Advance Directives in the Nursing Home Setting: An Initiative to Increase Completion and Reduce Potentially Avoidable Hospitalizations.

Advance directive (AD) completion can improve transitions between hospitals and skilled nursing facilities (SNF's). One Centers for Medicare and Medicaid Services (CMS) Innovations Demonstration Project, The Missouri Quality Initiative (MOQI), focused on improving AD documentation and use in sixteen SNF's. The intervention included education, training, consultation and improvements to discussion process, policy development, increased AD enactment, and increased community education and awareness activities. An analysis was conducted of data collected from annual chart inventories occurring over four years. Using a logistic mixed model, results indicated statistical significance (p < .001) for increased AD documentation. Greatest gains occurred at project mid-point. The relationship between having an AD and occurrence of transfer to a hospital was tested on a sample of 1,563 residents with length of stays more than 30 days. Residents who did not have an AD were 29% more likely to be transferred. A logistic regression was conducted, and the results were statistically significant (p < .02).

Validation of the Health-Related Independence for Young Adults with Autism Spectrum Disorder Measure- Caregiver Version.

Little is known about Young adults with Autism Spectrum Disorder (YA-ASD) health, healthcare and safety needs. This study describes the validation of a health care transition measure for YA-ASD, the Health-Related Independence (HRI). We collected data from caregivers (n = 490) at five Autism Treatment Network sites and compared the psychometric properties of HRI to the gold standard (STARx) and other validated measures. A Confirmatory Factor Analysis and item culling resulted in 30 items addressing six subscales. Content, criterion, and construct validity and internal consistency indicated high validity and reliability for the scale and subscales. HRI is a validated caregiver-report measure of YA-ASD's self-management, safety, and transition skills. This novel measure will be a useful tool in clinics, intervention development, and research.

Admission Glucose Levels May Increase the Risk for Early Neurological Deterioration in Females With Acute Ischemic Stroke.

Background and purpose: Early neurological deterioration (END) is associated with poor outcome for patients with acute ischemic stroke (AIS). Patients with hyperglycemia have increased risk for stroke and tend to have poor outcome with and without diabetes after stroke. The present study aimed to determine if blood glucose was associated with END and if sex difference was present in the development of END in AIS patients. Methods: A total of 220 consecutive patients (both males and females) with AIS between 2012 and 2015 were screened for this retrospective study. After exclusion, 213 patients were included for analysis. Propensity-score matching was used for normalization of variables including stroke severity, time from symptom onset to treatment, and treatment methods. Results: END was present in 68 patients (31.9%). Multivariate regression analysis showed that the risk of END was significantly higher in males with AIS than in females (P < 0.001), and admission blood glucose level was independently associated with END (P < 0.001). However, subgroup analysis demonstrated that admission glucose levels were significantly associated with increased risk for END only in females, but not in males (P = 0.008). When the cutoff value of 107.1 mg/dL was used, the admission blood glucose level had a significant predictive value for END prediction with a sensitivity of 100% and a specificity of 53% in female patients. Conclusions: The data demonstrated that sex difference was present for the development of END in AIS patients with an increased risk for males. The present study also showed that admission glucose level could be an important predicting factor for END in female patients with AIS.

Reengineering Skilled Nursing Facility Discharge: Analysis of Reengineered Discharge Implementation.

BACKGROUND: There is a need to adopt evidence-based approaches to discharge planning in the skilled nursing facility (SNF) short stay population. PURPOSE: This article describes implementation of the Reengineered Discharge (RED) process in SNFs and makes recommendations for its future implementation. METHODS: The methods included a pre- and postanalysis of an 18-month RED implementation with a contemporaneous comparison of 4 Midwestern SNFs randomly assigned to 2 different RED implementation strategies. The Standard facilities received less implementation than Enhanced facilities. RESULTS: Standard SNFs made more improvements and were more satisfied with the improved process than Enhanced SNFs. Field notes revealed that corporate willingness to make process changes impacted the Standard group's capacity for change; both groups were heavily influenced by external forces, and turnover was an impediment to RED implementation. CONCLUSION: This research revealed that discharge processes are similar across settings and that evidence-based programs such as RED can be adapted to the SNF setting.

