and American nursing home patients with late-stage dementia. Design. Prospective studies in The Netherlands and the American state of Missouri. METHOD: In 61 Dutch nursing homes and 36 in Missouri, severely demented patients with pneumonia were included in the periods October 1996-July 1998 and August 1995-September 1998 respectively. Data was collected on their state of health, comorbidity, symptoms of pneumonia and treatment aspects such as antibiotic use, hospital admission and relief of symptoms. Comparisons were made between treatments in both countries and between groups of patients with a similar probability of mortality within 2 weeks. RESULTS: A total of 328 Dutch and 280 American patients were selected. Antibiotics were more frequently withheld in The Netherlands (in 33% of patients) than in Missouri (24%). Differences in antibiotic use were more pronounced in patients with a poor prognosis (56% versus 15%). Dutch patients were more frequently dehydrated but were less likely to receive rehydration therapy than American patients, with a larger difference in patients with a poor prognosis (2% versus 63%). Treatments to relieve symptoms that were provided more often in patients with a poor prognosis (in 20-26%) were: oxygen (both countries), and in The Netherlands also opiates, and hypnotics, sedatives or anxiolytics. CONCLUSION: In The Netherlands, curative treatment was frequently withheld in patients with severe dementia and pneumonia, and even more frequently when the prognosis was poorer. Conversely, treatment in Missouri was more active in patients with a poor prognosis. Despite more frequent palliative treatment goals in The Netherlands, treatments to relieve symptoms were provided infrequently and inconsistent with this approach. These insights may be helpful for decision-making in the treatment of pneumonia in patients with severe dementia.

Metabolic effects of interventions to increase exercise in adults with type 2 diabetes.

AIMS/HYPOTHESIS: The aim of this meta-analysis was to integrate the results of primary research testing the effect of diabetes self-management interventions that included recommendations to increase exercise on metabolic outcomes among adults with type 2 diabetes. MATERIALS AND METHODS: Extensive literature searching strategies were used to identify published and unpublished intervention studies that measured glycated haemoglobin outcomes. Primary study results were coded. Fixed- and random-effects meta-analytic procedures included moderator analyses. RESULTS: Data were synthesised across 10,455 subjects from 103 research reports. The overall mean weighted effect size for two-group comparisons was 0.29 (higher mean for treatment than control). This effect size is consistent with a difference in HbA1c means of 0.45% (e.g. 7.38% for treatment subjects vs 7.83% for control subjects). For single-group studies, the overall mean weighted effect size was 0.32-0.34. Control group subjects experienced no improvement in metabolic control during participation in the studies. Interventions that targeted multiple health behaviours resulted in smaller effect size estimates (0.22) than interventions that focused only on exercise behaviours (0.45). Funded studies reported greater improvements in metabolic controls. Studies with a greater proportion of female subjects reported lower effect sizes. Baseline HbA1c and BMI were unrelated to metabolic outcomes. CONCLUSIONS/INTERPRETATION: These findings suggest that self-management interventions that include exercise recommendations improve metabolic control, despite considerable heterogeneity in the magnitude of the intervention effect. Interventions that emphasise exercise may be especially effective in improving metabolic control. Primary research testing interventions in randomised trials to confirm causal relationships would be constructive.

Predicting mortality in nursing home residents with lower respiratory tract infection: The Missouri LRI Study.

