Do financial incentives of introducing case mix reimbursement increase feeding tube use in nursing home residents?

Social Ecological Perspectives of Tube-Feeding Older Adults with Advanced Dementia: A Systematic Literature Review

Dementia is a progressive, debilitating disease that often results in weight loss, malnutrition, and dehydration. Feeding tubes are often prescribed; however, this practice can lead to complications. The purpose of this systematic review was to examine the use of feeding tubes in elderly demented patients from a social ecological perspective. Results indicated that family members often receive inadequate decision-making education. Many health care professionals lack knowledge of evidence-based guidelines pertaining to feeding tube use. Organizational and financial reimbursement structures influence feeding tube use. Feeding practices for patients with advanced dementia is a complex issue, warranting approaches that target each level of the Social Ecological Model.

How Does Medicaid Reimbursement Impact Nursing Home Quality? The Effects of Small Anticipatory Changes

OBJECTIVE

In 2006, Ohio changed its Medicaid reimbursement methodology for nursing homes (NHs) to promote more efficient staffing levels. This study examines the impacts of this policy change on quality.

RESEARCH DESIGN AND SUBJECTS

Ohio NHs were categorized based on their anticipated change in reimbursement under a new reimbursement system initiated in 2006. Linear regressions were utilized to determine how quality changed from 2006 to 2010 relative to a group of NHs that were not anticipated to experience any significant change in reimbursement. We examine resident outcomes constructed from the Minimum Data Set, deficiency citations, staffing levels, and satisfaction scores for residents and families as measures of quality.

PRINCIPAL FINDINGS

Nursing homes in the group receiving increased reimbursement showed an increase in nursing and nursing aide staffing levels. NHs in the group receiving a reduction in reimbursement did lower staffing levels. None of the nonstaffing quality outcomes were impacted by changes in Medicaid reimbursement.

CONCLUSION

Increased Medicaid reimbursement was found to increase staffing levels, but it had a limited effect, at least in the short run, on an array of nonstaffing quality outcomes.

How Does Medicaid Reimbursement Impact Nursing Home Quality? The Effects of Small Anticipatory Changes

OBJECTIVE

In 2006, Ohio changed its Medicaid reimbursement methodology for nursing homes (NHs) to promote more efficient staffing levels. This study examines the impacts of this policy change on quality.

RESEARCH DESIGN AND SUBJECTS

Ohio NHs were categorized based on their anticipated change in reimbursement under a new reimbursement system initiated in 2006. Linear regressions were utilized to determine how quality changed from 2006 to 2010 relative to a group of NHs that were not anticipated to experience any significant change in reimbursement. We examine resident outcomes constructed from the Minimum Data Set, deficiency citations, staffing levels, and satisfaction scores for residents and families as measures of quality.

PRINCIPAL FINDINGS

Nursing homes in the group receiving increased reimbursement showed an increase in nursing and nursing aide staffing levels. NHs in the group receiving a reduction in reimbursement did lower staffing levels. None of the nonstaffing quality outcomes were impacted by changes in Medicaid reimbursement.

CONCLUSION

Increased Medicaid reimbursement was found to increase staffing levels, but it had a limited effect, at least in the short run, on an array of nonstaffing quality outcomes.

[Choosing wisely together with the patient]

Within the framework of the Choosing wisely initiative of the German Society for Internal Medicine, all scientific societies associated with internal medicine were requested to highlight the unnecessary or underused medical tests or procedures out of the 60 defined examples, which are of immediate relevance within the doctor-patient interaction. Each of the 12 scientific internal medicine societies compiled and substantiated 2 recommendations. This resulted in a spectrum of important recommendations covering the entire field of internal medicine. In difficult situations these recommendations should contribute to developing and supporting the dialogue with patients on an evidence-based level.

A targeted infection prevention intervention in nursing home residents with indwelling devices: a randomized clinical trial

IMPORTANCE

Indwelling devices (eg, urinary catheters and feeding tubes) are often used in nursing homes (NHs). Inadequate care of residents with these devices contributes to high rates of multidrug-resistant organisms (MDROs) and device-related infections in NHs.

OBJECTIVE

To test whether a multimodal targeted infection program (TIP) reduces the prevalence of MDROs and incident device-related infections.

DESIGN, SETTING, AND PARTICIPANTS

Randomized clinical trial at 12 community-based NHs from May 2010 to April 2013. Participants were high-risk NH residents with urinary catheters, feeding tubes, or both.

