A multi-stage process to develop quality indicators for community-based palliative care using interRAI data.

BACKGROUND: Individuals receiving palliative care (PC) are generally thought to prefer to receive care and die in their homes, yet little research has assessed the quality of home- and community-based PC. This project developed a set of valid and reliable quality indicators (QIs) that can be generated using data that are already gathered with interRAI assessments-an internationally validated set of tools commonly used in North America for home care clients. The QIs can serve as decision-support measures to assist providers and decision makers in delivering optimal care to individuals and their families. METHODS: The development efforts took part in multiple stages, between 2017-2021, including a workshop with clinicians and decision-makers working in PC, qualitative interviews with individuals receiving PC, families and decision makers and a modified Delphi panel, based on the RAND/ULCA appropriateness method. RESULTS: Based on the workshop results, and qualitative interviews, a set of 27 candidate QIs were defined. They capture issues such as caregiver burden, pain, breathlessness, falls, constipation, nausea/vomiting and loneliness. These QIs were further evaluated by clinicians/decision makers working in PC, through the modified Delphi panel, and five were removed from further consideration, resulting in 22 QIs. CONCLUSIONS: Through in-depth and multiple-stakeholder consultations we developed a set of QIs generated with data already collected with interRAI assessments. These indicators provide a feasible basis for quality benchmarking and improvement systems for care providers aiming to optimize PC to individuals and their families.

The Forensic Supplement to the interRAI Mental Health Assessment Instrument: Evaluation and Validation of the Problem Behavior Scale.

Background: Numerous validation studies support the use of the interRAI Mental Health (MH) assessment system for inpatient mental health assessment, triage, treatment planning, and outcome measurement. However, there have been suggestions that the interRAI MH does not include sufficient content relevant to forensic mental health. We address this potential deficiency through the development of a Forensic Supplement (FS) to the interRAI MH system. Using three forensic risk assessment instruments (PCL-R; HCR-20; VRAG) that had a record of independent cross validation in the forensic literature, we identified forensic content domains that were missing in the interRAI MH. We then independently developed items to provide forensic coverage. The resulting FS is a single-page, 19-item supplementary document that can be scored along with the interRAI MH, adding approximately 10-15 min to administration time. We constructed the Problem Behavior Scale (PBS) using 11 items from the interRAI MH and FS. The Developmental Sample, 168 forensic mental health inpatients from two large mental health specialty hospitals, was assessed with both an earlier version of the interRAI MH and FS. This sample also provided us access to scores on the PCL-R, the HCR-20 and the VRAG. To validate our initial findings, we sought additional samples where scoring of the interRAI MH and the FS had been done. The first, the Forensic Sample (N = 587), consisted of forensic inpatients in other mental health units/hospitals. The second, the Correctional Sample (N = 618) was a random, representative sample of inmates in prisons, and the third, the Youth Sample (N = 90) comprised a group of youth in police custody. Results: The PBS ranged from 0 to 11, was positively skewed with most scores below 3, and had good internal consistency (Cronbach's Alpha = 0.80). In a test of concurrent validity, correlations between PBS scores and forensic risk scores were moderate to high (i.e., r with PCL-R Factor two of 0.317; with HCR-20 Clinical of 0.46; and with HCR-20 Risk of 0.39). In a test of convergent validity, we used Binary Logistic Regression to demonstrate that the PBS was related to three negative patient experiences (recent verbal abuse, use of a seclusion room, and failure to attain an unaccompanied leave). For each of these three samples, we conducted the same convergent validity statistical analyses as we had for the Developmental Sample and the earlier findings were replicated. Finally, we examined the relationship between PBS scores and care planning triggers, part of the interRAI systems Clinical Assessment Protocols (CAPs). In all three validity samples, the PBS was significantly related to the following CAPs being triggered: Harm to Others, Interpersonal Conflict, Traumatic Life Events, and Control Interventions. These additional validations generalize our findings across age groups (adult, youth) and across health care and correctional settings. Conclusions: The FS improves the interRAI MH's ability to identify risk for negative patient experiences and assess clinical needs in hospitalized/incarcerated forensic patients. These results generalize across age groups and across health care and correctional settings.

