Development and testing of a process measure of nursing home quality of care.

OBJECTIVE: To develop and test quality of care process measures for three medical conditions of nursing home patients: fever, shortness of breath, and chest pain. DESIGN: Flowsheets designed to capture the critical elements of care for the above conditions were developed by an expert panel. Nursing home residents charts were reviewed retrospectively using the flow sheets. The reviews were translated into clinical scenarios, and the quality of care the scenarios represented was rated by an expert panel. SETTING: All nursing homes in Hennepin County, MN, that care for Medicaid patients. PATIENTS: A random sample of 1405 Medicaid nursing home residents from 1984 and 1988. MEASURES: Measures of quality of physician assessment and intervention, quality of nurse assessment and intervention, and global quality were developed and the intra- and interrater reliability were tested. The measures' validity was assessed by their ability to predict resident death. RESULTS: Intrarater reliability was measured as the correlation of the ratings of blinded duplicates. The correlation for the global scale and the four subscales ranged from .74 to .88 (P < .001 for all). Interrater reliability was tested by examining what percentage of the quality ratings were within one unit (1-5 scale) for all three raters. All three raters were within one unit for more than 72% scenarios for all scales. The subscale of quality of physician assessment was able to predict resident death when the worst episode of care (OR = .47, 95% CI(.31-.74)) or the mean episode of care (OR .54, 95% CI(.30-.99)) was used. None of the other subscales or the global measure predicted death. CONCLUSIONS: Through the use of an expert panel, measures of nursing home quality of care were developed for shortness of breath, fever, and chest pain. These measures have reasonable reliability and significant face validity. Their validity is supported further by the ability of one of the measures to predict resident death.

The effect of DHEAS on influenza vaccination in aging adults.

OBJECTIVE: To determine whether simultaneous administration of dehydroepiandrosterone sulfate (DHEAS) exhibits adjuvant activity in the immune response of aging humans by supplementing influenza vaccination with the maximum single dose of DHEAS that could be practically injected subcutaneously (approximately 7.5 mg). DESIGN: A randomized, double-blind, placebo-controlled trial of DHEAS injection with 1993-94 and 1994-95 influenza vaccine in older subjects. In addition, initial safety, tolerability, and control testing with 1993-94 influenza vaccine was conducted in young subjects. SETTING: An urban primary care geriatrics clinic. PARTICIPANTS: Seventy-eight older adult volunteers (mean age 78.61 +/- 3.43 years, range 73-90 years) and 20 younger controls (< 40 years, means age 32.76 +/- 5.39 years) were recruited from clinic and community advertising. Subjects were free of disease or medication known to affect immune function. MEASUREMENTS: Immune responses to vaccine at 0, 2, and 4 weeks were measured by vaccine antigen-induced lymphoproliferation in peripheral blood mononuclear cells (PBMC) and serum antibody response by hemagglutination inhibition (HI). RESULTS: The maximum DHEAS dose that could be practically administered subcutaneously was 7.5 mg. Baseline DHEAS levels were significantly lower in older adults (52.1 vs 236.4 micrograms/dL, P < .001). The 1993 old adult DHEAS group HI response tended to be higher for the H3N2 Beijing antigen but not for the H1N1 or B antigen. In subjects with HI titers less then 1:40 for the H3N2 Beijing antigen (n = 29), the post-vaccination titer response tended to be higher among the 16 subjects who received DHEAS (P = .06). The peak response for the H3N2 antigen was associated with the initial DHEAS serum concentration in the DHEAS and placebo groups (R2 = .22, P = .04 and R2 = .21, P = .06, respectively). No significant differences were found for antibody responses to the H1N1 and B antigens or vaccine-antigen induced lymphoproliferation. CONCLUSION: A one-time supplemental dose of DHEAS with influenza vaccination appeared to enhance the specific HI antibody response to the 1993-94 H3N2 antigen in a small group of older adults. These findings were limited to those with lower prevaccination titers and lower DHEAS concentrations. Although clinical implications of these findings for influenza vaccine are uncertain, these results suggest additional detailed immunologic investigations on the role of DHEAS in the aging human immune response are warranted.

Effectiveness of oral antibiotic treatment in nursing home-acquired pneumonia.