INTERVENTIONS

Multimodal, including preemptive barrier precautions, active surveillance for MDROs and infections, and NH staff education.

MAIN OUTCOMES AND MEASURES

The primary outcome was the prevalence density rate of MDROs, defined as the total number of MDROs isolated per visit averaged over the duration of a resident's participation. Secondary outcomes included new MDRO acquisitions and new clinically defined device-associated infections. Data were analyzed using a mixed-effects multilevel Poisson regression model (primary outcome) and a Cox proportional hazards model (secondary outcome), adjusting for facility-level clustering and resident-level variables.

RESULTS

In total, 418 NH residents with indwelling devices were enrolled, with 34,174 device-days and 6557 anatomic sites sampled. Intervention NHs had a decrease in the overall MDRO prevalence density (rate ratio, 0.77; 95% CI, 0.62-0.94). The rate of new methicillin-resistant Staphylococcus aureus acquisitions was lower in the intervention group than in the control group (rate ratio, 0.78; 95% CI, 0.64-0.96). Hazard ratios for the first and all (including recurrent) clinically defined catheter-associated urinary tract infections were 0.54 (95% CI, 0.30-0.97) and 0.69 (95% CI, 0.49-0.99), respectively, in the intervention group and the control group. There were no reductions in new vancomycin-resistant enterococci or resistant gram-negative bacilli acquisitions or in new feeding tube-associated pneumonias or skin and soft-tissue infections.

CONCLUSIONS AND RELEVANCE

Our multimodal TIP intervention reduced the overall MDRO prevalence density, new methicillin-resistant S aureus acquisitions, and clinically defined catheter-associated urinary tract infection rates in high-risk NH residents with indwelling devices. Further studies are needed to evaluate the cost-effectiveness of this approach as well as its effects on the reduction of MDRO transmission to other residents, on the environment, and on referring hospitals.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01062841.

Do Medicaid incentive payments boost quality? Florida's direct care staffing adjustment program

Beginning in April 2000 and continuing for 21 months, Florida's legislature allocated $31.6 million (annualized) to nursing homes through a Medicaid direct care staffing adjustment. Florida's legislature paid the highest incentives to nursing homes with the lowest staffing levels and the greatest percentage of Medicaid residents--the bottom tier of quality. Using Donabedian's structure-process-outcomes framework, this study tracks changes in staffing, wages, process of care, and outcomes. The incentive payments increased staffing and wages in nursing home processes (decreased restraint use and feeding tubes) for the facilities receiving the largest amount of money but had no change on pressure sores or decline in activities of daily living. The group receiving the lowest incentives payment (those highest staffed at baseline) saw significant improvement in two quality measures: pressure sores and decline in activities of daily living. All providers receiving more resources improved on deficiency scores, suggesting more Medicaid spending improves quality of care regardless of total incentive payments.

Advance directives in Japanese nursing homes

CONTEXT

Advance directives are poorly understood in Japanese nursing homes. In April 2006, additional funding for end-of-life care became available as the first support for terminal care at Japanese nursing homes.

OBJECTIVES

The objectives of this study were to investigate the adoption of advance directives by Japanese nursing homes, the effect of additional funding for end-of-life care in nursing homes from long-term care insurance on the use of advance directives, and the types of directives used.

METHODS

A nationwide questionnaire survey of nursing homes was performed in Japan. The participants were 913 nursing homes. We investigated the prevalence of advance directives, details of the directives, and demographic data of the responders.

RESULTS

Advance directives were used in 58.4% of nursing homes. The timing of introduction of the directives and the results of multivariate analysis at the facility level suggested a relation between the availability of additional funding for end-of-life care and the adoption of advance directives. Most nursing homes used instructional directives, especially directives providing an explanation and informed consent for end-of-life care in the nursing home.

CONCLUSION

More than half of Japanese nursing homes have introduced advance directives, and additional funding for end-of-life care is related to their introduction. Most nursing homes have adopted instructional directives, especially those providing an explanation and informed consent regarding end-of-life care at the nursing home.

