Nursing home costs and risk-adjusted outcome measures of quality.

BACKGROUND: The inadequacy of quality of care in nursing homes has been and continues to be a focus of public concerns. Understanding the relationship between quality and costs can offer guidance to policies designed to encourage high quality. OBJECTIVES: To investigate the relationship between costs and quality of care in nursing homes, and to test the hypothesis that higher quality may be associated with lower costs. RESEARCH DESIGN: Statistical regression techniques were used to estimate nursing home variable-cost functions that included three risk-adjusted outcome measures of quality. Quality measures were based on decline in functional status, worsening pressure ulcers, and mortality. The study hypothesis was tested by an F test for the exclusion of nonlinear quality variables in the cost functions. SUBJECTS: The study included 525 free-standing private and public nursing homes in New York State, or 84% of all nursing homes in the state during 1991. RESULTS: F tests rejected the hypotheses that the three quality measures could be excluded from the cost function and that the association between costs and quality was linear. An inverted U-shaped relationship between quality and costs suggests that there are quality regimens in which higher quality is associated with lower costs. CONCLUSIONS: Policies that encourage research to identify care protocols and management strategies leading to better outcomes and lower costs, as well as policies that encourage dissemination of such practices, may prevent decline in quality despite the continued financial constraints faced by nursing homes.

The impact of ownership type on nursing home outcomes.

This paper examines the sorting of residents between for-profit and nonprofit nursing homes and the health outcomes of those residents conditional on ownership type. Using data from the 1987 National Medical Expenditure Survey, we find evidence of systematic sorting of residents by ownership type, and significant effects of ownership type on outcomes. These results are broadly consistent with the hypothesis that for-profit and nonprofit homes exploit their informational advantages to differing extents in a market characterized by asymmetric information.

Combining activities of daily living with instrumental activities of daily living to measure functional disability.

Measures of functional disability typically contain items that reflect limitations in performing activities of daily living (ADLs) or instrumental activities of daily living (IADLs). Combining IADL and ADL items together in the same scale would provide enhanced range and sensitivity of measurement. This article presents psychometric justification for a combined ADL/IADL scale. Data come from 2,977 disabled respondents in the 1989 National Long-Term Care Survey. Respondents indicated whether they received human help on 7 ADL items; they also indicated whether they were unable to perform each of 9 IADL items due to health reasons. Factor analyses using tetrachoric correlations demonstrated that 15 of the 16 items reflected one major dimension. Item response theory (IRT) methods were used to calibrate the items; a one-parameter IRT model fit the data. Item calibrations showed that ADL and IADL items were not hierarchically related. Analyses showed that a simple sum of item responses could be used to derive a measure of functional disability. Implications of using a 15-item ADL/IADL scale for eligibility determination and for comparing groups are discussed.

Pressure ulcer prevalence in Ohio nursing homes: clinical and facility correlates.

Pressure ulcers remain a common medical problem in nursing homes, despite the development of clinical guidelines for prevention and treatment. Prevention involves low technology but vigilant care. If the disease progresses, infections can develop, and surgery may be necessary to prevent death. This article examines pressure ulcer correlates in a representative sample of 15,121 nursing home residents in 1994 in the state of Ohio. The prevalence of pressure ulcers was 12%, 8% for Stage 2 or greater. The study found that many nursing home residents remain at great risk of developing pressure ulcers. Important risk factors included a history of cured pressure ulcers, new admission and readmissions, dependencies in activities of daily living, weight loss and dehydration, diabetes, edema, and incontinence. After controlling for clinical factors, residents in rural facilities were less likely to have a pressure ulcer. These findings suggest that the quality of pressure ulcer care in nursing homes could improve.

Using outcomes to make inferences about nursing home quality.

Recent concerns about containing the growth of public expenditures on nursing home care and the development of prospective and casemix reimbursement systems with incentives for cost containment have increased the importance of monitoring quality in nursing homes. The current view is that quality assurance systems should include more outcome measures to improve quality. This article discusses why it is difficult to develop facility-level outcome measures that can be used to evaluate and compare the quality of care of nursing homes. The article places the current interest in outcomes measures in its historical policy context and reviews important conceptual and methodological issues associated with outcome-based quality assessment. The authors discuss the difficulty in isolating the facility effect when studying nursing home outcomes and implications of using different estimation approaches. In conclusion, they discuss the need to integrate research with outcome-based quality assurance systems to allow ongoing evaluation and quality improvement.