CONTEXT: Lower respiratory tract infection (LRI) is a leading cause of mortality and hospitalization in nursing home residents. Treatment decisions may be aided by a clinical prediction rule that identifies residents at low and high risk of mortality. OBJECTIVE: To identify patient characteristics predictive of 30-day mortality in nursing home residents with an LRI. DESIGN, SETTING, AND PATIENTS: Prospective cohort study of 1406 episodes of LRI in 1044 residents of 36 nursing homes in central Missouri and the St Louis, Mo, area between August 15, 1995, and September 30, 1998. MAIN OUTCOME MEASURE: Thirty-day all-cause mortality. RESULTS: Thirty-day mortality was 14.7% (n = 207). In a logistic analysis, using generalized estimating equations to adjust for clustering, we developed an 8-variable model to predict 30-day mortality, including serum urea nitrogen, white blood cell count, body mass index, pulse rate, activities of daily living status, absolute lymphocyte count of less than 800/microL (0.8 x 10(9)/L), male sex, and deterioration in mood over 90 days. In validation testing, the model exhibited reasonable discrimination (c =.76) and calibration (nonsignificant Hosmer-Lemeshow goodness-of-fit statistic, P =.54). A point score based on this model's variables fit to the entire data set closely matched observed mortality. Fifty-two percent of residents had low (score of 0-4) or relatively low (score of 5-6) predicted 30-day mortality, with 2.2% and 6.2% actual mortality, respectively. CONCLUSIONS: Our model distinguishes nursing home residents at relatively low risk for mortality due to LRI. If independently validated, our findings could help physicians identify nursing home residents in need of different therapeutic approaches for LRI.

Clinical findings associated with radiographic pneumonia in nursing home residents.

OBJECTIVE: Subtle presentation and the frequent lack of on-site physicians complicate the diagnosis of pneumonia in nursing home residents. We sought to identify clinical findings (signs, symptoms, and simple laboratory studies) associated with radiographic pneumonia in sick nursing home residents. STUDY DESIGN: This was a prospective cohort study. POPULATION: The residents of 36 nursing homes in central Missouri and the St. Louis area with signs or symptoms suggesting a lower respiratory infection were included. OUTCOME MEASURED: We compared evaluation findings by project nurses with findings reported from chest radiographs. RESULTS: Among 2334 episodes of illness in 1474 nursing home residents, 45% of the radiograph reports suggested pneumonia (possible=12%; probable or definite = 33%). In 80% of pneumonia episodes, subjects had 3 or fewer respiratory or general symptoms. Eight variables were significant independent predictors of pneumonia (increased pulse, respiratory rate =30, temperature =38 degrees C, somnolence or decreased alertness, presence of acute confusion, lung crackles on auscultation, absence of wheezes, and increased white blood count). A simple score (range = -1 to 8) on the basis of these variables identified 33% of subjects (score > or =3) with more than 50% probability of pneumonia and an additional 24% (score of 2) with 44% probability of pneumonia. CONCLUSIONS: Pneumonia in nursing home residents is usually associated with few symptoms. Nonetheless, a simple clinical prediction rule can identify residents at very high risk of pneumonia. If validated in other studies, physicians could consider treating such residents without obtaining a chest radiograph.

Randomized clinical trial of a quality improvement intervention in nursing homes.

PURPOSE: The purpose of the study was to determine if simply providing nursing facilities with comparative quality performance information and education about quality improvement would improve clinical practices and subsequently improve resident outcomes, or if a stronger intervention, expert clinical consultation with nursing facility staff, is needed. DESIGN AND METHODS: Nursing facilities (n = 113) were randomly assigned to one of three groups: workshop and feedback reports only, workshop and feedback reports with clinical consultation, and control. Minimum Data Set (MDS) Quality Indicator (QI) feedback reports were prepared and sent quarterly to each facility in intervention groups for a year. Clinical consultation by a gerontological clinical nurse specialist (GCNS) was offered to those in the second group. RESULTS: With the exception of MDS QI 27 (little or no activity), no significant differences in resident assessment measures were detected between the groups of facilities. However, outcomes of residents in nursing homes that actually took advantage of the clinical consultation of the GCNS demonstrated trends in improvements in QIs measuring falls, behavioral symptoms, little or no activity, and pressure ulcers (overall and for low-risk residents). IMPLICATIONS: Simply providing comparative performance feedback is not enough to improve resident outcomes. It appears that only those nursing homes that sought the additional intensive support of the GCNS were able to effect enough change in clinical practice to improve resident outcomes significantly.

Prevalence, incidence, management, and predictors of venous ulcers in the long-term-care population using the MDS.

