The Nursing Home Severity Index and Application to Pressure Injury Risk: Measure Development and Validation Study.

BACKGROUND: An assessment tool is needed to measure the clinical severity of nursing home residents to improve the prediction of outcomes and provide guidance in treatment planning. OBJECTIVE: This study aims to describe the development of the Nursing Home Severity Index, a clinical severity measure targeted for nursing home residents with the potential to be individually tailored to different outcomes, such as pressure injury. METHODS: A retrospective nonexperimental design was used to develop and validate the Nursing Home Severity Index using secondary data from 9 nursing homes participating in the 12-month preintervention period of the Turn Everyone and Move for Ulcer Prevention (TEAM-UP) pragmatic clinical trial. Expert opinion and clinical literature were used to identify indicators, which were grouped into severity dimensions. Index performance and validation to predict risk of pressure injury were accomplished using secondary data from nursing home electronic health records, Minimum Data Sets, and Risk Management Systems. Logistic regression models including a resident's Worst-Braden score with/without severity dimensions generated propensity scores. Goodness of fit for overall models was assessed using C statistic; the significance of improvement of fit after adding severity components to the model was determined using the likelihood ratio chi-square test. The significance of each component was assessed with odds ratios. Validation based on randomly selected 65% training and 35% validation data sets was used to confirm the reliability of the severity measure. Finally, the discriminating ability of models was evaluated using propensity stratification to evaluate which model best discriminated between residents with/without pressure injury. RESULTS: Data from 1015 residents without pressure injuries on admission were used for the Nursing Home Severity Index-Pressure Injury and included laboratory, weights/vitals/pain, underweight, and locomotion severity dimensions. Logistic regression C statistic measuring predictive accuracy increased by 19.3% (from 0.627 to 0.748; P<.001) when adding four severity dimensions to Worst-Braden scores. Significantly higher odds of developing pressure injuries were associated with increasing dimension scores. The use of the three highest propensity deciles predicting the greatest risk of pressure injury improved predictive accuracy by detecting 21 more residents who developed pressure injury (n=58, 65.2% vs n=37, 42.0%) when both severity dimensions and Worst-Braden score were included in prediction modeling. CONCLUSIONS: The clinical Nursing Home Severity Index-Pressure Injury was successfully developed and tested using the outcome of pressure injury. Overall predictive capacity was enhanced when using severity dimensions in combination with Worst-Braden scores. This index has the potential to significantly impact the quality of care decisions aimed at improving individual pressure injury prevention plans. TRIAL REGISTRATION: ClinicalTrials.gov NCT02996331; http://clinicaltrials.gov/ct2/show/NCT02996331.

Nursing Assessment of Pressure Injury Risk with the Braden Scale Validated against Sensor-Based Measurement of Movement.

Nursing staff assessment to accurately identify pressure injury (PrI) risk is a hallmark in PrI prevention care. Risk scores from the Braden Scale for Predicting Pressure Sore Risk© (hereafter Braden), a commonly used tool for assessing PrI risk, signal the need for preventative care. Braden Mobility, Activity, and Sensory Perception subscale subgroups associated with repositioning movement features help identify preventative strategies that minimize pressure intensity and duration. Evidence confirming subscale rating accuracy is needed. This study compared assessment score accuracy with movement data collected via accelerometer sensor. Sample included 913 nursing home residents from the Turn Everyone and Move for Pressure Ulcer Prevention (TEAM-UP) cluster randomized trial. Movements and Braden Mobility and Activity subscale scores were evaluated for significant differences and associations. Mobility subgroups explained a small-medium amount of variance in mean lying and upright movement features (0.002 ≤ R2 ≤ 0.195). Activity subgroups explained a small-medium amount of variance in mean lying, upright, and ambulating movements (0.016 ≤ R2 ≤ 0.248). Significant associations occurred among subscale subgroups and most movements. Nursing assessment ratings using Braden scale's Mobility and Activity subscale scores are accurate indicators of actual repositioning movements and can be relied upon for PrI prevention care planning for older adults.

Movement Patterns of Transient and Prolonged Positioning Events in Nursing Home Residents: Results from the TEAM-UP Trial.