Risk of behavior problems among nursing home residents in the United States.

This study identified personal risk factors associated with behavior problems among nursing home residents using data based on a national survey of nursing home residents. Data are based on the Institutional Population Component of the 1987 National Medical Expenditure Survey and include nursing home residents living in licensed facilities on January 1, 1987. Multiple regression analyses were conducted to examine characteristics of residents that place them at risk of behavior problems. Independent variables include physical functioning, sensory impairment, cognitive impairment, psychiatric diagnoses, and demographics. Eleven behavior problems grouped into four categories based on factor analysis serve as dependent variables: wandering/safety, aggressive behaviors, collecting behaviors, and delusions/hallucinations. Risk factors emerging as predictors included sex (male), cognitive impairment, ADL dependency, incontinence, psychiatric history, receptive communication, walking, and difficulty seeing. Risk factors differ by type of behavior problem. Results suggest a multiple etiology in which biological, psychological, and sociocultural factors all play a role in generating behavior problems in the long-term care setting.

Measuring functioning in daily activities for persons with dementia.

The author reviews scales that include independent living tasks, with a special focus on scales designed to be used with demented persons. The main focus of the paper is evaluation of dementia-specific scales, both proxy report and performance scales. Criticisms of generic independent living measures are reviewed and approaches to dementia-specific scales are assessed. The overall state of the art of measuring functional disability for persons with dementia is reviewed, with special emphasis on validity, measurement bias, and scaling properties. The author attempts to clarify whether dementia-specific scales are measuring the disability consequences of cognitive impairments or the cognitive impairments themselves.

Appropriate placement of nursing-home residents in lower levels of care.

Too often individuals with long-term-care needs are placed in nursing homes when they might well be better served at a lower level of care. The uneven distribution of residents across settings stems from interacting factors of supply and demand: clinical need; lack of consensus among physicians about what constitutes the best setting for their patients; regulations restricting services in personal care homes. Three sets of clinical criteria identify nursing-home residents according to their appropriateness for lower levels of care. Factors like cost and ability of the patient's family to make informed decisions affect placement as well. Policies for shifting patients to lower levels of care must be carefully designed in order to save costs and ensure that quality of care is retained.

The effect of Medicaid reimbursement on quality of care in nursing homes.

This study uses a nationally representative sample of nursing homes and nursing home residents to examine the effect of Medicaid reimbursement on quality of care. The analysis shows that both reimbursement approach and level affect nursing home quality, as measured by case-mix adjusted staff to resident ratios. The analysis also shows that staffing ratios have a significant impact on resident outcomes, and these impacts vary by professional category of staff. Reimbursement does not have a significant impact on outcomes, however.

Disability and cognitive impairment criteria: targeting those who need the most home care.

Proposed federal long-term care reforms include eligibility criteria based on disability and cognitive impairment. This article illustrates the process of evaluating alternative eligibility criteria based on one possible targeting goal--serving those who need the most care. Channeling data are used to construct a measure of total care needs which is used to evaluate success at meeting the targeting goal. Results indicate the difficulty of establishing eligibility cutoffs that are equitable and meet the targeting goal.

Correlates of pressure sores in nursing homes: evidence from the National Medical Expenditure Survey.

Pressure sores are a serious medical problem that is most commonly found in nursing homes and hospitals. Most sores can be prevented. To prevent pressure sores in nursing homes through intervention, it is first necessary to identify factors associated with sore formation. Factors associated with the formation of pressure sores relate to skin susceptibility combined with the presence of moisture, constant pressure, and shear force or friction on the skin. This paper is the first to study the correlates of pressure sores for a nationally representative sample of nursing home residents. The paper estimates the relative contribution of resident health characteristics to the probability of having had a pressure sore during a nursing home stay for a cross-sectional sample of residents. Data are from 699 facilities and 2803 residents in nursing homes included in the 1987 Institutional Population Component of the National Medical Expenditure Survey. The principal caregiver in the facility was asked if "during the current stay" the resident had a "bed sore (decubitus ulcer)." Findings indicate that having diagnoses of Parkinson's disease, diabetes, or paraplegia, being underweight, older, male, unable to walk, needing help feeding or unable to feed, having frequent fecal and urinary incontinence accidents, and being admitted from a hospital increase the likelihood of having had a pressure sore during the stay. Cognitively impaired residents who could feed themselves independently or with help were less likely to have had a sore, but cognitively impaired residents who were unable to feed themselves at all were at more risk than cognitively intact residents.

