Measuring Health Outcomes for Older People Using the Sage Database

Beyond the 'iron lungs of gerontology': using evidence to shape the future of nursing homes in Canada

Institutionalization of the Elderly in Canada suggested that efforts to address the underlying causes of age-related declines in health might negate the need for nursing homes. However, the prevalence of chronic disease has increased, and conditions like dementia mean that nursing homes are likely to remain important features of the Canadian health care system. A fundamental problem limiting the ability to understand how nursing homes may change to better meet the needs of an aging population was the lack of person-level clinical information. The introduction of interRAI assessment instruments to most Canadian provinces/territories and the establishment of the national Continuing Care Reporting System represent important steps in our capacity to understand nursing home care in Canada. Evidence from eight provinces and territories shows that the needs of persons in long-term care are highly complex, resource allocations do not always correspond to needs, and quality varies substantially between and within provinces.

Cholinesterase inhibitor and memantine use in newly admitted nursing home residents with dementia

OBJECTIVES

To quantify the use of cholinesterase inhibitors (ChEIs) and memantine in nursing home (NH) residents with dementia upon NH admission and 3 months later and to examine factors associated with reduction in therapy.

DESIGN

Retrospective cohort study.

SETTING

Nationwide sample of U.S. NHs.

PARTICIPANTS

Three thousand five hundred six NH residents with dementia newly admitted in 2006.

MEASUREMENTS

Data from pharmacy dispensing records were used to determine ChEI and memantine medication use upon NH admission and at 3-month follow-up. The Minimum Data Set was used to determine resident- and facility-level characteristics. Severity of dementia was defined using the Cognitive Performance Scale (CPS).

RESULTS

Overall, 40.1% (n=1,407) of newly admitted NH residents with dementia received ChEIs and memantine on NH admission. Use of ChEIs and memantine on admission was significantly greater in residents with mild to moderately severe dementia (41.2%) than in those with advanced dementia (33.3%, P=.001). After 3 months, ChEI and memantine use decreased by about half in both groups (48.6% with mild to moderately severe dementia vs 57.0% with advanced dementia, P<.05). NH residents with advanced dementia were significantly more likely reduce their use of ChEIs and memantine than those with mild to moderately severe dementia (odds ratio=1.44, 95% confidence interval=1.03-2.01, P=.04).

CONCLUSION

Many NH residents with advanced dementia receive ChEIs and memantine upon NH admission, and approximately half of these decrease their medication use over the ensuing months. Further study is required to optimize use of ChEIs and memantine in NH populations and to determine the effects of withdrawing therapy on resident outcomes.

Effect of triplicate prescription policy on benzodiazepine administration in nursing home residents

OBJECTIVE

To estimate the effect of a triplicate prescription policy on administration of benzodiazepines and possible substitute drugs in nursing home residents during 1994-1995.

DESIGN

Retrospective cross-sectional study

SETTING

Medicare- and Medicaid-certified nursing homes in five states: New York, which has a policy requiring triplicate prescription forms for certain drugs, and four states without such a policy.

SUBJECTS

A total of 211,177 nursing home residents.

MEASUREMENTS AND MAIN RESULTS

Data were collected using the Minimum Data Set; logistic regression provided an estimated effect of the policy on prescribing benzodiazepines. We also estimated possible substitute drugs for benzodiazepines (e.g., barbiturates, antidepressants, antipsychotics, and miscellaneous sedative-hypnotics) while adjusting simultaneously for potential confounders. New York nursing home residents were less likely to be receiving benzodiazepine therapy than those in nonpolicy states (odds ratio 0.42; 95% confidence interval 0.41-0.44). No increases occurred in administration of benzodiazepine substitute drugs in New York versus states without a triplicate prescription policy.

CONCLUSION

Policy did affect prescription and administration of benzodiazepines in nursing homes in states with versus without a triplicate prescription policy Lack of substitution with other drugs makes it unclear whether overprescribing occurred in states without a policy, or undertreatment occurred in the state with a policy.

