Nov-05

PROGRESS IN GERIATRICS

Accuracy of Nursing Home Medical Record Information about Care-Process Delivery: Implications for Staff Management and Improvement
John F. Schnelle, PhD, Barbara M. Bates-Jensen, PhD, RN, Lily Chu, MD, and Sandra F. Simmons, PhD

Arguments have been made that the culture of nursing homes (NHs) must change to improve the quality of care, and two initiatives have been designed to accomplish this goal. One initiative is to provide resident outcome information (quality indicators) to NH management and consumers via public reporting systems. This initiative is based on the assumptions that resident outcomes are related to care processes implemented by NH staff, the NH industry will respond to market forces, and there are management systems in place within NHs to change the behavior of direct care staff if outcomes are poor. A separate staffing initiative argues that NH care will not improve until there are resources available to increase the number of direct care staff and improve staff training. This initiative also assumes that systems are in place to manage staff resources. Unfortunately, these initiatives may have limited efficacy because information useful for managing the behavior of direct care providers is unavailable within NHs. Medical record documentation about daily care-process implementation may be so erroneous that even the best-intentioned efforts to improve the care received by residents will not be successful. A culture of inaccurate documentation is largely created by a discrepancy between care expectations placed on NHs by regulatory guidelines and inadequate reimbursement to fulfill these expectations. Nursing home staff have little incentive to implement the technologies necessary to audit and assure data quality if accurate documentation reveals that care consistent with regulatory guidelines is not or cannot be provided. A survey process that largely focuses on chart documentation to assess quality provides further incentive for care-process documentation as opposed to care-process delivery. This article reviews methods to improve the accuracy of NH medical record documentation and to create data systems useful for staff training and management. J Am Geriatr Soc 2004;52(8):1378-1383.

-----

Use of the Physician Orders for Life-Sustaining Treatment Program in Oregon Nursing Facilities: Beyond Resuscitation Status
Susan E. Hickman, PhD, Susan W. Tolle, MD, Kenneth Brummel-Smith, MD, and Margaret Murphy Carley, RN, JD

Objectives: Program was designed to communicate resident/surrogate treatment preferences in the form of medical orders. To assess statewide nursing facility use of the Physician Orders for Life-Sustaining Treatment (POLST) and to identify the patterns of orders documented on residents’ POLST forms.

Design: Telephone survey; on-site POLST form review.

Setting: Oregon nursing facilities.

Participants: One hundred forty-six nursing facilities in the telephone survey; 356 nursing facility residents aged 65 and older at seven nursing facilities in the POLST form review.

Measurements: A telephone survey; onsite POLST form reviews.

Results: In the telephone survey, 71% of facilities reported using the POLST program for at least half of their residents. In the POLST form review, do-not-resuscitate (DNR) orders were present on 88% of POLST forms. On forms indicating DNR, 77% reflected preferences for more than the lowest level of treatment in at least one other category. On POLST forms indicating orders to resuscitate, 47% reflected preferences for less than the highest level of treatment in at least one other category. The oldest old (≥85, n=167) were more likely than the young old (65-74, n=48) to have orders to limit resuscitation, medical treatment, and artificial nutrition and hydration.

Conclusion: The POLST program is widely used in Oregon nursing facilities. A majority of individuals with DNR orders requested some other form of life-extending treatment, and advanced age was associated with orders to limit treatments. J Am Geriatr Soc 2004;52(9):1424-1429.

-----

Risk Factors for Harm in Cognitively Impaired Seniors Who Live Alone: A Prospective Study
Mary C. Tierney, PhD, Jocelyn Charles, MD, Gary Naglie, MD, Susan Jaglal, PhD, Alex Kiss, PhD, and Rory H. Fisher, MB

Objectives: To identify risk factors for harm due to self-neglect or behaviors related to disorientation in cognitively impaired seniors who live alone that can be used in primary care.

Design: Inception cohort followed prospectively for 18 months.

Setting: Participants were referred by their primary care physicians and community service agencies or were patients of several medical units of a large teaching hospital.

Participants: One hundred thirty-nine community-residing participants, aged 65 and older who scored less than 131 on the Dementia Rating Scale and lived alone.

Measurements: Baseline Mini-Mental State Examination (MMSE); a social resources questionnaire; presence of chronic obstructive pulmonary disease (COPD), cerebrovascular disease, diabetes mellitus, Charlson Comorbidity Index, and medication use were examined as predictors of incident harm. Informants and primary care physicians provided information about the nature of any harm at 3-month intervals over an 18-month period. An incident of harm was included if it occurred as the result of self-neglect or behaviors related to disorientation, resulted in physical injury or property loss or damage, and required emergency community interventions.

Results: Based on the consensual agreement of four raters, 21.6% had an incident of harm. The proportional hazards model was highly significant (P<.001) and supported by bootstrapping estimates. Four variables were significantly predictive of time to incident harm: perception of fewer social resources, poorer performance on MMSE, presence of COPD, and presence of cerebrovascular disorders.

Conclusion: Predictors of incident harm can be identified in the primary care setting and provide direction for the early identification of those at highest risk. Validation of findings with a new cohort is necessary. J Am Geriatr Soc 2004;52(9):1435-1441.