OBJECTIVE: To describe the prevalence, incidence, management, and predictors of venous ulcers in residents of certified long-term-care facilities using the Minimum Data Set. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: 32,221 residents admitted to long-term-care facilities in Missouri between January 1, 1996, and October 30, 1998. MAIN OUTCOME MEASURES: Version 2.0 of the Minimum Data Set was utilized. Assessment items included selected measures from background information, disease diagnoses, physical functioning and structural problems, health conditions, oral/nutritional status, and skin condition. MAIN RESULTS: Venous ulcer prevalence on admission was 2.5%. The incidence of venous ulcer development for long-term-care residents admitted without an ulcer at 90, 180, 270, and 365 days after admission was 1.0%, 1.3%, 1.8%, and 2.2%, respectively. The most frequent skin treatments for residents with a venous ulcer were ulcer care, dressings, and ointments. Factors associated with venous ulcer development within a year of admission were diabetes mellitus, peripheral vascular disease, and edema. CONCLUSION: Venous ulcer prevalence and incidence are greater in the long-term-care population than in the community at-large. Residents with a venous ulcer are likely to have comorbid conditions such as diabetes mellitus, peripheral vascular disease, congestive heart failure, edema, wound infection, and pain. Based on these data, risk factors such as history of leg ulcers, recent edema, diabetes mellitus, congestive heart failure, or peripheral vascular disease should prompt clinicians to carefully plan care that will manage a resident's risk for venous ulcer development.

Predictors of physician nursing home practice: does what we do in residency training make a difference?

BACKGROUND AND OBJECTIVES: The number of physicians who care for nursing home patients is inadequate. This study determined predictors of current nursing home practice, including whether making nursing home rounds with an attending physician during residency is a predictor of subsequent nursing home practice. METHODS: We used a cross-sectional survey to study 170 family physicians in private or academic practice in a large, university-based Midwestern family practice residency program. RESULTS: The response rate was 86%. Fifty-five percent of respondents had an active nursing home practice. Rounding in a nursing home with an attending during residency had no relation to current nursing home practice. In comparison to physicians without an active nursing home practice, physicians with an active nursing home practice were more likely to reside in a smaller community, have a hospital practice (60.5% versus 39.5%), see more outpatients per week (105 versus 78), and work more hours per week (57 versus 49). In a logistic regression model, decreasing community size, number of hours worked per week, and having an active hospital practice were associated with active nursing home practice. CONCLUSIONS: Factors other than educational experience have an effect on physician nursing home practice.

Initial field testing of an instrument to measure: observable indicators of nursing home care quality.

The "Observable Indicators of Nursing Home Care Quality" instrument was developed as a new measure of nursing home care quality. The instrument is based on a theoretical model of quality nursing home care grounded in data from provider and consumer focus groups. The instrument was piloted in 10 Missouri nursing homes. Subsequent versions were tested in 109 Missouri and 11 Icelandic nursing homes. Content validity was established using experts. Concurrent and known groups validity was evaluated using Minimum Data Set quality indicators, survey citations, and a process of care measure. Interrater and test-retest reliabilities were calculated as well as coefficient alpha. The "Observable Indicators of Nursing Home Care Quality" instrument is a new measure that can be used by researchers, and potentially by regulators, consumers, or providers, to observe and score specific indicators of quality care following a 20- to 30-minute inspection of a nursing home.

Setting thresholds for quality indicators derived from MDS data for nursing home quality improvement reports: an update.

BACKGROUND: Determining meaningful thresholds to reinforce excellent performance and flag potential problem areas in nursing home care is critical for preparing reports for nursing homes to use in their quality improvement programs. This article builds on the work of an earlier panel of experts that set thresholds for quality indicators (QIs) derived from Minimum Data Set (MDS) assessment data. Thresholds were now set for the revised MDS 2.0 two-page quarterly form and Resource Utilization Groups III (RUGS III) quarterly instrument. SETTING THRESHOLDS: In a day-long session in October 1998, panel members individually determined lower (good) and upper (poor) threshold scores for each QI, reviewed statewide distributions of MDS QIs, and completed a follow-up Delphi of the final results. REPORTING MDS QIS FOR QUALITY IMPROVEMENT: The QI reports compiled longitudinal data for all residents in the nursing home during each quarter and cumulatively displayed data for five quarters for each QI. A resident roster was provided to the nursing home so that the quality improvement team could identify the specific residents who developed the problems defined by each QI during the last quarter. Quality improvement teams found the reports helpful and easy to interpret. SUMMARY AND CONCLUSIONS: As promised in an earlier report, to ensure that thresholds reflect current practice, research using experts in a panel to set thresholds was repeated as needed. As the MDS instrument or recommended calculations for the MDS QIs change, thresholds will be reestablished to ensure a fit with the instrument and data.