Helicobacter pylori infection selectively increases the risk for carotid atherosclerosis in young males.

BACKGROUND AND AIMS: Atherosclerosis is an important contributing factor to cardiovascular mortality. The role of Helicobacter pylori (H. pylori) infection in atherosclerosis is inconsistent and sometimes controversial. The present study aimed to determine if H. pylori infection is associated with carotid atherosclerosis. METHODS: 17,613 males and females with both carotid ultrasonic examination and 13C-urea breath test for H. pylori infection were screened by a major Chinese university hospital from March 2012 to March 2017 for the study. Baseline demographics, cardiac risk factors, and laboratory studies were obtained. After exclusion for pre-specified conditions, 12,836 individuals were included in the analysis, including 8157 men (63.5%) and 4679 women (36.5%). Analysis was also made for 5-year follow-up data of 1216 subjects (869 males and 347 females) with and without H. pylori infection for development and progression of carotid atherosclerosis. RESULTS: After adjusting for age, sex, body mass index, lipid profile, hypertension, renal function, diabetes mellitus, and smoking, H. pylori infection was found as an independent risk factor for carotid atherosclerosis in males under 50 years, but not in older males or females (odds ratio 1.229, 95% CI 1.054-1.434, p = 0.009). Follow-up data analysis showed that the incidence of carotid atherosclerosis from no atherosclerosis to detectable lesions was significantly higher in young males with persistent H. pylori infection than those without H. pylori infection (p = 0.028) after 3 years. CONCLUSIONS: These data suggest that H. pylori infection might be an important risk factor for carotid atherosclerosis in young Chinese males under 50.

Socioeconomic Status and Other Factors Associated with Childhood Obesity.

BACKGROUND: Childhood obesity in the United States is a critical public health issue. Although multiple child and parental factors are associated with childhood obesity, few models evaluate how socioeconomic status influences these risk factors. We aimed to create a model to examine how socioeconomic status modifies risk factors for child obesity. METHODS: We conducted a secondary data analysis of the Early Childhood Longitudinal Birth Cohort. Using logistic regression, we modeled childhood obesity status from known parental and child risk factors for childhood obesity and tested interactions with socioeconomic status. RESULTS: Compared with healthy-weight children, socioeconomic status, race, birth weight, parental smoking, and not eating dinner as a family were associated with kindergarten-aged children being overweight or obese. Parental smoking increased the odds of a child being overweight or obese by 40%, and eating dinner as a family reduced the odds of a child being overweight or obese by 4%. In addition, black or Hispanic children had a 60% increased odds of being overweight or obese when compared with their white counterparts. Native American children had almost double the odds of being overweight or obese compared with white children. Socioeconomic status did not modify any of these associations. CONCLUSION: Parental smoking, birth weight, and not eating dinner as a family were two modifiable factors associated with overweight and obesity in kindergarten-age children, regardless of socioeconomic status. Changing these life-style factors could reduce the child's risk for obesity.

Hospice Family Caregiver Involvement in Care Plan Meetings: A Mixed-Methods Randomized Controlled Trial.