OBJECTIVE: To characterize transient and prolonged body position patterns in a large sample of nursing home (NH) residents and describe the variability in movement patterns based on time of occurrence. METHODS: This study is a descriptive, exploratory analysis of up to 28 days of longitudinal accelerometer data for 1,100 NH residents from the TEAM-UP (Turn Everyone and Move for Ulcer Prevention) clinical trial. Investigators analyzed rates of transient events (TEs; less than 60 seconds) and prolonged events (PEs; 60 seconds or longer) and their interrelationships by nursing shift. RESULTS: Residents' positions changed for at least 1 minute (PEs) nearly three times per hour. Shorter-duration movements (TEs) occurred almost eight times per hour. Residents' PE rates were highest in shift 2 (3 pm to 11 pm ), when the median duration and maximum lengths of PEs were lowest; the least active time of day was shift 3 (11 pm to 7 am ). Three-quarters of all PEs lasted less than 15 minutes. The rate of TEs within PEs decreased significantly as the duration of PEs increased. CONCLUSIONS: The NH residents demonstrate complex patterns of movements of both short and prolonged duration while lying and sitting. Findings represent how NH residents naturally move in real-world conditions and provide a new set of metrics to study tissue offloading and its role in pressure injury prevention.

Characteristics of Nursing Home Resident Movement Patterns: Results from the TEAM-UP Trial.

OBJECTIVE: To determine movement patterns of nursing home residents, specifically those with dementia or obesity, to improve repositioning approaches to pressure injury (PrI) prevention. METHODS: A descriptive exploratory study was conducted using secondary data from the Turn Everyone And Move for Ulcer Prevention (TEAM-UP) clinical trial examining PrI prevention repositioning intervals. K-means cluster analysis used the average of each resident's multiple days' observations of four summary mean daily variables to create homogeneous movement pattern clusters. Growth mixture models examined movement pattern changes over time. Logistic regression analyses predicted resident and nursing home cluster group membership. RESULTS: Three optimal clusters partitioned 913 residents into mutually exclusive groups with significantly different upright and lying patterns. The models indicated stable movement pattern trajectories across the 28-day intervention period. Cluster profiles were not differentiated by residents with dementia (n = 450) or obesity (n = 285) diagnosis; significant cluster differences were associated with age and Braden Scale total scores or risk categories. Within clusters 2 and 3, residents with dementia were older (P < .0001) and, in cluster 2, were also at greater PrI risk (P < .0001) compared with residents with obesity; neither group differed in cluster 1. CONCLUSIONS: Study results determined three movement pattern clusters and advanced understanding of the effects of dementia and obesity on movement with the potential to improve repositioning protocols for more effective PrI prevention. Lying and upright position frequencies and durations provide foundational knowledge to support tailoring of PrI prevention interventions despite few significant differences in repositioning patterns for residents with dementia or obesity.

Effect of Varying Repositioning Frequency on Pressure Injury Prevention in Nursing Home Residents: TEAM-UP Trial Results.

OBJECTIVE: To investigate the clinical effectiveness of three nursing-home-wide repositioning intervals (2-, 3-, or 4-hour) without compromising pressure injury (PrI) incidence in 4 weeks. METHODS: An embedded pragmatic cluster randomized controlled trial was conducted in nine nursing homes (NHs) that were randomly assigned to one of three repositioning intervals. Baseline (12 months) and 4-week intervention data were provided during the TEAM-UP (Turn Everyone And Move for Ulcer Prevention) study. Intervention residents were without current PrIs, had PrI risk (Braden Scale score) ≥10 (not severe risk), and used viable 7-inch high-density foam mattresses. Each arm includes three NHs with an assigned single repositioning interval (2-, 3-, or 4-hour) as standard care during the intervention. A wireless patient monitoring system, using wearable single-use patient sensors, cued nursing staff by displaying resident repositioning needs on conveniently placed monitors. The primary outcome was PrI incidence; the secondary outcome was staff repositioning compliance fidelity. RESULTS: From May 2017 to October 2019, 1,100 residents from nine NHs were fitted with sensors; 108 of these were ineligible for some analyses because of missing baseline data. The effective sample size included 992 residents (mean age, 78 ± 13 years; 63% women). The PrI incidence during the intervention was 0.0% compared with 5.24% at baseline, even though intervention resident clinical risk scores were significantly higher (P < .001). Repositioning compliance for the 4-hour repositioning interval (95%) was significantly better than for the 2-hour (80%) or 3-hour (90%) intervals (P < .001). CONCLUSIONS: Findings suggest that current 2-hour protocols can be relaxed for many NH residents without compromising PrI prevention. A causal link was not established between repositioning interval treatments and PrI outcome; however, no new PrIs developed. Compliance improved as repositioning interval lengthened.

