Efficacy and cost savings with the use of a minimal sedation / anxiolysis protocol for intra-articular corticosteroid injections in children with juvenile idiopathic arthritis: a retrospective review of prospectively collected data.

BACKGROUND: Intra-articular corticosteroid injections (IACI) are frequently used in the treatment of juvenile idiopathic arthritis. There is a paucity of evidence-based research describing methods of pain and anxiety control for this procedure. IACI were mostly performed under general anesthesia for children younger than 13 years old in our institution as of 2014. We started to integrate sedation services more commonly in our institution with the minimal sedation/anxiolysis (MSA) protocol outlined as an alternative to general anesthesia for IACI in 2015. The purpose of this study was to evaluate the effectiveness and cost savings of a minimal sedation protocol for intra-articular corticosteroid injections in juvenile idiopathic arthritis patients after instituting this protocol at our institution. METHODS: The MSA protocol included nitrous oxide, intranasal fentanyl, a topical numbing agent, acetaminophen, ibuprofen, ondansetron and child life intervention. A retrospective review of prospectively collected data was performed on a total of 80 consecutive patients with juvenile idiopathic arthritis who underwent joint injections using the protocol. RESULTS: The procedure was successfully completed in greater than 95% of the patients. The median pain score (measured on a verbal numeric scale of 0-10) reported by the patient was 1 (IQR 0-2.5), by the parent 1 (IQR 0-2), by the rheumatologist 1 (IQR 0-1), and by the sedationist 1 (IQR 0-1). Degree of motion during the procedure was reported by the rheumatologist and the sedationist as none in 68% of the patients, mild in 36% and moderate in 6%. Patient, parent, rheumatologist and sedationist rated satisfaction as very high in the vast majority (94%). Emesis was reported in only 2 (2.5%) patients, no significant adverse events were reported, and no patients progressed to a deeper level of sedation than intended. Financial analysis revealed a 33% cost reduction compared with the use of general anesthesia in the operating room. CONCLUSIONS: A minimal sedation/anxiolysis protocol (including nitrous oxide, intranasal fentanyl, a topical numbing agent, acetaminophen, ibuprofen, ondansetron and child life intervention), provides safe and effective analgesia for intra-articular corticosteroid injection in a subset of patients with juvenile idiopathic arthritis and offers a lower cost alternative to general anesthesia.

Financial Implications of Sepsis Prevention, Early Identification, and Treatment: A Population Health Perspective.

Each day an estimated 2000 to 3000 new cases of sepsis are identified and treated in US hospitals. Despite the enormity of the problem, less than one-half of all US adults have heard of sepsis. This article reviews the financial costs of sepsis in the United States, examining the evidence for its economic impact across both hospitals and nursing homes. A brief description of payment models and government programs to promote more coordinated care between hospitals and nursing homes is provided to highlight areas where advances in sepsis care may be incentivized and sustained in new systems emerging in response to the Affordable Care Act. Finally, the costs of sepsis care to the Medicare program in a specific health care market (Pittsburgh) are estimated to highlight the challenges and opportunities for interorganizational collaborative strategies in value-based models of care delivery.

Physician Orders for Life Sustaining Treatment in US Nursing Homes: A Case Study of CRNP Engagement in the Care Planning Process.

This case study describes changes in Physician Orders for Life Saving Treatment (POLST) status among long-stay residents of a US nursing home who had a certified registered nurse practitioner (CRNP) adopt the practice of participating in nursing home staff care plan meetings. The CRNP attended a nonrandomized sample of 60 care plan meetings, each featuring a review of POLST preferences with residents and/or family members. Days since original POLST completion, Charlson Comorbidity Index score, number of hospitalizations since index admission, and other sociodemographic characteristics including religion and payer source were among the data elements extracted via chart review for the sample as well as for a nonequivalent control group of 115 residents also under the care of the medical provider group practice at the nursing home. Twenty-three percent (n = 14) of the 60 care conferences attended by the CRNP resulted in a change in POLST status after consultations with the resident and/or family. In all cases, POLST changes involved restated preferences from a higher level of intervention to a lower level of intervention. Fifty-nine percent of the CRNP-attended conferences resulted in the issuance of new medical provider orders. CRNP participation in care conferences may represent a best practice opportunity to revisit goals of care with individuals and their family members in the context of broader interprofessional treatment planning.