OBJECTIVE: To determine factors associated with success or failure of oral antibiotic treatment for nursing home-acquired pneumonia (NHAP). DESIGN: Retrospective study of outcomes for all identifiable NHAP cases in 1991. SETTING: The Nursing Home Services Program of St. Paul Ramsey Medical Center and 31 metropolitan St. Paul, Minnesota, community nursing homes. PARTICIPANTS: Nursing home (NH) cohort: 124 patients (mean age 85.2 years) with a new respiratory symptom and new infiltrate on portable chest X-ray for whom oral antibiotics were prescribed. Hospital cohort: 74 NH patients (mean age 84.3 years) admitted to hospital with new X-ray infiltrate and pneumonia diagnosis. Supportive care status patients were excluded. Forty-three physician/nurse practitioner (MD/NP) teams were represented. MEASUREMENTS: Nursing home cohort: Outcomes of hospitalization within 14 days or 30-day mortality. A discriminant model was applied to predict outcome and discriminant rule performance was analyzed. Hospital cohort: 30-day mortality. RESULTS: Of 198 episodes of NH pneumonia, 63% were treated in the facility; 30.6% (38) failed NH treatment. Thirty-day mortality was 13%. There was no examination by the MD or NP for 59% of NH-treated episodes. The hospital cohort had a higher mean pulse (P < .05) but a similar frequency of feeding dependence. Hospital cohort mortality was 17.6%. The NH treatment failure group had significantly higher proportions of pulse > 90/min, temperature > 100.5 degrees F, respirations > 30/min, feeding dependence, and mechanically altered diets. A discriminant model using these factors was significant (P = .002). The NH treatment failure rate was 11% for no factors present, 23% for two or fewer factors, and 59.5% for three or more (likelihood ratio 3.1). Thirty-two percent of the hospital cohort had zero or one factor present and were alive at 30 days. CONCLUSION: The majority of NHAP episodes were treated successfully with oral antibiotics, but 31% failed treatment in the NH. Patients with a mechanically altered diet or requiring feeding assistance by staff had significantly higher failure rates. Feeding dependence and need for a mechanically altered diet as well as abnormal vital signs are associated with oral antibiotic treatment failure. These factors should be considered in treatment decisions for NHAP.

Amantadine-resistant influenza A in a nursing facility.

Rapid index case treatment and amantadine prophylaxis were implemented in two nursing homes exposed to influenza A. Facility A had no isolation of cases, and 18 of 22 cases occurred after amantadine hydrochloride therapy was initiated. Three patients exhibited amantadine-resistant virus. Facility B had day 1 isolation of the index case. A facility-wide outbreak did not occur. The experience of these facilities suggests that concurrent amantadine treatment and prophylaxis without adequate case isolation may promote further influenza A infection in a nursing facility.

Ofloxacin use in a geriatric population.

The efficacy and safety of ofloxacin for the treatment of pneumonia, urinary infection and skin infections in the institutionalized elderly is being studied in a multicenter North American trial. The two study arms include an open, randomized, comparison of intravenous or oral ofloxacin with standard therapy in subjects requiring admission to acute care institutions, and an open study of oral ofloxacin in residents of chronic care facilities. To date 58 subjects have been enrolled with a mean age of 84 +/- 8 years. The preliminary observations from this ongoing multicenter study suggest that ofloxacin will be a safe and effective option for antimicrobial therapy in the treatment of these common infections in the institutionalized elderly.

Comparison of pharmacokinetic and safety profiles of amantadine 50- and 100-mg daily doses in elderly nursing home residents.

Pharmacokinetic and adverse event profiles of 50- and 100-mg amantadine doses administered daily for up to 21 days for influenza prophylaxis were compared in 82 elderly nursing home residents (mean age 85 yrs, 68% female). We sought to determine if a standard daily dose of 50 mg would achieve mean steady-state trough serum concentrations (CPSSt) of 300 ng/ml and be associated with a lower frequency of adverse events than 100-mg doses. Statistically significant relationships were found between CPSSt and dosage (in mg/kg/day) and serum creatinine. Adverse events were more common with the 100-mg dose (24% vs 14%); 94% occurred in women. Amantadine CPSSt and apparent clearance were not significantly different between sexes. Thirty-nine residents (89%) receiving 50 mg daily achieved CPSSt below 300 ng/ml compared to 42% receiving 100 mg. Standard daily amantadine doses of 50 mg may not achieve adequate CPSSt in elderly nursing home residents, but 100 mg may lead to excessive CPSSt and adverse events, especially in the presence of renal impairment.

Occurrence of adverse effects and high amantadine concentrations with influenza prophylaxis in the nursing home.

Amantadine, in a dose of 100 mg/day, is recommended for influenza prevention in older nursing home residents. We studied an influenza prevention protocol in a 98-bed community nursing home (96% female; mean age = 87.4 years). Fifty-five residents received amantadine when influenza A was confirmed. Although no further influenza cases were diagnosed, 22% experienced adverse events. Dose in mg/kg/day was significantly higher in the group experiencing adverse events (2.24 +/- 0.98 vs 1.76 +/- 0.35; P less than .01). Amantadine concentrations in 32 residents ranged from 128-5,810 ng/mL. Six residents had amantadine concentrations greater than 1,000 ng/mL. Seventy-eight percent would have qualified for further dose reduction on the basis of estimated creatinine clearance. The results suggest that adverse events may be an important problem with the 100 mg/day dose, and this dose may be excessive for influenza prophylaxis in many nursing home residents.