A Case-Mix System for Children and Youth With Developmental Disabilities.

Limited funding across health and social service programs presents a challenge regarding how to best match resources to the needs of the population. There is increasing consensus that differences in individual characteristics and care needs should be reflected in variations in service costs, which has led to the development of case-mix systems. The present study sought to develop a new approach to allocate resources among children and youth with intellectual and developmental disabilities (IDD) as part of a system-wide Medicaid payment reform initiative in Arkansas. To develop the system, assessment data collected using the interRAI Child and Youth Mental Health-Developmental Disability instrument was matched to paid service claims. The sample consisted of 346 children and youth with developmental disabilities in the home setting. Using automatic interactions detection, individuals were sorted into unique, clinically relevant groups (ie, based on similar resource use) and a standardized relative measure of the cost of services provided to each group was calculated. The resulting case-mix system has 8 distinct, final groups and explains 30% of the variance in per diem costs. Our analyses indicate that this case-mix classification system could provide the foundation for a future prospective payment system that is centered around stability and equitability in the allocation of limited resources within this vulnerable population.

A Case-Mix System for Adults with Developmental Disabilities.

Effective management of publicly funded services matches the provision of needed services with cost-efficient payment methods. Payment systems that recognize differences in care needs (eg, case-mix systems) allow for greater proportions of available funds to be directed to providers supporting individuals with more needs. We describe a new way to allocate funds spent on adults with intellectual disabilities (ID) as part of a system-wide Medicaid payment reform initiative in Arkansas. Analyses were based on population-level data for persons living at home, collected using the interRAI ID assessment system, which were linked to paid service claims. We used automatic interactions detection to sort individuals into unique groups and provide a standardized relative measure of the cost of the services provided to each group. The final case-mix system has 33 distinct final groups and explains 26% of the variance in costs, which is similar to other systems in health and social services sectors. The results indicate that this system could be the foundation for a future case-mix approach to reimbursement and stand the test of "fairness" when examined by stakeholders, including parents, advocates, providers, and political entities.

Clinical predictors of protracted length of stay in Ontario Complex Continuing Care hospitals.

BACKGROUND: Post-acute care hospitals are often subject to patient flow pressures because of their intermediary position along the continuum of care between acute care hospitals and community care or residential long-term care settings. The purpose of this study was to identify patient attributes associated with a prolonged length of stay in Complex Continuing Care hospitals. METHODS: Using information collected using the interRAI Resident Assessment Instrument Minimum Data Set 2.0 (MDS 2.0), a sample of 91,113 episodes of care for patients admitted to Complex Continuing Care hospitals between March 31, 2001 and March 31, 2013 was established. All patients in the sample were either discharged to a residential long-term care facility (e.g., nursing home) or to the community. Long-stay patients for each discharge destination were identified based on a length of stay in the 95th percentile. A series of multivariate logistic regression models predicting long-stay patient status for each discharge destination pathway were fit to characterize the association between demographic factors, residential history, health severity measures, and service utilization on prolonged length of stay in post-acute care. RESULTS: Risk factors for prolonged length of stay in the adjusted models included functional and cognitive impairment, greater pressure ulcer risk, paralysis, antibiotic resistant and HIV infection need for a feeding tube, dialysis, tracheostomy, ventilator or a respirator, and psychological therapy. Protective factors included advanced age, medical instability, a greater number of recent hospital and emergency department visits, cancer diagnosis, pneumonia, unsteady gait, a desire to return to the community, and a support person who is positive towards discharge. Aggressive behaviour was only a risk factor for patients discharged to residential long-term care facilities. Cancer diagnosis, antibiotic resistant and HIV infection, and pneumonia were only significant factors for patients discharged to the community. CONCLUSIONS: This study identified several patient attributes and process of care variables that are predictors of prolonged length of stay in post-acute care hospitals. This is valuable information for care planners and health system administrators working to improve patient flow in Complex Continuing Care and other post-acute care settings such as skilled nursing and inpatient rehabilitation facilities.

The interRAI Suite of Mental Health Assessment Instruments: An Integrated System for the Continuum of Care.