Nursing Home Quality as a Common Good.

A long-standing assumption among economists is that nursing home quality is common across Medicaid and private-pay patients within a shared facility. However, there has been only limited empirical work addressing this issue. Using a unique individual level panel of residents of nursing homes from seven states, we exploit both within-facility and within-person variation in payer source and quality to examine this issue. We also test the robustness of these results across states with different Medicaid and private-pay rate differentials. Across various identification strategies, our results are consistent with the assumption of common quality across Medicaid and private-paying patients within facilities.

Effect of educational level and minority status on nursing home choice after hospital discharge.

OBJECTIVES: The movement to publicly report data on provider quality to inform consumer choices is predicated on assumptions of equal access and knowledge. We examine the validity of this assumption by testing whether minority/less educated Medicare patients are at greater risk of being discharged from a hospital to the lowest-quality nursing homes in a geographic area. METHODS: We used the 2002 national Minimum Data Set to identify 62601 new Medicare admissions to nursing homes in 95 hospital service areas with at least 4 freestanding nursing homes and at least 50 African Americans aged 65 years or older with Medicare admissions to nursing homes. RESULTS: The probability of African Americans' being admitted to nursing homes in the lowest-quality quartile in the area was greater (relative risk [RR]=1.26; 95% confidence interval [CI]=1.0, 8.45) in comparison with Whites. Individuals without a high-school degree were also more likely to be admitted to a low-quality nursing home (RR=1.22; 95% CI=1.0, 1.46). CONCLUSIONS: African American and poorly educated patients enter the worst-quality nursing facilities. This finding raises concerns about the usefulness of the current public reporting model for certain consumers.

The use of contract licensed nursing staff in U.S. nursing homes.

The extent to which nursing homes rely on the use of contracted licensed staff, factors associated with this staffing practice, and the resultant effect on the quality of resident care has received little public attention. Merging the On-line Survey Certification and Reporting System database with the Area Resource File from 1992 through 2002, the authors regressed organizational and market-level variables on the use of 5 percent or more contract full-time equivalent registered nurses and licensed practical nurses. Since 1997, the proportion of facilities using 5 percent or more contract licensed staff more than tripled. Use of contract nurses was associated with more deficiency citations, characteristics of poorer facilities, and tight labor markets. Nursing homes increasingly rely on contract nurses. The failure of nursing homes to attract and retain a competent, stable workforce creates a vicious cycle of staffing practices, which may lead to decline in quality of care.

Medicaid payment and risk-adjusted nursing home quality measures.

Various studies have observed low quality in the nursing home industry. Although Medicaid is the dominant payer of U.S. nursing home services, the association of Medicaid payment rates and quality is not entirely clear, in part because resident-level, risk-adjusted information on quality is lacking. This study examined the relationship between Medicaid payment rates and three risk-adjusted quality measures, controlling for market and facility characteristics. Higher payment was associated with lower incidence of pressure ulcers and physical restraints but not daily pain. Quality of nursing home care may suffer if budget shortfalls force state legislatures to freeze or reduce Medicaid rates.

The relationship of Medicaid payment rates, bed constraint policies, and risk-adjusted pressure ulcers.

OBJECTIVE: To examine the effect of Medicaid reimbursement rates on nursing home quality in the presence of certificate-of-need (CON) and construction moratorium laws. DATA SOURCES/STUDY SETTING: A single cross-section of Medicaid certified nursing homes in 1999 (N = 13,736). STUDY DESIGN: A multivariate regression model was used to examine the effect of Medicaid payment rates and other explanatory variables on risk-adjusted pressure ulcer incidence. The model is alternatively considered for all U.S. nursing home markets, those most restrictive markets, and those high-Medicaid homes to isolate potentially resource-poor environments. DATA EXTRACTION METHODS: A merged data file was constructed with resident-level information from the Minimum Data Set, facility-level information from the On-Line, Survey, Certification, and Reporting (OSCAR) system and market- and state-level information from various published sources. PRINCIPAL FINDINGS: In the analysis of all U.S. markets, there was a positive relationship between the Medicaid payment rate and nursing home quality. The results from this analysis imply that a 10 percent increase in Medicaid payment was associated with a 1.5 percent decrease in the incidence of risk-adjusted pressure ulcers. However, there was a limited association between Medicaid payment rates and quality in the most restrictive markets. Finally, there was a strong relationship between Medicaid payment and quality in high-Medicaid homes providing strong evidence that the level of Medicaid payment is especially important within resource poor facilities. CONCLUSIONS: These findings provide support for the idea that increased Medicaid reimbursement may be an effective means toward improving nursing home quality, although CON and moratorium laws may mitigate this relationship.