-----

Footwear Style and Risk of Falls in Older Adults
Thomas D. Koepsell, MD, MPH, Marsha E. Wolf, PhD, David M. Buchner, MD, MPH, Walter A. Kukull, PhD, Andrea Z. LaCroix, PhD, Allan F. Tencer, PhD, Cara L. Frankenfeld, MS, Milda Tautvydas, MFA, and Eric B. Larson, MD, MPH

Objectives: To determine how the risk of a fall in an older adult varies in relation to style of footwear worn.

Design: Nested case-control study.

Setting: Group Health Cooperative, a large health maintenance organization in Washington state.

Participants: A total of 1,371 adults aged 65 and older were monitored for falls over a 2-year period; 327 qualifying fall cases were compared with 327 controls matched on age and sex.

Measurements: Standardized in-person examinations before fall occurrence, interviews about fall risk factors after the fall occurred, and direct examination of footwear were conducted. Questions for controls referred to the last time they engaged in an activity broadly similar to what the case was doing at the time of the fall.

Results: Athletic and canvas shoes (sneakers) were the styles of footwear associated with lowest risk of a fall. Going barefoot or in stocking feet was associated with sharply increased risk, even after controlling for measures of health status (adjusted odds ratio=11.2, 95% confidence interval (CI)=2.451.8). Relative to athletic/canvas shoes, other footwear was associated with a 1.3-fold increase in the risk of a fall (95% CI=0.91.9), varying somewhat by style.

Conclusion: Contrary to findings from gait-laboratory studies, athletic shoes were associated with relatively low risk of a fall in older adults during everyday activities. Fall risk was markedly increased when participants were not wearing shoes. J Am Geriatr Soc 2004;52(9):1495-1501.

-----

The Physician Orders for Life-Sustaining Treatment Program: Oregon Emergency Medical Technicians’ Practical Experiences and Attitudes
Terri A. Schmidt, MD, MS, Susan E. Hickman, PhD, Susan W. Tolle, MD, and Heather S. Brooks, BS

Objectives: To evaluate emergency medical technicians’ (EMTs) experiences with the Physician Orders for Life-Sustaining Treatment (POLST) program and learn about attitudes regarding its effectiveness.

Design: Anonymous survey mailed to a stratified random sample. Setting: Tri-County Portland, Oregon, area.

Participants: A total of 572 Oregon EMT respondents (out of 1,048 surveys) were included in the analysis.

Measurements: Survey questions about experiences with the POLST form and opinions about POLST.

Results: Respondents were mostly male (76%) and paramedics (66%). Most respondents (73%) had treated a patient with a POLST, and 74% reported receiving education about POLST. EMTs reported that POLST, when present, changed treatment in 45% of cases. Seventy-five percent of the respondents agreed that the POLST form provides clear instructions about patient preferences, and 93% agreed that the POLST form is useful in determining which treatments to provide when the patient is in cardiopulmonary arrest. Fewer (63%) agreed that the form is useful in determining treatments when the patient has a pulse and is breathing.

Conclusion: Most respondents have experience with the POLST program. EMTs find the POLST form useful and often use it to change treatment decisions for patients. J Am Geriatr Soc 2004;52(9):1430-1434.

-----

Effectiveness of a Group Outpatient Visit Model for Chronically Ill Older Health Maintenance Organization Members: A 2-Year Randomized Trial of the Cooperative Health Care Clinic
John C. Scott, MD, Douglas A. Conner, PhD, Ingrid Venohr, RN, PhD, Glenn Gade, MD, Marlene McKenzie, RN, Andrew M. Kramer, MD, Lucinda Bryant, PhD, and Arne Beck, PhD

Objectives: To compare the effectiveness of Cooperative Health Care Clinic ((CHCC) group outpatient model for chronically ill, older health maintenance organization (HMO) patients) with usual care.

Design: Two-year, randomized, controlled trial conducted with recruitment from February 1995 through July of 1996.

Setting: Nonprofit group model HMO.

Participants: Two hundred ninety-four adults (145 intervention and 149 usual care), aged 60 and older (mean age 74.1) with 11 or more outpatient visits in the prior 18 months, one or more self-reported chronic conditions, and expressed interest in participating in a group clinic. Intervention: Monthly group meetings held by patients’ primary care physicians.

Measurement: Differences in clinic visits, inpatient admissions, emergency room visits, hospital outpatient services, professional services, home health, and skilled nursing facility admissions; measures of patient satisfaction, quality of life, self-efficacy, and activities of daily living (ADLs).

Results: Outpatient, pharmacy services, home health, and skilled nursing facility use did not differ between groups, but CHCC patients had fewer hospital admissions (P=.012), emergency visits (P=.008), and professional services (P=.005). CHCC patients’ costs were $41.80 per member per month less than those of control patients. CHCC patients reported higher satisfaction with their primary care physician (P=.022), better quality of life (P=.002), and greater self-efficacy (P=.03). Health status and ADLs did not differ between groups.

Conclusion: The CHCC model resulted in fewer hospitalizations and emergency visits, increased patient satisfaction, and self-efficacy, but no effect on outpatient use, health, or functional status. J Am Geriatr Soc 2004;52(9):1463.