The lives of persons living with mental illness are affected by psychological, biological, social, economic, and environmental factors over the life course. It is therefore unlikely that simple preventive strategies, clinical treatments, therapeutic interventions, or policy options will succeed as singular solutions for the challenges of mental illness. Persons living with mental illness receive services and supports in multiple settings across the health care continuum that are often fragmented, uncoordinated, and inadequately responsive. Appropriate assessment is an important tool that health systems must deploy to respond to the strengths, preferences, and needs of persons with mental illness. However, standard approaches are often focused on measurement of psychiatric symptoms without taking a broader perspective to address issues like growth, development, and aging; physical health and disability; social relationships; economic resources; housing; substance use; involvement with criminal justice; stigma; and recovery. Using conglomerations of instruments to cover more domains is impractical, inconsistent, and incomplete while posing considerable assessment burden. interRAI mental health instruments were developed by a network of over 100 researchers, clinicians, and policy experts from over 35 nations. This includes assessment systems for adults in inpatient psychiatry, community mental health, emergency departments, mobile crisis teams, and long-term care settings, as well as a screening system for police officers. A similar set of instruments is available for child/youth mental health. The instruments form an integrated mental health information system because they share a common assessment language, conceptual basis, clinical emphasis, data collection approach, data elements, and care planning protocols. The key applications of these instruments include care planning, outcome measurement, quality improvement, and resource allocation. The composition of these instruments and psychometric properties are reviewed, and examples related to homeless are used to illustrate the various applications of these assessment systems.

Hearing the Voice of the Resident in Long-Term Care Facilities-An Internationally Based Approach to Assessing Quality of Life.

OBJECTIVES: interRAI launched this study to introduce a set of standardized self-report measures through which residents of long-term care facilities (LTCFs) could describe their quality of life and services. This article reports on the international development effort, describing measures relative to privacy, food, security, comfort, autonomy, respect, staff responsiveness, relationships with staff, friendships, and activities. First, we evaluated these items individually and then combined them in summary scales. Second, we examined how the summary scales related to whether the residents did or did not say that the LTCFs in which they lived felt like home. DESIGN: Cross-sectional self-report surveys by residents of LTCFs regarding their quality of life and services. SETTING/PARTICIPANTS: Resident self-report data came from 16,017 individuals who resided in 355 LTCFs. Of this total, 7113 were from the Flanders region of Belgium, 5143 residents were from Canada, and 3358 residents were from the eastern and mid-western United States. Smaller data sets were collected from facilities in Australia (20), the Czech Republic (72), Estonia (103), Poland (118), and South Africa (87). MEASUREMENTS: The interRAI Self-Report Quality of Life Survey for LTCFs was used to assess residents' quality of life and services. It includes 49 items. Each area of inquiry (eg, autonomy) is represented by multiple items; the item sets have been designed to elicit resident responses that could range from highly positive to highly negative. Each item has a 5-item response set that ranges from "never" to "always." RESULTS: Typically, we scored individual items scored based on the 2 most positive categories: "sometimes" and "always." When these 2 categories were aggregated, among the more positive items were: being alone when wished (83%); decide what clothes to wear (85%); get needed services (87%); and treated with dignity by staff (88%). Areas with a less positive response included: staff knows resident's life story (30%); resident has enjoyable things to do on weekends (32%); resident has people to do things with (33%); and resident has friendly conversation with staff (45%). We identified 5 reliable scales; these scales were positively associated with the resident statement that the LTCF felt like home. Finally, international score standards were established for the items and scales. CONCLUSIONS: This study establishes a set of standardized, self-report items and scales with which to assess the quality of life and services for residents in LTCFs. The study also demonstrates that these scales are significantly related to resident perception of the home-like quality of the facilities.

Short-Term Lifestyle Strategies for Sustaining Cognitive Status.