Driven to tiers: socioeconomic and racial disparities in the quality of nursing home care.

Nursing home care is currently a two-tiered system. The lower tier consists of facilities housing mainly Medicaid residents and, as a result, has very limited resources. The nearly 15 percent of U.S. nonhospital-based nursing homes that serve predominantly Medicaid residents have fewer nurses, lower occupancy rates, and more health-related deficiencies. They are more likely to be terminated from the Medicaid/Medicare program, are disproportionately located in the poorest counties, and are more likely to serve African-American residents than are other facilities. The public reporting of quality indicators, intended to improve quality through market mechanisms, may result in driving poor homes out of business and will disproportionately affect nonwhite residents living in poor communities. This article recommends a proactive policy stance to mitigate these consequences of quality competition.

Inter-rater reliability of nursing home quality indicators in the U.S.

BACKGROUND: In the US, Quality Indicators (QI's) profiling and comparing the performance of hospitals, health plans, nursing homes and physicians are routinely published for consumer review. We report the results of the largest study of inter-rater reliability done on nursing home assessments which generate the data used to derive publicly reported nursing home quality indicators. METHODS: We sampled nursing homes in 6 states, selecting up to 30 residents per facility who were observed and assessed by research nurses on 100 clinical assessment elements contained in the Minimum Data Set (MDS) and compared these with the most recent assessment in the record done by facility nurses. Kappa statistics were generated for all data items and derived for 22 QI's over the entire sample and for each facility. Finally, facilities with many QI's with poor Kappa levels were compared to those with many QI's with excellent Kappa levels on selected characteristics. RESULTS: A total of 462 facilities in 6 states were approached and 219 agreed to participate, yielding a response rate of 47.4%. A total of 5758 residents were included in the inter-rater reliability analyses, around 27.5 per facility. Patients resembled the traditional nursing home resident, only 43.9% were continent of urine and only 25.2% were rated as likely to be discharged within the next 30 days. Results of resident level comparative analyses reveal high inter-rater reliability levels (most items >.75). Using the research nurses as the "gold standard", we compared composite quality indicators based on their ratings with those based on facility nurses. All but two QI's have adequate Kappa levels and 4 QI's have average Kappa values in excess of.80. We found that 16% of participating facilities performed poorly (Kappa <.4) on more than 6 of the 22 QI's while 18% of facilities performed well (Kappa >.75) on 12 or more QI's. No facility characteristics were related to reliability of the data on which Qis are based. CONCLUSION: While a few QI's being used for public reporting have limited reliability as measured in US nursing homes today, the vast majority of QI's are measured reliably across the majority of nursing facilities. Although information about the average facility is reliable, how the public can identify those facilities whose data can be trusted and whose cannot remains a challenge.

Linkages in the rural continuum: the balanced budget act and beyond.

PURPOSE: This study examined how rural hospitals altered their postacute and long-term care strategies after the Balanced Budget Act of 1997 (BBA97). DESIGN AND METHODS: A nationally representative sample of 540 rural hospital discharge planners were interviewed in 1997. In the year 2000, 513 of 540 discharge planners were reinterviewed. The study is a descriptive analysis of how rural hospitals formed new and altered existing organizational strategies during a time of turbulent changes in federal government reimbursement policy. We classify rural hospital strategic behavior in 1997 according to the Miles and Snow typology of Prospectors, Analyzers, Defenders, and Reactors, and then we examine how the various hospital types altered key strategies following BBA97. RESULTS: Between 1997 and 2000, more than 26% of sampled rural hospitals that did not participate in the swing-bed program in 1997 (44/167) had chosen to do so in 2000, whereas only 3% of those using swing beds in 1997 had eliminated them (12/346). Other strategies such as divestiture of hospital-based nursing homes were related to concurrent swing-bed adoption. Rural hospitals also increased their reliance on formal linkages with external providers of long-term care. IMPLICATIONS: After the BBA97 reimbursement changes, rural hospitals increased their reliance on swing beds and formal linkages to external providers. We observed changes in overall strategy types, away from the Defender and toward the Prospector and Analyzer strategy types. Our findings illustrate the importance of swing beds as a critical buffer for rural hospitals challenged by the uncertainty of the post-BBA97 environment.