Special considerations for endoscopists on PEG indications in older patients

Undernutrition in frail elderly people is a pathological condition that needs to be recognized and addressed early. Neurological dysphagia is among the most frequent causes of this condition in the elderly but should be considered a terminal event in Alzheimer-type dementias. Tube feeding is an important resource for facilitating metabolic recovery in cachectic patients and is particularly successful in "bridging" and stabilizing therapies prior to major treatment able to cure the patient. Clinical management of tube feeding in "incurable" conditions is complex and becomes part of the palliative care and comfort provided in the terminal stages of illness. Non-specialized physicians are often unfamiliar with the theory and practice of end-of-life interventions, and the resulting decisions are in many cases actually contrary to patient comfort. These problems deserve to be more carefully addressed when the patient is unable to cooperate or express his/her preferences and needs. The success of percutaneous endoscopic gastrostomy has led to increasingly frequent referrals for placement in critically ill elderly patients. Endoscopists therefore become a key figure in stimulating rational, correct treatment of these patients.

Infection rate and colonization with antibiotic-resistant organisms in skilled nursing facility residents with indwelling devices

The objective of this prospective surveillance study was to quantify colonization with antimicrobial-resistant organisms (AROs) and infections attributable to indwelling devices in skilled nursing facility (SNF) residents. The study was conducted in 15 SNFs in Southeast Michigan. Residents with (n=90) and without (n=88) an indwelling device were enrolled and followed for 907 resident-months. Residents were cultured monthly from multiple anatomic sites and data on infections were obtained. The device-attributable rate was calculated by subtracting the infection rate in the device group from the infection rate in the non-device group. A total of 197 new infections occurred during the study period; 87 in the device group (incidence rate [IR] =331/1,000 resident-months) and 110 infections in the non-device group (IR=171/1,000 resident-months), with a relative risk of 1.9 (95% confidence interval [CI]: 1.4-2.6). The attributable rate of excess infections among residents in the device group was 160/1,000 resident-months, with an attributable fraction of 48% (95% CI: 31-61%). Prevalence rates for all AROs were higher in the device group compared with the no-device group. The prevalence of the number of AROs per 1,000 residents cultured increased from no-device to those with only feeding tubes, followed by those with only urinary catheters and both these devices. In conclusion, the presence of indwelling devices is associated with higher incidence rates for infections and prevalence rates for AROs. Our study quantifies this risk and shows that approximately half of all infections in SNF residents with indwelling devices can be eliminated with device removal. Effective strategies to reduce infections and AROs in these residents are warranted.

Conceptual model for reducing infections and antimicrobial resistance in skilled nursing facilities: focusing on residents with indwelling devices

Infections in skilled nursing facilities (SNFs) are common and result in frequent hospital transfers, functional decline, and death. Colonization with multidrug-resistant organisms (MDROs) - including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and multidrug-resistant gram-negative bacilli (R-GNB) - is also increasingly prevalent in SNFs. Antimicrobial resistance among common bacteria can adversely affect clinical outcomes and increase health care costs. Recognizing a need for action, legislators, policy-makers, and consumer groups are advocating for surveillance cultures to identify asymptomatic patients with MDROs, particularly MRSA in hospitals and SNFs. Implementing this policy for all SNF residents may be costly, impractical, and ineffective. Such a policy may result in a large increase in the number of SNF residents placed in isolation precautions with the potential for reduced attention by health care workers, isolation, and functional decline. Detection of colonization and subsequent attempts to eradicate selected MDROs can also lead to more strains with drug resistance. We propose an alternative strategy that uses a focused multicomponent bundle approach that targets residents at a higher risk of colonization and infection with MDROs, specifically those who have an indwelling device. If this strategy is effective, similar strategies can be studied and implemented for other high-risk groups.

[Approach to dysphagia in advanced dementia]

From the onset, dementia affects the patient's nutritional status, producing anorexia, weight loss, feeding apraxia and dysphagia. Distinct strategies are required in each of the stages of this disease, starting with awareness and knowledge of the problem and its prompt detection. In dementia, dysphagia usually appears in advanced phases, when the patient is often institutionalized. When dysphagia is suspected, the patient's tolerance must be evaluated by the volume/viscosity test, environmental and postural strategies should be introduced, and the texture of the diet should be modified. This is a complex task requiring the involvement of a properly trained interdisciplinary team, able to provide information and alternatives and integrate the family environment in the patient's care. The adapted diet should be based on the traditional diet that can also be combined with artificial supplements to provide a varied diet that increases patients', caregivers' and relatives' satisfaction. Tube feeding has shown no nutritional benefits in patients with advanced dementia. Therefore, we propose assisted oral feeding as the most natural and appropriate form of feeding in these patients, always respecting their previously expressed wishes.