Cognitive decline impacts older adults, particularly their independence. The goal of this project was to increase understanding of how short-term, everyday lifestyle options, including physical activity, help an older adult sustain cognitive independence. Using a secondary analysis of lifestyle choices, we drew on a dataset of 4,620 community-dwelling elders in the US, assessed at baseline and one year later using 2 valid and reliable tools, the interRAI Community Health Assessment and the interRAI Wellness tool. Decline or no decline on the Cognitive Performance Scale was the dependent variable. We examined sustaining one's status on this measure over a one-year period in relation to key dimensions of wellness through intellectual, physical, emotional, social, and spiritual variables. Engaging in physical activity, formal exercise, and specific recreational activities had a favorable effect on short-term cognitive decline. Involvement with computers, crossword puzzles, handicrafts, and formal education courses also were protective factors. The physical and intellectual domains of wellness are prominent aspects in protection from cognitive decline. Inherent in these two domains are mutable factors suitable for targeted efforts to promote older adult health and well-being.

The Health and Well-Being of Older Adults with Dual Sensory Impairment (DSI) in Four Countries.

OBJECTIVES: Dual sensory impairment (DSI) is a combination of vision and hearing impairments that represents a unique disability affecting all aspects of a person's life. The rates of DSI are expected to increase due to population aging, yet little is known about DSI among older adults (65+). The prevalence of DSI and client characteristics were examined among two groups, namely, older adults receiving home care services or those residing in a long-term care (LTC) facility in four countries (Canada, US, Finland, Belgium). METHODS: Existing data, using an interRAI assessment, were analyzed to compare older adults with DSI to all others across demographic characteristics, functional and psychosocial outcomes. RESULTS: In home care, the prevalence of DSI across the four countries ranged from 13.4% to 24.6%; in LTC facilities, it ranged from 9.7% to 33.9%. Clients with DSI were more likely to be 85+, have moderate/severe cognitive impairment, impairments in activities of daily living, and have communication difficulties. Among residents of LTC facilities, individuals with DSI were more likely to be 85+ and more likely have a diagnosis of Alzheimer's disease. Having DSI increased the likelihood of depression in both care settings, but after adjusting for other factors, it remained significant only in the home care sample. CONCLUSIONS: While the prevalence of DSI cross nationally is similar to that of other illnesses such as diabetes, depression, and Alzheimer's disease, we have a limited understanding of its affects among older adults. Raising awareness of this unique disability is imperative to insure that individuals receive the necessary rehabilitation and supportive services to improve their level of independence and quality of life.

Do SSRI Antidepressants Increase The Risk of Extrapyramidal Side Effects In Patients Taking Antipsychotics?

PURPOSE: Among antidepressants, selective serotonin reup-take inhibitors (SSRIs) have enjoyed great popularity among clinicians as well as generally wide acceptance and tolerance among patients. A potentially overlooked side effect of SSRIs is the occasional occurrence of extrapyramidal symptoms (EPS), which could be a concern when SSRIs are used with antipsychotics. This study was designed to explore the possible association between SSRI antidepressant use and the incidence of EPS side effects in patients who take concomitant antipsychotic medications. METHODS: The University of Michigan conducted a study at the four Michigan state mental health hospitals between May 2010 and October 2010. The Michigan Public Health Institute collected data using the InterRAI Mental Health Assessment (InterRAI MH). The present study is a retrospective cohort analysis of the cross-sectional data that were collected. Within these institutions, 693 residents were using antipsychotics. We measured the observed frequency of seven EPS recorded in the InterRAI MH within three groups of patients: 1) those on antipsychotic drugs who were taking an SSRI antidepressant; 2) those on antipsychotic drugs who were not taking an antidepressant; and 3) those on antipsychotic drugs who were taking a non-SSRI antidepressant. Differences in the prevalence of EPS were tested using one-way analysis of variance. RESULTS: There were no significant differences in the observed EPS frequencies among the three groups (F 2,18 = 0.01; P < 0.9901). CONCLUSION: In this study, SSRIs did not appear to potentiate the occurrence of EPS in patients using antipsychotics.

Updating the Cognitive Performance Scale.

This study presents the first update of the Cognitive Performance Scale (CPS) in 20 years. Its goals are 3-fold: extend category options; characterize how the new scale variant tracks with the Mini-Mental State Examination; and present a series of associative findings. Secondary analysis of data from 3733 older adults from 8 countries was completed. Examination of scale dimensions using older and new items was completed using a forward-entry stepwise regression. The revised scale was validated by examining the scale's distribution with a self-reported dementia diagnosis, functional problems, living status, and distress measures. Cognitive Performance Scale 2 extends the measurement metric from a range of 0 to 6 for the original CPS, to 0 to 8. Relating CPS2 to other measures of function, living status, and distress showed that changes in these external measures correspond with increased challenges in cognitive performance. Cognitive Performance Scale 2 enables repeated assessments, sensitive to detect changes particularly in early levels of cognitive decline.