The quality of quality measurement in U.S. nursing homes.

PURPOSE: This article examines various technical challenges inherent in the design, implementation, and dissemination of health care quality performance measures. DESIGN AND METHODS: Using national and state-specific Minimum Data Set data from 1999, we examined sample size, measure stability, creation of ordinal ranks, and risk adjustment as applied to aggregated facility quality indicators. RESULTS: Nursing home Quality Indicators now in use are multidimensional and quarterly estimates of incidence-based measures can be relatively unstable, suggesting the need for some averaging of measures over time. IMPLICATIONS: Current public reports benchmarking nursing homes' performances may require additional technical modifications to avoid compromising the fairness of comparisons.

Oversight of nursing homes: pruning the tree or just spotting bad apples?

PURPOSE: This study investigated whether higher rates of nursing home quality citations are associated with increased risk of voluntary and involuntary facility terminations from the Medicare/Medicaid certification process. DESIGN AND METHODS: We examined nationwide Online Survey Certification and Reporting (OSCAR) data from 1992 through 2000 and used a multinomial logistic regression model with time-varying covariates to estimate the relationship between nursing home deficiencies and terminations. RESULTS: In the study period, 8.7% of nursing homes voluntarily terminated and 2.4% of facilities were involuntarily terminated. Deficiencies significantly predicted both types of termination, controlling for state and market characteristics. Low occupancy and very high Medicaid mix were strongly related to voluntary and involuntary terminations (p <.05). IMPLICATIONS: Nursing homes that receive a high number of deficiencies exit the Medicare/Medicaid market and have lower occupancy rates before termination, although the relationship varies considerably across states. If competition on the basis of quality is increased because of public reporting efforts, our analyses suggest that terminations, both voluntary and involuntary, will likely increase.

The impact of the prospective payment system for skilled nursing facilities on therapy service provision: a transaction cost approach.

OBJECTIVE: To examine skilled nursing facilities (SNFs) "make-or-buy" decisions with respect to rehabilitation therapy service provision in the 1990s, both before and after implementation of Medicare's Prospective Payment System (PPS) for SNFs. DATA SOURCES: Longitudinal On-line Survey Certification and Reporting (OSCAR) data (1992-2001) on a sample of 10,241 freestanding urban SNFs. STUDY DESIGN: We estimated a longitudinal multinomial logistic regression model derived from transaction cost economic theory to predict the probability of the outcome in each of four service provision categories (all employed staff, all contract, mixed, and no services provided). PRINCIPAL FINDINGS: Transaction frequency, uncertainty, and complexity result in greater control over therapy services through employment as opposed to outside contracting. For-profit status and chain affiliation were associated with greater control over therapy services. Following PPS, nursing homes acted to limit transaction costs by either exiting the rehabilitation market or exerting greater control over therapy services by managing rehabilitation services in-house. CONCLUSIONS: The financial incentives associated with changes in reimbursement methodology have implications that extend beyond the boundaries of the health care industry segment directly affected. Unintended quality and access consequences need to be carefully monitored by the Medicare program.

Access to postacute nursing home care before and after the BBA. Balanced Budget Act.

Anecdotal reports in the wake of the Balanced Budget Act (BBA) of 1997 raised concerns about restricted access to postacute nursing facility care for Medicare beneficiaries requiring costly, medically complex services. Using all Medicare Part A hospital and nursing facility claims for providers in the state of Ohio and a refined method of identifying hospitalized beneficiaries who were the most at risk, we observed only a small decrease in the proportion of the costliest patients discharged to nursing facilities in 1999 compared with pre-BBA years. Average hospital length-of-stay increased only slightly in 1999, and there were no changes in rehospitalization rates for the costliest patient types. However, reduced rates of admission were concentrated in specific types of nursing facilities, suggesting a need to closely monitor the effects of ongoing post-BBA policy updates.