Health Care Expenditures of Medicare Beneficiaries with Normal Pressure Hydrocephalus.

BACKGROUND: Normal pressure hydrocephalus (NPH) is an underdiagnosed and undertreated condition affecting the elderly population and with costs associated with its surgical management reported to be less than those associated with conservative management. OBJECTIVE: To determine if the rate of diagnosis of NPH has improved over the last decade, the rate of treatment has increased, and if surgical treatment costs and socioeconomic factors related to receipt of treatment have changed over time compared with conservative therapy. METHODS: A retrospective study based on data from a nationally representative random sample of 2,378,637 Medicare beneficiaries (2006-2010) was performed. Shunt surgery, shunt revision, replacement, and removal were analyzed as independent variables. RESULTS: A total of 2321 patients with NPH were included, with 580 (24.99%) receiving a first shunt procedure. The adjusted effect of the procedure is that total 5-year expenditures are $11,676 more per patient (P < 0.001) than expenditures associated with nonsurgical management. Shunt revision ($22,715, P < 0.01) and/or replacement ($46,607, P < 0.001) add significantly to 5-year expenditures. Socioeconomic factors including African American race (P = 0.006); age 75-79 years (P = 0.024), 80-84 years (P < 0.001), and ≥85 years (P < 0.001); and Medicaid (P < 0.001) have significant negative associations with shunt surgery. CONCLUSIONS: There was a 1.66-fold increase in the rate of diagnosis of NPH, from 0.12% in 1999 to 0.2% in 2008. The total costs per surgical patient rose by approximately 145% to 160% comparing 2001 and 2010. This increase was mainly due to hospital (by 167% to 168%) and home health costs (by 118% to 148%). Providing appropriate care across the socioeconomic spectrum warrants further study and requires identifying the factors that limit access to care.

Variation in Rehabilitation Treatment Patterns for Hip Fracture Treated With Arthroplasty.

BACKGROUND: Recommendations for health care redesign often advocate for comparative effectiveness research that is patient-centered. For patients who require rehabilitation services, a first step in this research process is to understand current practices for specific patient groups. OBJECTIVE: To document in detail the physical and occupational therapy treatment activities for inpatient hip fracture rehabilitation among 3 patient subgroups distinguished by their early rate of functional recovery between time of surgery to rehabilitation admission. DESIGN: Multicenter prospective observational cohort, practice-based evidence, study. SETTING: Seven skilled nursing facilities and 11 inpatient rehabilitation facilities across the United States. PARTICIPANTS: A total of 226 patients with hip fractures treated with hip arthroplasty. METHODS: Comparisons of physical and occupational therapy treatment activities among 3 groups with different initial recovery trajectory (IRT) rates (slower, moderate, faster). MAIN OUTCOME MEASURE(S): Percent of patients in each IRT group exposed to each physical and occupational therapy activity (exposure), and mean minutes per week for each activity (intensity). RESULTS: The number of patients exposed to different physical or occupational therapy activities varied within the entire sample. More specifically, among the 3 IRT groups, significant differences in exposure occurred for 44% of physical therapy activities and 39% of occupational therapy activities. More patients in the slower recovery group, IRT 1, received basic activities of daily living treatments and more patients in the faster recovery group, IRT 3, received advanced activities. The moderate recovery group, IRT 2, had some treatments similar to IRT 1 group and others similar to IRT 3 group. CONCLUSIONS: Analyses of practice-based evidence on inpatient rehabilitation of hip fracture patients treated with arthroplasty identified differences in therapy activities among three patient groups classified by IRT rates. These results may enhance physiatrists', other physicians', and rehabilitation teams' understanding of inpatient rehabilitation for these patients and help design future comparative effectiveness research.