BACKGROUND AND OBJECTIVE: Untrained family caregivers struggle with complicated medical management regimens for hospice patients. An intervention was tested to improve caregiver's perception of pain management and patient's pain. DESIGN, SETTING, AND PARTICIPANTS: The intervention was tested with a 2-group (usual care vs intervention) randomized controlled trial using parallel mixed-methods analysis of 446 caregivers in 3 Midwestern hospice programs representing rural and urban settings. INTERVENTION: Web conferencing or telephones were used to connect caregivers with the hospice care team during care plan meetings. MEASUREMENTS: Caregiver's perceptions of pain management were the primary outcome. Secondary outcomes included caregiver quality of life, patient's pain, and anxiety. Video recordings, field notes, and caregiver and staff interviews provided qualitative data. RESULTS: The overall perception of pain management was not changed by the participation in hospice team meetings. Perceptions of fatalism improved for intervention participants, and the intervention participants perceived their patients' pain was better controlled than those in the control group. The intervention was found to be feasible to deliver in rural areas. Caregiver's anxiety and patient's pain were correlated ( r = .18; P = .003), and subanalysis indicated that caregivers of patients with cancer may benefit more from the intervention than other hospice caregivers. Qualitative analyses provided understanding of caregiver's perceptions of pain, cost, and facilitators and barriers to routine involvement of family in care plan meetings. Limitations and Conclusion: The hospice philosophy is supportive of caregiver involvement in care planning, and technology makes this feasible; the intervention needs modification to become translational as well as additional measurement to assess effectiveness. Caregiver education and emotional support should occur outside the meeting, and a strong leader should facilitate the meeting to control efficiency. Finally, the intervention may benefit caregivers of patients with cancer more than others.

Radiosurgery to the Postoperative Tumor Bed for Metastatic Carcinoma Versus Whole Brain Radiation After Surgery.

BACKGROUND: The treatment paradigm from postoperative whole brain radiation therapy (WBRT) to post-operative stereotactic radiosurgery (SRS) to the tumor bed has shifted with little data to evaluate whether each treatment modality confers equivalent tumor control and survival outcomes. METHODS: Patients with surgical resection of single brain metastases from January 2010 to December 2014 were treated postoperatively with either WBRT or SRS. Retrospective patient data was compared for local control, distant brain recurrence, overall survival, and radiation complications. RESULTS: Forty-six received WBRT, and 37 received tumor bed SRS. Twelve of 35 (34%) SRS patients experienced local recurrence compared to 17 of 31 (55%) WBRT patients (p = 0.09). The median survival was 440 days (14.7 months) for SRS and 202 days (6.7 months) for WBRT (p = 0.062, log-rank). SRS demonstrated improved survival benefit in the first six months (p = 0.0034; Wilcoxon). Radiation-related adverse changes after SRS (22%) were not statistically different from WBRT (8.7%) (p = 0.152). Age (p = 0.08), systemic cancer status (p = 0.30), Graded Prognostic Assessment (p = 0.28), number of brain metastases at diagnosis (p = 0.65), tumor volume at diagnosis (p = 0.13), new brain lesions (p = 0.74) and neurologic versus systemic cause of death (p = 0.11) did not differ between the groups. CONCLUSIONS: Following surgical resection, tumor bed SRS can be used effectively in lieu of WBRT to treat brain metastases with comparable local control and distant control and without significantly more adverse events.

The Negative Impact of Anemia in Outcome from Traumatic Brain Injury.

BACKGROUND: Whether anemia complicating traumatic brain injury (TBI) has an impact on patient outcomes is controversial; therefore, recommendations for blood transfusions for such patients are inconsistent. We hypothesized that patient outcome after TBI would be worse in patients with lower hemoglobin levels. METHODS: We retrospectively reviewed records of patients with TBI and head Abbreviated Injury Scale >3 with abnormal head computed tomography findings and neurologic injury. The relationships between initial hemoglobin and lowest hemoglobin during hospitalization at threshold values of ≤7, ≤8, ≤9, and ≤10 g/dL were investigated relative to Glasgow Outcome Score at last follow-up not exceeding 1 year. RESULTS: Of 939 patients meeting inclusion criteria, initial and lowest hemoglobin concentrations were significant predictors of poor outcome (P < 0.0001). For each 1 g/dL higher hemoglobin value, the likelihood of a good outcome increased by 33%. More severe levels of initial anemia were associated with lower Glasgow Coma Scale, greater head Abbreviated Injury Scale, and greater Injury Severity Score (P < 0.0001). Female patients had worse outcome than male patients only for initial hemoglobin between 7 and 8 g/dL (P < 0.05). Blood transfusion was associated with poorer outcome at hemoglobin levels ≤9 and ≤10 g/dL (P < 0.05), but not at lower hemoglobin thresholds. CONCLUSIONS: Patient outcome after TBI is worse in patients with lower hemoglobin. Initial hemoglobin and lowest hemoglobin after admission are independently associated with poor outcome. Our data support consideration of blood transfusion when hemoglobin is ≤8 g/dl.