Derivation of a frailty index from the interRAI acute care instrument.

BACKGROUND: A better understanding of the health status of older inpatients could underpin the delivery of more individualised, appropriate health care. METHODS: 1418 patients aged ≥ 70 years admitted to 11 hospitals in Australia were evaluated at admission using the interRAI assessment system for Acute Care. This instrument surveys a large number of domains, including cognition, communication, mood and behaviour, activities of daily living, continence, nutrition, skin condition, falls, and medical diagnosis. RESULTS: Variables across multiple domains were selected as health deficits. Dichotomous data were coded as symptom absent (0 deficit) or present (1 deficit). Ordinal scales were recoded as 0, 0.5 or 1 deficit based on face validity and the distribution of data. Individual deficit scores were summed and divided by the total number considered (56) to yield a Frailty index (FI-AC) with theoretical range 0-1. The index was normally distributed, with a mean score of 0.32 (±0.14), interquartile range 0.22 to 0.41. The 99% limit to deficit accumulation was 0.69, below the theoretical maximum of 1.0. In logistic regression analysis including age, gender and FI-AC as covariates, each 0.1 increase in the FI-AC increased the likelihood of inpatient mortality twofold (OR: 2.05 [95% CI 1.70-2.48]). CONCLUSIONS: Quantification of frailty status at hospital admission can be incorporated into an existing assessment system, which serves other clinical and administrative purposes. This could optimise clinical utility and minimise costs. The variables used to derive the FI-AC are common to all interRAI instruments, and could be used to precisely measure frailty across the spectrum of health care.

Functional outcomes after lower extremity revascularization in nursing home residents: a national cohort study.

IMPORTANCE: Lower extremity revascularization often seeks to allow patients with peripheral arterial disease to maintain the ability to walk, a key aspect of functional independence. Surgical outcomes in patients with high levels of functional dependence are poorly understood. OBJECTIVE: To determine functional status trajectories, changes in ambulatory status, and survival after lower extremity revascularization in nursing home residents. DESIGN: Using full Medicare claims data for 2005 to 2009, we identified nursing home residents who underwent lower extremity revascularization. With the Minimum Data Set for Nursing Homes activities of daily living summary score, we examined changes in their ambulatory and functional status after surgery. We identified patient and surgery characteristics associated with a composite measure of clinical and functional failure-death or nonambulatory status 1 year after surgery. SETTING: All nursing homes in the United States participating in Medicare or Medicaid. PARTICIPANTS: Nursing home residents who underwent lower extremity revascularization. MAIN OUTCOMES AND MEASURES: Functional status, ambulatory status, and death. RESULTS: During the study period, 10,784 long-term nursing home residents underwent lower extremity revascularization. Prior to surgery, 75% of the residents were not walking; 40% had experienced functional decline. One year after surgery, 51% of patients had died, 28% were nonambulatory, and 32% had sustained functional decline. Among 1672 residents who were ambulatory before surgery, 63% had died or were nonambulatory at 1 year; among 7188 who were nonambulatory, 89% had died or were nonambulatory. After multivariate adjustment, factors independently associated with death or nonambulatory status were 80 years or older (adjusted hazard ratio [AHR], 1.28; 95% CI, 1.16-1.40), cognitive impairment (AHR, 1.23; 95% CI, 1.18-1.29), congestive heart failure (AHR, 1.16; 95% CI, 1.11-1.22), renal failure (AHR, 1.09; 95% CI, 1.04-1.14), emergent surgery (AHR, 1.29; 95% CI, 1.23-1.35), nonambulatory status before surgery (AHR, 1.88; 95% CI, 1.78-1.99), and decline in activities of daily living before surgery (AHR, 1.23; 95% CI, 1.18-1.28). CONCLUSIONS AND RELEVANCE: Of nursing home residents in the United States who undergo lower extremity revascularization, few are alive and ambulatory 1 year after surgery. Most who were still alive had gained little, if any, function.