Outcomes and weight-bearing status during rehabilitation after arthroplasty for hip fractures.

OBJECTIVE: To examine the association of weight-bearing status with patient-related variables and outcomes of inpatient rehabilitation after hip arthroplasty for acute hip fracture. DESIGN: A multi-site prospective observational cohort study. SETTING: Eighteen skilled nursing and inpatient rehabilitation facilities. SUBJECTS: Patients with hip fractures (N = 224) treated with hip arthroplasty and admitted to either skilled nursing or inpatient rehabilitation facilities; a subset (N = 84) with telephone follow-up outcomes 8 months after rehabilitation discharge. METHODS: Measurements included demographic variables, medical severity using the Comprehensive Severity Index, and functional levels using the Functional Independence Measure. MAIN OUTCOMES MEASUREMENT: Cognitive, motor, and total Functional Independence Measure scores at rehabilitation discharge and at 8-month follow-up; living location at discharge and follow-up. RESULTS: Patients on average (standard deviation) were 76.8 ± 11.4 years old, mainly women (78%), and mainly white (87%). In unadjusted analysis, weight bearing as tolerated (WBAT) was associated with less osteoarthritis (P = .025) and lower admission medical severity (ACSI) (P = .014). One participating facility had a significant preponderance of restricted weight-bearing cases. WBAT had no bivariate association with cognitive or motor function at discharge. Therapists cited restricted weight bearing as a barrier to therapy in 11% of cases. In logistic regressions, lower medical admission severity, older age, and one specified site significantly predicted WBAT (c statistic = 0.714). Significant predictors for home discharge included lower maximum severity (P < .001), younger age (P < .001), higher cognition (P = .037), and WBAT (P = .051) (c statistic = 0.863). CONCLUSIONS: WBAT is associated with a greater likelihood of home discharge and had similar functional outcomes compared with restricted weight bearing. These findings add support for allowing WBAT after arthroplasty for hip fracture.

Initial recovery trajectories among patients with hip fracture: a conceptual approach to exploring comparative effectiveness in postacute care.

OBJECTIVE: To assess whether clusters of patients with hip fracture and with distinct initial recovery trajectories (IRT) could be identified by using practice-based evidence data and to examine the validity of these data. DESIGN: Analysis of multisite prospective observational cohort study database. SETTING: Eighteen skilled nursing and inpatient rehabilitation facilities. PATIENTS: Patients with hip fractures (N = 226) treated with joint replacement and admitted to skilled nursing or inpatient rehabilitation facilities, subset (n = 85), with telephone follow-up results approximately 8 months after rehabilitation discharge. Patients' ages were 76.8 ± 11.4 years; the majority were women (78%) and white (87%). METHODS: Measurements included medical severity by using the Comprehensive Severity Index and functional levels by using Functional Independence Measure (FIM). The IRT was calculated for each patient as the rate of change in function from the time of surgery to rehabilitation admission. We used cluster analysis to partition patients into subsets that shared common IRT scores. Validity was explored by comparing subgroups across patient characteristics and treatment patterns. Significance was defined as P ≤ .05. MAIN OUTCOMES MEASUREMENTS: IRT grouping, Comprehensive Severity Index, FIM, discharge location, living location at follow-up. RESULTS: We identified 3 patient clusters with differentiated IRT scores: group 1: 4.96 ± 2.45 (range, 0.4-8.6) FIM point change per day; group 2: 12.42 ± 2.51 (range, 8.9-17.0); group 3: 26.80 ± 13.78 (range, 17.5-70.0). Clinical group validation was established from statistically different Comprehensive Severity Index scores on admission; FIM scores at admission, discharge, and follow-up; and discharge and 8-month living settings. Calculation of IRT recovery curves by using FIM scores and associated time in days through logarithmic regression curves confirmed each group's IRT remained distinct through rehabilitation and follow-up. CONCLUSIONS: The IRT concept appears to be valid in patients with hip fracture who were treated with hip arthroplasty, and may assist in evaluating and comparing the effectiveness of postacute rehabilitation services.