Identifying Patients at Risk of High Healthcare Utilization.

Objective. To develop a systematic and reproducible way to identify patients at increased risk for higher healthcare costs. Methods. Medical records were analyzed for 9,581 adults who were primary care patients in the University of Missouri Health System and who were enrolled in Medicare or Medicaid. Patients were categorized into one of four risk tiers as of October 1, 2013, and the four tiers were compared on demographic characteristics, number of healthcare episodes, and healthcare charges in the year before and the year after cohort formation. Results. The mean number of healthcare episodes and the sum of healthcare charges in the year following cohort formation were higher for patients in the higher-risk tiers. Conclusions. Retrospective information that is easily extracted from medical records can be used to create risk tiers that provide highly useful information about the prospective risk of healthcare utilization and costs.

The Quality Improvement Knowledge Application Tool Revised (QIKAT-R).

PURPOSE: Quality improvement (QI) has been part of medical education for over a decade. Assessment of QI learning remains challenging. The Quality Improvement Knowledge Application Tool (QIKAT), developed a decade ago, is widely used despite its subjective nature and inconsistent reliability. From 2009 to 2012, the authors developed and assessed the validation of a revised QIKAT, the "QIKAT-R." METHOD: Phase 1: Using an iterative, consensus-building process, a national group of QI educators developed a scoring rubric with defined language and elements. Phase 2: Five scorers pilot tested the QIKAT-R to assess validity and inter- and intrarater reliability using responses to four scenarios, each with three different levels of response quality: "excellent," "fair," and "poor." Phase 3: Eighteen scorers from three countries used the QIKAT-R to assess the same sets of student responses. RESULTS: Phase 1: The QI educators developed a nine-point scale that uses dichotomous answers (yes/no) for each of three QIKAT-R subsections: Aim, Measure, and Change. Phase 2: The QIKAT-R showed strong discrimination between "poor" and "excellent" responses, and the intra- and interrater reliability were strong. Phase 3: The discriminative validity of the instrument remained strong between excellent and poor responses. The intraclass correlation was 0.66 for the total nine-point scale. CONCLUSIONS: The QIKAT-R is a user-friendly instrument that maintains the content and construct validity of the original QIKAT but provides greatly improved interrater reliability. The clarity within the key subsections aligns the assessment closely with QI knowledge application for students and residents.

Exploring the collective hospice caregiving experience.

BACKGROUND: Collective caregiving, performed by caregivers working in pairs (informal primary and secondary caregivers working together), is common in the hospice setting. Research suggests that caregiving pairs may experience different caregiver outcomes. However, little is known about how caregiving pairs differ from solo caregivers (informal primary caregivers) on outcome measures. OBJECTIVE: The goal of this study was to determine whether being in a caregiver pair affected caregiver anxiety and depression and how outcomes changed over time. DESIGN: A mixed model analysis was used. SETTING/SUBJECTS: Hospice caregivers (260 solo caregivers and 44 caregivers in 22 pairs) who participated in a larger, randomized controlled trial completed caregiver measures upon hospice admission and periodically until the death of the patient or hospice decertification. MEASUREMENTS: Measured were caregiver quality of life, social support, anxiety, and depression. RESULTS: Caregiver pairs had higher anxiety and depression scores than solo caregivers. Emotional, financial, and physical quality of life were associated with decreased depression, whereas only emotional and financial quality of life were correlated with lower levels of anxiety. Social support was associated with lower levels of depression and anxiety. CONCLUSIONS: Despite assumptions that social support is positively facilitated vis-a-vis collective caregiving, caregiving pairs may be at higher risk for anxiety and depression. Future research is needed to address why individuals become anxious and/or depressed when working as part of a caregiving pair.

Medication safety teams' guided implementation of electronic medication administration records in five nursing homes.