Why geriatrics? Academic geriatricians' perceptions of the positive, attractive aspects of geriatrics.

BACKGROUND: Recruitment of geriatrics trainees has been poor, and the current shortage of academic geriatricians is expected to worsen. Although barriers to entering geriatrics practice have been identified, a review of the literature found few studies about why people choose to enter geriatrics. METHODS: We used qualitative methods to investigate the positive, attractive aspects of geriatrics. Long interviews with six academic geriatricians were taped and transcribed. Transcripts were entered into a textual database computer program and reviewed independently by two investigators. RESULTS: Six themes emerged: 1) traditional learning experiences, 2) value on personal relationships, 3) a perception of distinctive differences, 4) a desire to feel needed personally and societally, 5) prefer democracy versus autocracy, and 6) desire intellectual challenges. Academic geriatrics, therefore, is particularly attractive to people who value enduring relationships, see challenges in complexity, practice social responsibility, prefer working within a multidisciplinary team, and derive satisfaction from making seemingly small but nonetheless important changes in peoples' lives. CONCLUSIONS: If further studies validate these findings, they could promote geriatrics as a career, by, for example, identifying students and family practice and internal medicine residents who share these values, beliefs, and attitudes and encouraging them to consider this important field.

Nursing home care quality: a multidimensional theoretical model integrating the views of consumers and providers.

This exploratory study was undertaken to discover the defining dimensions of nursing home care quality from the viewpoint of consumers of nursing home care. Eleven focus groups were conducted in five Missouri communities. The seven dimensions of the consumer multidimensional model of nursing home care quality are: staff, care, family involvement, communication, environment, home, and cost. The views of consumers and families are compared with the results of a previous study of providers of nursing home services. An integrated, multidimensional theoretical model is presented for testing and evaluation. An instrument based on the model is being tested to observe and score the dimensions of nursing home care quality.

Mortality from lower respiratory infection in nursing home residents. A pilot prospective community-based study.

BACKGROUND: Lower respiratory infections (LRI) are an important cause of morbidity, mortality, and hospitalization of nursing home residents, yet treatment recommendations have primarily been based on the minority who are hospitalized. We sought to prospectively evaluate risk factors for mortality from LRI in community nursing home residents. METHODS: We studied residents of 10 central Missouri nursing homes (910 beds) from January 1994 to September 1994. Attending physicians authorized nurse evaluations of ill residents who showed symptoms of an LRI. Those residents who met the study definition of LRI received a more detailed assessment and follow ups at 30 and 90 days. RESULTS: The 231 evaluations identified 141 LRIs in 121 individuals. Sixteen (11%) residents died within 30 days of evaluation. The most important univariate predictor of 30-day mortality was severe activities of daily living (ADL) dependency (relative risk = 8.8, 95% confidence interval, 2.55-30.1). Several other clinical and laboratory findings were also significant predictors. In multivariable logistic regression, ADL dependency, respiratory rate, and pneumonia on chest radiograph independently predicted mortality; the model showed good discriminating ability (c = .83). CONCLUSIONS: For nursing home residents with LRI, ADL dependency is an important mortality predictor. Further research with a larger sample should lead to a useful prediction rule for outcome from nursing home-acquired LRI.

Diagnosis and management of weight loss in the elderly.

Weight loss occurs commonly in elderly individuals, and is associated with functional decline and mortality. A 10% loss of body weight over 10 years is consistently associated with increased mortality and functional decline. A 4% body weight loss over 1 year should trigger a search for causes, which commonly include depression, cancers, benign gastrointestinal conditions, and medication toxicity. To evaluate weight loss, physicians should distinguish between four problems: anorexia, dysphagia, weight loss despite normal intake, or socioeconomic problems. In most cases, the cause of weight loss is identified by a thorough history, a targeted physical examination, and a simple laboratory evaluation. Assessment should include evaluation of functional and nutritional status. Management should include correction of potential causes and nutritional supplementation.