Valproic Acid as a potentiator of metabolic syndrome in institutionalized residents on concomitant antipsychotics: fat chance, or slim to none?

BACKGROUND: Valproic acid (VPA) is one of the most commonly used antiepileptic medications worldwide; it is also a popular mood stabilizer for use in bipolar disorder and dementia. This study assessed whether VPA may potentiate metabolic side effects in patients with psychiatric disorders taking concomitant antipsychotics (APs). VPA alone has been associated with weight gain, dyslipidemia, hypertension, and diabetes. Patients with psychiatric disorders, especially those on second-generation (atypical) APs, appear to be at increased risk of these metabolic effects. A secondary purpose was to determine if a linear dose-response relationship exists between the VPA dose and adverse metabolic effects. METHODS: This cross-sectional study was conducted using data collected on all patients in the four state-operated psychiatric hospitals in Michigan using a comprehensive assessment instrument, the interRAI Mental Health. All patients taking both VPA and APs (n = 200) were compared to a control group of patients taking APs without VPA (n = 426). Patients were assessed for the presence of the following surrogate indicators of metabolic syndrome: weight gain; high body mass index (BMI greater than 30 kg/m(2)); very high BMI (BMI greater than 40 kg/m(2)); a diagnosis of diabetes mellitus; use of a prescribed statin medication; diagnosis of hyperlipidemia or dyslipidemia; hypertension; or the combination of any three of these factors: high BMI, hyperlipidemia or dyslipidemia, diabetes, and hypertension. Analysis also included assessment of the effect of VPA dosage on metabolic side effects. RESULTS: Patients in the VPA plus APs group were 3.2 kg heavier than those in the APs group (P = 0.05) at baseline. Compared with the APs group, the VPA plus APs group had a higher prevalence of high and very high BMI, diabetes, hypertension, and the combination of any three factors of high BMI, hyperlipidemia/dyslipidemia, diabetes, and hypertension. However, these differences were not statistically significant. Conversely, there was a slight but non-significant reduction in the prevalence of weight gain, prescribed statins, and hyperlipidemia/dyslipidemia in the VPA plus APs group than the APs group. Finally, higher doses of VPA were not found to be associated with a higher incidence of these metabolic side effects. CONCLUSION: Although the patients on VPA were slightly more than 3 kg heavier, VPA did not appear to be associated with significant metabolic effects in patients with psychiatric conditions taking typical and atypical APs. These metabolic effects also do not appear to be related to the dose of VPA.

Measuring the prevalence of current, severe symptoms of mental health problems in a canadian correctional population: implications for delivery of mental health services for inmates.

This study measured the prevalence of current, severe symptoms of a mental health problem in an adult population of inmates in Ontario, Canada. The Resident Assessment Instrument-Mental Health was used to measure the prevalence of symptoms among a sample of 522 inmates. Propensity score weighting was used to adjust for nonrandom selection into the sample. Prevalence estimates were derived for the total inmate population, remand and sentenced, males and females, and Aboriginal and non-Aboriginal inmates. It is estimated that 41.1% of Ontario inmates will have at least one current, severe symptom of a mental health problem; of this group, 13.0%, will evidence two or more symptoms. The number of symptoms is strongly associated with presence of a psychiatric diagnosis and level of mental health care needs. Female (35.1%) and Aboriginal (18.7%) inmates are more likely to demonstrate two or more current, severe symptoms. Greater efforts must be made to bridge the gap between correctional and mental health care systems to ensure inmates in correctional facilities can access and receive appropriate mental health care services.

Predicting risk of hospital and emergency department use for home care elderly persons through a secondary analysis of cross-national data.

