To what degree does provider performance affect a quality indicator? The case of nursing homes and ADL change
ABSTRACT This research investigates what factors affect the degree to which nursing home performance explains variance in residents' change in status of activities of daily living (ADL) after admission.
The database included all residents admitted in 2002 to a 10% random sample of nursing homes in the United States. Longitudinal analyses of outcomes at 3 months after admission test the ability of individual characteristics and nursing home identifiers to explain variance in ADL change for different groups of residents.
As we compared the best and worst providers (top 20% vs bottom 20%, then 10%, then 5%) and we restricted analyses to more homogeneous groups of residents, we found that more of the variance in ADL change was attributable to provider performance. Cognitive function and race also affected the degree to which home performance had an impact on outcomes.
The results imply that some quality indicators may be most useful in distinguishing between nursing homes that provide the best or the worst care. Futhermore, the degree to which a quality indicator is driven by a nursing home's performance may vary considerably, depending on the characteristics of the consumer. These findings raise questions about the usefulness of performance measures that focus on heterogeneous groups of consumers or entire provider populations. "How much of the variance in a quality indicator does provider performance explain?" is an issue we think has not received the attention it deserves in current discussions of performance-measurement strategies and pay-for-performance models.
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ABSTRACT: Recommendations for directing quality improvement initiatives at particular levels (eg, patients, physicians, provider groups) have been made on the basis of empirical components of variance analyses of performance. To review the literature on use of multilevel analyses of variability in quality. Systematic literature review of English-language articles (n = 39) examining variability and reliability of performance measures in Medline using PubMed (1949-November 2008). Variation was most commonly assessed at facility (eg, hospital, medical center) (n = 19) and physician (n = 18) levels; most articles reported variability as the proportion of total variation attributable to given levels (n = 22). Proportions of variability explained by aggregated levels were generally low (eg, <19% for physicians), and numerous authors concluded that the proportion of variability at a specific level did not justify targeting quality interventions to that level. Few articles based their recommendations on absolute differences among physicians, hospitals, or other levels. Seven of 12 articles that assessed reliability found that reliability was poor at the physician or hospital level due to low proportional variability and small sample sizes per unit, and cautioned that public reporting or incentives based on these measures may be inappropriate. The proportion of variability at levels higher than patients is often found to be "low." Although low proportional variability may lead to poor measurement reliability, a number of authors further suggested that it also indicates a lack of potential for quality improvement. Few studies provided additional information to help determine whether variation was, nevertheless, clinically meaningful.Medical care 02/2010; 48(2):140-8. DOI:10.1097/MLR.0b013e3181bd4dc3 · 2.94 Impact Factor
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ABSTRACT: Contractures represent a common but preventable source of excess disability among nursing home residents. They result in many negative consequences such as pain, increased fall risk and decreased functional ability. Studies of prevalence vary in the definition of contracture and thus the exact enumeration, but consistently report the commonality in the nursing home setting. In this population, the clinician should focus on tertiary prevention and/or treatment. Methods such as those consistent with restorative care nursing have shown improvement in function and are a reasonable recommendation as a preventive measure for contractures. Assessment, prevention, and treatment approaches are discussed.Journal of the American Medical Directors Association 02/2010; 11(2):94-9. DOI:10.1016/j.jamda.2009.04.010 · 4.78 Impact Factor
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ABSTRACT: BACKGROUND: The increasing need for long-term care as well as diminished financial resources may compromise the quality of care of older people. Thus the need for clinically based quality of care monitoring to guide development of long-term services has been pointed out. OBJECTIVES: The aim of this study was to investigate trends in quality of care during 2003-2009 as reflected in the Minimum Data Set quality indicator outcome in Icelandic nursing homes and to investigate the association of Minimum Data Set quality indicators with residents' health status (health stability, pain, depression and cognitive performance) and functional profile (activities of daily living and social engagement). DESIGN: Retrospective analysis of nursing home data over 7 years. METHODS: The sample used for analysis was 11,034 Minimum Data Set assessments of 3694 residents living in Icelandic nursing homes in 2003-2009. Minimum Data Set quality indicators were used to measure quality of care. The chi-square test for trend and multivariate logistic regression were used to analyse the data. RESULTS: The mean age of residents during the period of the study ranged from 82.3 (SD 9.1) to 85.1 (SD 8.3) and women accounted for from 65.2% to 67.8%. Findings for 16 out of 20 quality indicators indicated a decline in quality of care (p<0.05), although in 12 out of 20 indicators the prevalence was lower than 25%. One quality indicator showed improvement, i.e. for "Bladder and bowel incontinence without a toileting plan" from 17.4% in 2003 decreasing to 11.5% in 2009 (p<0.001). Residents' health and functional status partially explain the increased prevalence of the quality indicators over time. CONCLUSION: Further developments in quality of care in Icelandic nursing homes need to be monitored as well as the association between residents' health and functional status and the Minimum Data Set quality indicator outcome. The areas of care where the Minimum Data Set quality indicators showed need for improvement included treatment of depression, number of medications, resident activity level and behavioural symptoms.International journal of nursing studies 06/2012; 49(11). DOI:10.1016/j.ijnurstu.2012.06.004 · 2.25 Impact Factor