Nursing home care quality: a multidimensional theoretical model.

This exploratory study was undertaken to discover the defining dimensions of nursing home care quality and to propose a conceptual model to guide nursing home quality research and the development of instruments to measure nursing home care quality. Three focus groups were conducted in three central Missouri communities. A naturalistic inductive analysis of the transcribed content was completed. Two core variables (interaction and odor) and several related concepts emerged from the data. Using the core variables, related concepts, and detailed descriptions from participants, three models of nursing home care quality emerged from the analysis: (1) a model of a nursing home with good quality care; (2) a model of a nursing home with poor quality care; and (3) a multidimensional model of nursing home care quality. The seven dimensions of the multidimensional model of nursing home care quality are: central focus, interaction, milieu, environment, individualized care, staff, and safety. To pursue quality, the many dimensions must be of primary concern to nursing homes. We are testing an instrument based on the model to observe and score the dimensions of nursing home care quality.

Verifying nursing home care quality using minimum data set quality indicators and other quality measures.

Researchers, providers and government agencies have devoted time and resources to the development of a set of Quality Indicators derived from Minimum Data Set (MDS) data. Little effort has been directed toward verifying that Quality Indicators derived from MDS data accurately measure nursing home quality. Researchers at the University of Missouri-Columbia have independently verified the accuracy of QI derived from MDS data using four different methods; 1) structured participative observation, 2) QI Observation Scoring Instrument, 3) Independent Observable Indicators of Quality Instrument, and 4) survey citations. Our team was able to determine that QIs derived from MDS data did differentiate nursing homes of good quality from those of poorer quality.

What alters physicians' decisions to admit to the coronary care unit?

BACKGROUND: A trial of a decision-support tool to modify utilization of the coronary care unit (CCU) failed because utilization improved after explanation of the tool but before its actual employment in the trial. We investigated this unexpected phenomenon in light of an emerging theory of decision-making under uncertainty. METHODS: A prospective trial of the decision-support intervention was performed on the Family Practice service at a 100-bed rural hospital. Cards with probability charts from the acute ischemic Heart Disease Predictive Instrument (HDPI) were distributed to residents on the service and withdrawn on alternate weeks. Residents were encouraged to consult the probability charts when making CCU placement decisions. The study decision was between placement in the CCU and in a monitored nursing bed. Analyses included all patients admitted during the intervention trial year for suspected acute cardiac ischemia (n = 89), plus patients admitted in two pretrial periods (n = 108 and 50) and one posttrial period (n = 45). RESULTS: In the intervention trial, HDPI use did not affect CCU utilization (odds ratio 1.046, P > .5). However, following the description of the instrument at a departmental clinical conference, CCU use markedly declined at least 6 months before the intervention trial (odds ratio 0.165, P < .001). Simply in learning about the instrument. residents achieved sensitivity and specificity equal to the instrument's optimum, whether or not they actually used it. CONCLUSIONS: Physicians introduced to a decision-support tool achieved optimal CCU utilization without actually performing probability estimations. This may have resulted from improved focus on relevant clinical factors identified by the tool. Teaching simple decision-making strategies might effectively reduce unnecessary CCU utilization.

Assessing contributors to cost of care in nursing homes.

In 1994 12.7% of the population was 65 and over, while 10.6% were 85 and over. Expenditures for nursing homes reached $72.3 billion in 1994 (much of which is tax-supported) accounting for 8.7% of all personal health money spent. Data from the 1993 Missouri Medicaid cost reports for 403 nursing homes were reviewed to determine differences in costs per resident day (PRD) and discover which factors most influenced these differences. Mid-sized facilities with 60-120 beds reported the lowest resident-related PRD costs. PRD expenses for aides and orderlies were higher in tax-exempt facilities, which was thought to be related to their "more altruistic" mission. Investor-owned facilities showed significantly greater administrative costs PRD, which may relate to higher administrative salaries and fancier offices. The authors suggest further study that would incorporate location, occupancy rate, quality of care, case mix, and payer mix data.