Effect of nonsteroidal anti-inflammatory drug use on the rate of gastrointestinal hospitalizations among people living in long-term care

OBJECTIVES

Gastrointestinal (GI) complications are the most-common serious adverse reactions associated with nonsteroidal anti-inflammatory drugs (NSAIDs). We quantified the effect of specific NSAIDs on the rate of GI hospitalizations among older people living in long-term care.

DESIGN

Retrospective cohort study.

SETTING

All Medicare/Medicaid certified nursing homes in four states (Maine, Minnesota, New York, and South Dakota).

PARTICIPANTS

We identified 125,516 newly admitted residents from a database of all residents (1992-1996) of all Medicare/Medicaid certified nursing homes in four states. Using the federally mandated Minimum Data Set, which includes information on all drugs received (prescription and over-the-counter), we identified patients who received at least one prescription for aspirin (n = 19,101) or NSAIDs (n = 9,777). The control population consisted of all institutionalized persons who did not receive these drugs.

MEASUREMENTS

From Health Care Financing Administration inpatient claims, we identified the first hospitalization for GI perforation, ulcer, or hemorrhage that occurred during the year of follow up (ICD9-CM discharge codes: 531-534, 578). Cox proportional hazards models provided adjusted estimates of rate ratios.

RESULTS

NSAID exposure increased the GI-event-related hospitalization rate in both men (rate ratios (RR) = 2.64; 95% confidence interval (CI) = 1.17-5.99) and women (RR = 3.23; 95% CI = 1.85-5.65). The rate of GI hospitalizations for both men and women taking sulindac, naproxen, or indomethacin was higher than for nonusers. The risk of GI-event-related hospitalizations was greatest among women exposed to diflunisal (RR = 6.08; 95% CI = 2.27-16.26) or oxaprozin (RR = 6.03; 95% CI = 2.49-14.58).

CONCLUSIONS

Despite the high background rate of GI events, most NSAIDs increased the risk of GI hospitalization. Careful attention to choice of agent and dosing is needed in prescribing NSAIDs in this frail, older population.

Management of heart failure among very old persons living in long-term care: has the voice of trials spread? The SAGE Study Group

BACKGROUND

Increasing prevalence, use of health services, and number of deaths have made congestive heart failure (CHF) a new epidemic in the United States. Yet there are no adequate data to guide treatment of the more typical and complex cases of patients who are very old and frail.

METHODS

Using the SAGE database, we studied the cases of 86,094 patients with CHF admitted to any of the 1492 long-term care facilities of 5 states from 1992 through 1996. We described their clinical and functional characteristics and their pharmacologic treatment to verify agreement with widely approved guidelines. We evaluated age- and sex-related differences, and we determined predictors of receiving an angiotensin-converting enzyme (ACE) inhibitor by developing a multiple logistic regression model.

RESULTS

The mean age of the population was 84.9 +/- 8 years. Eighty percent of the patients 85 years of age or older were women. More than two thirds of patients underwent frequent hospitalizations related to CHF in the year preceding admission to a long-term care facility. Coronary heart disease and hypertension were the most common causes. Half of the patients received digoxin and 45% a diuretic, regardless of background cardiovascular comorbidities. Only 25% of patients had a prescription for ACE inhibitors. The presence of cardiovascular comorbidity, already being a recipient of a large number of medications, a previous hospitalization for CHF, and admission to the facility in recent years were associated with an increased likelihood of receiving an ACE inhibitor. The presence of severe physical limitation was inversely related to use of ACE inhibitors, as were a series of organizational factors related to the facilities.

CONCLUSIONS

Patients in long-term care who have CHF little resemble to those enrolled in randomized trials. This circumstance may explain, at least in part, the divergence from pharmacologic management consensus guidelines. Yet the prescription of ACE inhibitors varies significantly across facilities and depends on organizational characteristics.