Correlates of disruptive behaviors in nursing homes. A reanalysis.

This study reexamines factors associated with the occurrence of disruptive behaviors using a representative sample of nursing home residents in Rhode Island in 1984-1985. Four indicators of disruptive behaviors are examined using multivariate methods: evidence of any disruptive behaviors, abusive behavior, wandering, and noisiness. Results are compared with the 1989 study by Jackson et al., which was based on the same data. Findings indicate that the likelihood of exhibiting disruptive behaviors in nursing homes increases with the severity of cognitive impairment, ADL dysfunction, and incontinence, and decreases with immobility. Immobility not only is negatively associated with wandering behavior, but with other behaviors as well. Women are less likely to be abusive. In contrast to the earlier study, which did not use multivariate methods, age and communication problems are not related to disruptive behaviors.

Characteristics of nursing homes that affect resident outcomes.

Although there has been increased interest in using outcomes as measures of quality, few studies have shown a link between structure or process and outcomes. In this analysis, based on approximately 2,500 residents in 80 nursing homes in Rhode Island, multivariate models estimate which aspects of care are associated with resident outcomes after controlling for resident characteristics. Outcomes, measured over a 6-month period included death, functional decline, and functional improvement. Results suggest that higher staff levels and lower RN turnover were related to functional improvement. Facilities with high catheter use, low rates of skin care, and low participation in organized activities were associated with negative outcomes. Facilities with few private-pay residents were also associated with negative outcomes. Receipt of a serious federal citation was associated with improved outcomes. For-profit facilities appeared to be more efficient in use of resources.

Cognitive impairment and disruptive behaviors among community-based elderly persons: implications for targeting long-term care.

This study estimates the prevalence of cognitive impairment and disruptive behaviors among functionally disabled elderly persons living in the community. The relationship between cognitive impairment, disruptive behaviors, and functional limitations is assessed. The impacts of adding cognitive and disruptive behavior eligibility requirements to commonly used functional disability criteria for long-term care benefits on the number of eligible persons are estimated. The number of eligible persons varies greatly under different criteria, depending on how cognitive and disruptive criteria are combined.

Reforming nursing home quality regulation. Impact on cited deficiencies and nursing home outcomes.

The federally-mandated nursing home survey and certification process has been criticized for focusing more on the potential of each facility to provide good care than on the demonstrated quality of care delivered or on resultant resident outcomes. This paper presents the results of an evaluation of the pilot of a new federal survey process (Patient Care and Services, PaCS) that concentrates surveyor time on the review of resident care, reduces surveyor time spent reviewing policy and procedures, and, for the first time, mandates personal interviews with a sample of facility residents. In Rhode Island, a randomized control design was used to evaluate the impact of the survey on both the number and type of deficiencies cited, as well as on resident outcomes at six month follow-up. The PaCS team cited significantly more deficiencies, in total, than the traditional survey team, and significantly more patient-oriented deficiencies. However, no significant differences in resident outcomes were found when comparing nursing homes in which PaCS was administered and nursing homes in which only the traditional survey was administered.

The hierarchical relationship between activities of daily living and instrumental activities of daily living.

A three-level hierarchical scale including IADL (shopping and transportation) and ADL (bathing, dressing, transferring, and feeding) was tested and validated based on secondary analysis of three studies of elders in the community: a population-based sample, the Cleveland-GAO, and two service-based samples, the Alternative Health Services Project, a study of Medicaid-eligible elders in Georgia, and the Section 222 Homemaker-Day Care study, a sample of Medicare-eligible elders. Scalability analysis included evaluation of Kronbach's alpha, Guttman analysis, and analysis of the pairwise association of individual items using phi/phi max. Validation included discriminant validity and predictive validity. With respect to discriminant validity, the negative association between functional ability (as measured by the scale) and age was observed. With respect to predictive validity, the negative relationship between functional ability (as measured by the scale) and risk of decline to ADL, death, and hospitalization in a year was observed. A six-level scale similar in structure and detail to the Katz Index of ADL was examined with the three studies. This scale can be used to described a broader range of needs of elders in the community and will be particularly useful to health services planners, practitioners, and researchers.