BACKGROUND: Older adults remain the highest utilization group with unplanned visits to emergency departments and hospital admissions. Many have considered what leads to this high utilization and the answers provided have depended upon the independent measures available in the datasets used. This project was designed to further understanding of the reasons for older adult ED visits and admissions to acute care hospitals. METHODS: A secondary analysis of data from a cross-national sample of community residing elderly, 60 years of age or older, and most of whom received services from a local home-care program was conducted. The assessment instrument used in this study is the interRAI HC (home care), designed for use in assessing elderly home care recipients. The model specification stage of the study identified the baseline independent variables that do and do not predict the follow-up measure of hospitalization and ED use. Stepwise logistic regression was used next to identify characteristics that best identified elders who subsequently entered a hospital or visited an ED. The items generated from the final multivariate logistic equation using the interRAI home care measures comprise the interRAI Hospital-ED Risk Index. RESULTS: Independent measures in three key domains of clinical complications, disease diagnoses and specialized treatments were related to subsequent hospitalization or ED use. Among the eighteen clinical complication measures with higher, meaningful odds ratios are pneumonia, urinary tract infection, fever, chest pain, diarrhea, unintended weight loss, a variety of skin conditions, and subject self-reported poor health. Disease diagnoses with a meaningful relationship with hospital/ED use include coronary artery disease, congestive heart failure, cancer, emphysema and renal failure. Specialized treatments with the highest odds ratios were blood transfusion, IV infusion, wound treatment, radiation and dialysis. Two measures, Alzheimer's disease and day care appear to have a protective effect for hospitalization/ED use with lower odds ratios. CONCLUSIONS: Examination into "preventable" hospitalizations and re-hospitalizations for older adults who have the highest rates of utilization are occurring beneath an umbrella of assuring the highest quality of care and controlling costs. The interRAI Hospitalization-ED Risk Index offers an effective approach to predicting hospitalization utilization among community dwelling older adults.

Using the community health assessment to screen for continued driving.

This project used the interRAI based, community health assessment (CHA) to develop a model for identifying current elder drivers whose driving behavior should be reviewed. The assessments were completed by independent housing sites in COLLAGE, a non-profit, national senior housing consortium. Secondary analysis of data drawn from older adults in COLLAGE sites in the United States was conducted using a baseline assessment with 8042 subjects and an annual follow-up assessment with 3840 subjects. Logistic regression was used to develop a Driving Review Index (DRI) based on the most useful items from among the many measures available in the CHA assessment. Thirteen items were identified by the logistic regression to predict drivers whose driving behavior was questioned by others. In particular, three variables reference compromised decision-making abilities: general daily decisions, a recent decline in ability to make daily decisions, and ability to manage medications. Two additional measures assess cognitive status: short-term memory problem and a diagnosis of non-Alzheimers dementia. Functional measures reflect restrictions and general frailty, including receiving help in transportation, use of a locomotion appliance, having an unsteady gait, fatigue, and not going out on most days. The final three clinical measures reflect compromised vision, little interest or pleasure in things normally enjoyed, and diarrhea. The DRI focuses the review process on drivers with multiple cognitive and functional problems, including a significant segment of potentially troubled drivers who had not yet been publicly identified by others. There is a need for simple and quickly identified screening tools to identify those older adults whose driving should be reviewed. The DRI, based on the interRAI CHA, fills this void. Assessment at the individual level needs to be part of the backdrop of science as society seeks to target policy to identify high risk drivers instead of simply age-based testing.

Scaling functional status within the interRAI suite of assessment instruments.

BACKGROUND: As one ages, physical, cognitive, and clinical problems accumulate and the pattern of loss follows a distinct progression. The first areas requiring outside support are the Instrumental Activities of Daily Living and over time there is a need for support in performing the Activities of Daily Living. Two new functional hierarchies are presented, an IADL hierarchical capacity scale and a combination scale integrating both IADL and ADL hierarchies. METHODS: A secondary analyses of data from a cross-national sample of community residing persons was conducted using 762,023 interRAI assessments. The development of the new IADL Hierarchy and a new IADL-ADL combined scale proceeded through a series of interrelated steps first examining individual IADL and ADL item scores among persons receiving home care and those living independently without services. A factor analysis demonstrated the overall continuity across the IADL-ADL continuum. Evidence of the validity of the scales was explored with associative analyses of factors such as a cross-country distributional analysis for persons in home care programs, a count of functional problems across the categories of the hierarchy, an assessment of the hours of informal and formal care received each week by persons in the different categories of the hierarchy, and finally, evaluation of the relationship between cognitive status and the hierarchical IADL-ADL assignments. RESULTS: Using items from interRAI's suite of assessment instruments, two new functional scales were developed, the interRAI IADL Hierarchy Scale and the interRAI IADL-ADL Functional Hierarchy Scale. The IADL Hierarchy Scale consisted of 5 items, meal preparation, housework, shopping, finances and medications. The interRAI IADL-ADL Functional Hierarchy Scale was created through an amalgamation of the ADL Hierarchy (developed previously) and IADL Hierarchy Scales. These scales cover the spectrum of IADL and ADL challenges faced by persons in the community. CONCLUSIONS: An integrated IADL and ADL functional assessment tool is valuable. The loss in these areas follows a general hierarchical pattern and with the interRAI IADL-ADL Functional Hierarchy Scale, this progression can be reliably and validly assessed. Used across settings within the health continuum, it allows for monitoring of individuals from relative independence through episodes of care.