BACKGROUND: The 1.6 million nursing home residents in the United States are at high risk for adverse effects from medication errors. In an attempt to decrease medication errors and improve safety practices, from 2003 through 2007 the study investigators partnered with five Midwestern nursing homes in implementing electronic point-of-care medication administration records (eMARs) and focused quality improvement (QI) efforts. METHODS: The eMAR, designed by a vendor as a part of a larger integrated electronic health record, provided a point of information integration for a variety of users, including practitioners, nursing staff, medication administrators, and nursing home leadership. At each nursing home, a medication safety team guided the transition from traditional paper-based systems to the eMAR. RESULTS: The implementation and integration of the eMAR was monitored in more than 300 hours of detailed observation, resulting in nearly 16,000 medication doses across approximately 200 medication administrations (passes) for 3,700 residents. The types of medication errors most receptive to the combined impact of the eMAR and focused QI efforts were late and omitted (or missing) medications. DISCUSSION: Technology provided the structures and processes that improved communication and integrated complex processes. Yet, regardless of how effectively the technology was designed, it was "laid upon" nursing home medication administration systems that were archaic and fragmented. The implementation of technology could not solve chronic structure and process issues in isolation. However, using the technology to streamline processes, support effective decision making, integrate complex tasks, and bring real-time data to a medication safety team provided an effective mechanism to maximize the impact of technology and to minimize the unintended consequences of large-scale change.

Nursing home error and level of staff credentials.

Providing safe nursing home care is both a clinical and fiscal challenge in many countries. The fiscal realities result in the addition of other workers, such as medication technicians or aides (CMT/A), to the health care team. The purpose of this study was to determine the impact of various levels of credentialing among nursing home staff who deliver medications (RN, LPN, or CMT/A) on medication error. In addition, the impact of distractions and interruptions was explored. Using naïve observation, 39 medication administrators representing various levels of credentialing were unobtrusively observed to determine the number of medication errors, distractions, and interruptions in five nursing homes. There were no differences in medication error rates by level of credential. However, RNs had more interruptions during their medication administration, and these increased interruptions were associated with increased medication error rates when wrong time errors were excluded (p = .0348).

Nurse care coordination in community-based long-term care.

PURPOSE: To evaluate the clinical outcomes of a nurse care coordination program for people receiving services from a state-funded home and community-based waiver program called Missouri Care Options (MCO). DESIGN: A quasi-experimental design was used to compare 55 MCO clients who received nurse care coordination (NCC) and 30 clients who received MCO services but no nurse care coordination. METHODS: Nurse care coordination consists of the assignment of a registered nurse who provides home care services for both the MCO program and Medicare home health services. Two standardized datasets, the Minimum Data Set (MDS) for resident care and planning and the Outcome Assessment Instrument and Data Set (OASIS) were collected at baseline, 6 months, and 12 months on both groups. Cognition was measured with the MDS Cognitive Performance Scale (CPS), activities of daily living (ADL) as the sum of five MDS ADL items, depression with the MDS-Depression Rating Scale, and incontinence and pressure ulcers with specific MDS items. Three OASIS items were used to measure pain, dyspnea, and medication management. The Cochran-Mantel-Haenszel (CMH) method was used to test the association between the NCC intervention and clinical outcomes. FINDINGS: At 12 months the NCC group scored significantly better statistically in the clinical outcomes of pain, dyspnea, and ADLs. No significant differences between groups were found in eight clinical outcome measures at 6 months. CONCLUSIONS: Use of nurse care coordination for acute and chronic home care warrants further evaluation as a treatment approach for chronically ill older adults.

Predicting death in the nursing home: development and validation of the 6-month Minimum Data Set mortality risk index.