Influence of shunt surgery on healthcare expenditures of elderly fee-for-service Medicare beneficiaries with hydrocephalus.

OBJECT: The goal in this study was to determine the percentage of patients with hydrocephalus who were treated with shunt surgery and to assess Medicare expenditures for those with and without shunt surgery. METHODS: Retrospective cost analyses were performed using the Standard Analytic Files of paid claims for beneficiaries enrolled in both Parts A (Inpatient) and B (Outpatient) of the Medicare program for 1997 through 2001. The main outcome measures were 5-year total payments and 5-year payments for separate types of service; for example, acute hospital (inpatient and outpatient), skilled nursing facility, home health, and physician/supplier services. RESULTS: Of 1441 patients with hydrocephalus, 25.1% underwent shunt surgery during the study period. The effect of a shunt procedure on 5-year Medicare expenditures is a cost difference of $25,477 (p < 0.0001) less per patient, which is equal to a potential -$184.3 million difference in 5-year Medicare expenditures. The following three factors had a negative association with whether shunt surgery was performed: (1) age 80 to 84 years (odds ratio [OR] 0.619, confidence interval [CI] 0.390-0.984); (2) age 85 years or older (OR 0.201, CI 0.110-0.366); and (3) African-American race (OR 0.506, CI 0.295-0.869). The effect of age on the likelihood of shunt surgery persisted after adjusting for the propensity to die score. CONCLUSIONS: Medicare expenditures for patients with hydrocephalus treated with shunt surgery are significantly lower than expenditures for untreated patients. Research to improve the diagnosis and treatment of hydrocephalus has the potential to improve outcomes and reduce health care expenditures further.

Comorbid illnesses and health care utilization among Medicare beneficiaries with lung cancer.

We evaluated the association of chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) with outcomes in a 5% Medicare sample of 4447 elderly beneficiaries with lung cancer. Twenty-nine percent of patients had COPD and 13% had CHF. Patients with COPD or CHF had significantly decreased survival (hazard ratios 1.14 (1.05-1.25) and 1.38 (1.18-1.62), respectively); most of this differential was within 2 months after diagnosis. Patients with COPD or CHF were significantly less likely to receive surgery or chemotherapy than patients with neither COPD nor CHF. The association with less chemotherapy was similar in patients with the highest probability of surviving more than 2 months after the cancer diagnosis. In Medicare beneficiaries with lung cancer, COPD and CHF were common and were associated with both short-term mortality and decreased use of cancer treatments. Accounting for these two comorbid illnesses is important in evaluating health care utilization in this population.

The influence of health status, age, and race on screening mammography in elderly women.

BACKGROUND: Screening mammography is controversial for elderly women because of an absence of efficacy data. Decisions to screen are based on individualized assessment of risks and benefits. Our objective was to determine how screening mammography varies by age and race when adjusted for propensity to die. METHODS: In a retrospective cohort study, rates of screening mammogram performed in 2000-2001 based on claims, adjusted for propensity to die in 2000, were determined for a nationally representative 5% random sample of female fee-for-service Medicare beneficiaries 65 years and older in (N = 722,310). RESULTS: The overall rate of screening was 39%. When stratified into quintiles by propensity to die, 2-year rates ranged from 61% in the lowest-risk group to 5% in the highest-risk group. In analyses stratified by age and adjusted for propensity to die, 42% of women aged 65 to 69 years were screened, declining to 26% of women 85 years and older (P<.001). Adjusted screening rates for white women, black women, and women of other races were 40%, 30%, and 25%, respectively (P<.001). Thus, among women with similar health status, the youngest women were 1.61 times more likely to be screened compared with the oldest; compared with black women and women of other races, white women were 1.38 and 1.60 times, respectively, more likely to be screened. CONCLUSIONS: Decisions to screen for breast cancer are related not only to health status but also to age and race. Underuse and overuse of screening mammography likely occurs owing to age- and race-associated decision making. Assessment of life expectancy may more accurately identify women who could benefit from screening.