interRAI home care quality indicators.

BACKGROUND: This paper describe the development of interRAI's second-generation home care quality indicators (HC-QIs). They are derived from two of interRAI's widely used community assessments: the Community Health Assessment and the Home Care Assessment. In this work the form in which the quality problem is specified has been refined, the covariate structure updated, and two summary scales introduced. METHODS: Two data sets were used: at the client and home-care site levels. Client-level data were employed to identify HC-QI covariates. This sample consisted of 335,544 clients from Europe, Canada, and the United States. Program level analyses, where client level data were aggregated at the site level, were also based on the clients from the samples from Europe, Canada, and the United States. There were 1,654 program-based observations - 22% from Europe, 23% from the US, and 55% from Canada.The first task was to identify potential HC-QIs, including both change and prevalence measures. Next, they were reviewed by industry representatives and members of the interRAI network. A two-step process adjustment was followed to identify the most appropriate covariance structure for each HC-QI. Finally, a factor analytic strategy was used to identify HC-QIs that cluster together and thus are candidates for summary scales. RESULTS: The set of risk adjusted HC-QIs are multi-dimensional in scope, including measures of function, clinical complexity, social life, distress, and service use. Two factors were identified. The first includes a set of eleven measures that revolve around the absence of decline. This scale talks about functional independence and engagement. The second factor, anchored on nine functional improvement HC-QIs, referenced positively, this scale indicates a return to clinical balance. CONCLUSIONS: Twenty-three risk-adjusted, HC-QIs are described. Two new summary HC-QI scales, the "Independence Quality Scale" and the "Clinical Balance Quality Scale" are derived. In use at a site, these two scales can provide a macro view of local performance, offering a way for a home care agency to understand its performance. When scales perform less positively, the site then is able to review the HC-QI items that make up the scale, providing a roadmap for areas of greatest concern and in need of targeted interventions.

Impact of cigarette smoking on utilization of nursing home services.

INTRODUCTION: Few studies have examined the effects of smoking on nursing home utilization, generally using poor data on smoking status. No previous study has distinguished utilization for recent from long-term quitters. METHODS: Using the Health and Retirement Study, we assessed nursing home utilization by never-smokers, long-term quitters (quit >3 years), recent quitters (quit ≤3 years), and current smokers. We used logistic regression to evaluate the likelihood of a nursing home admission. For those with an admission, we used negative binomial regression on the number of nursing home nights. Finally, we employed zero-inflated negative binomial regression to estimate nights for the full sample. RESULTS: Controlling for other variables, compared with never-smokers, long-term quitters have an odds ratio (OR) for nursing home admission of 1.18 (95% CI: 1.07-1.2), current smokers 1.39 (1.23-1.57), and recent quitters 1.55 (1.29-1.87). The probability of admission rises rapidly with age and is lower for African Americans and Hispanics, more affluent respondents, respondents with a spouse present in the home, and respondents with a living child. Given admission, smoking status is not associated with length of stay (LOS). LOS is longer for older respondents and women and shorter for more affluent respondents and those with spouses present. CONCLUSIONS: Compared with otherwise identical never-smokers, former and current smokers have a significantly increased risk of nursing home admission. That recent quitters are at greatest risk of admission is consistent with evidence that many stop smoking because they are sick, often due to smoking.