BACKGROUND: Currently, 24% of all deaths nationally occur in nursing homes making this an important focus of care. However, many residents are not identified as dying and thus do not receive appropriate care in the last weeks and months of life. The aim of our study was to develop and validate a predictive model of 6-month mortality risk using functional, emotional, cognitive, and disease variables found in the Minimum Data Set. METHODS: This retrospective cohort study developed and validated a clinical prediction model using stepwise logistic regression analysis. Our study sample included all Missouri long-term-care residents (43,510) who had a full Minimum Data Set assessment transmitted to the Federal database in calendar year 1999. Death was confirmed by death certificate data. RESULTS: The validated predictive model with a c-statistic of.75 included the following predictors: a) demographics (age and male sex); b) diseases (cancer, congestive heart failure, renal failure, and dementia/Alzheimer's disease); c) clinical signs and symptoms (shortness of breath, deteriorating condition, weight loss, poor appetite, dehydration, increasing number of activities of daily living requiring assistance, and poor score on the cognitive performance scale); and d) adverse events (recent admission to the nursing home). A simple point system derived from the regression equation can be totaled to aid in predicting mortality. CONCLUSIONS: A reasonably accurate, validated model has been produced, with clinical application through a scored point system, to assist clinicians, residents, and family members in defining good goals of care around end-of-life care.

Clinical outcomes of aging in place.

BACKGROUND: Programs such as Medicaid Home and Community-based Services (HCBS) have provided an alternative to institutionalization through community-based, long-term care services; however, there are limited studies on the clinical outcomes of participants in these programs as compared to nursing home (NH) residents. OBJECTIVE: To compare clinical outcomes of individuals in a community-based, long-term care program to individuals of similar case mix in institutional-based, long-term care. METHODS: A program called Aging in Place (AIP) was developed by the Sinclair School of Nursing in cooperation with the state of Missouri's HCBS program. The AIP intervention consisted of nurse coordination of the HCBS program and Medicare home health services. A total of 78 AIP participants were matched with 78 NH residents on admission period, activities of daily living (ADLs), cognitive status, and age. The Minimum Data Set (MDS) was collected on the AIP group at admission and every 6 months over a 30-month period. Cognition was measured by the MDS Cognitive Performance Scale (CPS), ADLs by the sum of 5 MDS ADL items, depression by the MDS-Depression Rating Scale, and incontinence by rating on 2 MDS items related to urinary continence. The Cochran-Mantel-Haenszel method was used to test the association between the AIP intervention and clinical outcomes. RESULTS: The AIP group clinical outcomes were better at a statistically significant level (less than .05) for the following outcomes: (a) cognition at 6, 12, and 18 months (p = .00); (b) depression at 6 and 12 months (p = .00); (c) ADL at 6 (p = .02), 12 (p = .04), and 24 (p = .00) months; and (d) incontinence at 24 (p = .02) months. In all 4 outcome measures, the AIP group stabilized or improved outcome scores whereas the NH group's outcome scores deteriorated. DISCUSSION: Study results suggest that community-based care with nurse coordination enhances clinical outcomes of long-term care participants.

Comorbidity and 1-year mortality risks in nursing home residents.

OBJECTIVES: To investigate the effect of chronic diseases and disease combinations on 1-year mortality in nursing home residents. DESIGN: Retrospective cohort study using electronically submitted Minimum Data Set (MDS) information and Missouri death certificate data. SETTING: Five hundred twenty-two nursing homes in Missouri. PARTICIPANTS: Forty-three thousand five hundred ten nursing home residents with a full MDS assessment in 1999. MEASUREMENTS: Information about chronic diseases, age, sex, and performance in activities of daily living (ADLs) available from the first full MDS 2.0 assessment in 1999; death within 1 year after the first full MDS-assessment in 1999. RESULTS: After adjustment for age and sex, eight variables were predictive for 1-year mortality: seven chronic diseases (dementia, cancer, heart failure, renal failure, emphysema/chronic obstructive pulmonary disease, diabetes mellitus, and anemia) and an interaction variable containing age and cancer. Adding terms for disease combinations (e.g., diabetes mellitus and heart failure) did not enhance survival prediction. When there was also adjustment for ADL performance as measured using the MDS-ADL Short Form, dementia and anemia were not included, because they had no prognostic value above that of the other variables. CONCLUSION: Several chronic diseases were associated with 1-year mortality in the institutionalized elderly after adjustment for ADL performance, age, and sex. Evidence of a synergistic effect of disease combinations on mortality is lacking.