[The calculation of quality indicators for Home Care agencies in 11 European countries]

OBJECTIVES

To describe and calculate Home Care Quality Indicators from data of the European Aged in Home Care (ADHOC) project. With due regard for risk factors, home care agencies at country level have been compared with each other on quality of care.

METHODS

The indicators of Home Care quality of care (HCQIs) are calculated based on methods that have been developed in the US and Canada. The values of these QIs are risk adjusted on the basis of odds ratios of covariates resulting from logistic regression analysis on the ADHOC sample. To enhance the comparison of QIs between countries we have used the method of percentile thresholds and QI aggregate sum measure related to those.

RESULTS

Risk adjusted values of 22 Home Care Quality Indicators differed considerably between home care agencies in the eleven European countries that participated in ADHOC. The QI aggregate showed which countries probably had the best home care and which had the worst.

CONCLUSIONS

There are quality indicators available, derived from data of the Resident Assessment Instrument for Home Care, with which quality of care between home care agencies in and across nations can be adequately compared. Examples of this type of indicator are: social isolation, inadequate pain control, failure to improve in impaired locomotion in the home.

Increased work-load associated with faecal incontinence among home care patients in 11 European countries

The plurality of definition of faecal incontinence (FI) complicates the cross-national comparisons between studies conducted in the area. The aim of the study was to investigate work-load and subjective care-giver burden associated with FI, among home-care patients, in Europe.

DESIGN AND METHODS

In this cross-sectional retrospective study, a random sample of 4010 RAI-HC assessments were collected during 2001-02 from home care patients aged 65 years and over (74% females; age 82.8 +/- 7.2 years) in Czech Republic, Denmark, Finland, France, Germany, Iceland, Italy, The Netherlands, Norway, Sweden and United Kingdom.

RESULTS

Of the 4010 individuals, 411 (10.3%) suffered from FI (range 1.1-30.8% from site to site). The factors significantly associated with faecal incontinence were diarrhoea [odds ratio (OR) 10.3, 95% confidence interval (CI) 6.590-15.96], urinary incontinence (OR 3.99, 95% CI 2.991-5.309) and pressure ulcers (OR 3.15, 95% CI 2.196-4.512) together with severe impairments in physical (OR 4.25, 95% CI 2.872-6.295) and cognitive (OR 3.76, 95% CI 2.663-5.304) functions. High use of working hours of the visiting nurses (OR 2.04, 95% CI 1.221-3.414) and home health carers (OR 2.40, 95% CI 1.289-4.470) were additionally associated with faecal incontinence. Use of five or more medications was an inversely associated with FI (OR 0.62, 95% CI 0.473-0.820).

CONCLUSIONS

The additional work load associated with faecal incontinence comprises considerable numbers of formal health care hours and should be taken into account when planning home health services for the older in home care patients.

[Cross-national comparison of drug compliance and non-compliance associated factors in the elderly with polypharmacotherapy]

BACKGROUND

Population of seniors in the Czech Republic consumes more than 35 % of all prescribed medications. Currently, Czech seniors take on the average 4-5 prescribed drugs. However, our knowledge about factors influencing drug compliance is scarce particularly in seniors with polypharmacotherapy. Non-compliance can contribute to treatment failure and increases the risk of adverse drug reactions. The aim of the study is to compare drug compliance in the elderly in 11 European countries and to assess the impact of demographic and drug-related factors on non-compliance to medication.

METHODS AND RESULTS

Cross-sectional comparative study in 3881 elderly subjects living in the community receiving home-care services in 11 European countries participating in ADHOC (Aged in Home Care) study. In the sample of Czech subjects we performed in-depth analysis of causes and factors associated with non-compliance in patients with polypharmacotherapy. 12.5% (n=456) of European seniors were non-compliant with prescribed medication with significantly higher prevalence of non-compliance in the CR (33.5 %) and Germany (17.0 %). In the Czech sample following non-compliance risk factors have been identified: taking > or = 7 drugs per os (OR= 2.2), 10 single applications/day (OR= 2.5), more than twice daily dosing (OR= 2.4), problems with drug preparation (OR= 4.6), polypharmacotherapy 5 years and longer (OR= 5.5) and drug preparation without supervision or help (OR= 2.8). The highest prevalence of non-compliance was found for antidepressants (80 %), antiasthmatics (68 %), fibrates (60 %), nonsteroidal antiinflammatory drugs, vasodilatators, anticoagulants/antiplatelet drugs and nootropics (50 %). Among the most common causes, patients reported forgetting to take the drug (74.3 % patients), mistrust in drug effect (10.6%) and fear of taking "too many drugs" (8.6 %).

CONCLUSIONS

Non-compliance to prescribed drug regimen is a prevalent problem in one third of the Czech seniors and was found to be the highest among 11 European countries. Doctors prescribing to older people have to monitor purposefully compliance and strenghten co-operation and motivation of the patient to adhere with prescribed drug regimen. Particularly in seniors with polypharmacotherapy it seems necessary to simplify drug regimen as much as possible. In elderly patients with physical disability, cognitive impairment or depression supervision and/or help of another person with drug preparation and application may improve drug compliance.

The recognition of dementia in "non-EMI" nursing home residents in South East England

OBJECTIVES

To estimate the agreement between nursing staff's recognition of dementia and results of MMSE assessment in a probability sample of non-specialist nursing home residents in South East England, and to identify correlates of disagreement.

METHODS

Prospective survey. The most senior nurse on duty was interviewed about each resident sampled, and optionally about their own training and experience. Residents were interviewed using the MMSE, and assessed using the Cornell Scale for Depression in Dementia, the Barthel ADL index, and the Behave-AD scale for behavioural problems.

RESULTS

135 nurses were interviewed about 445 residents-116 reported on of the 291 residents scoring 23 or less on the MMSE-34% of these were acknowledged to have dementia. 46.4% of those with MMSE scores of 15 or less were acknowledged to have dementia. "Missed dementia" was associated with higher MMSE and lower Behave-AD scores, and inversely associated with RMN training and private home ownership for profit. It was not associated with training or duration of staff employment.

CONCLUSIONS

Most cognitive impairment in non-specialist nursing homes appeared to be unrecognised. This has implications for the prospects of good dementia care in these homes.

A new assessment for elders admitted to acute care: reliability of the MDS-AC

Assessment of older people rarely includes functional domains critical for ensuring optimum outcome of treatment in acute hospital care. We report the development of a new assessment instrument, and illustrate how differences between pre-hospital and hospital admission status can be systematically evaluated using the Minimum Data Set for Acute Care (MDS-AC). Content was developed by literature review and consultation with professionals working in acute areas. Dual independent assessments were conducted on hospital in-patients in 4 countries. Inter-assessor reliability coefficients were calculated for each item. Kappa was calculated for all binary and multi-level nominal variables. Quadratically weighted Kappa was estimated for all ordinal multi-level variables. Where one level of the variable contained 90% or more of the subjects, total observed agreement is reported. Separate reliability estimates were calculated for pre-hospitalization and inpatient items. Subjects had a mean age of 78. Completion of pre-hospitalization and hospital period assessment (combined) required 20 and 30 minutes. Excluding items for which 90% or more of subjects were classified into a single scoring level, average inter-assessor reliability coefficient for the pre-hospital period items was 0.57 and for in hospital 0.58. Overall exact agreement was 83% for pre-hospitalization assessment items, and 79% for the in-hospital items. The reliability achieved in the highly unstable situation of the acute admission phase is sufficient for use in clinical care and research. Differences in pre-hospital and admission status necessary for case-mix adjusted comparison of outcomes were illustrated. Development of a means for systematically comparing changes in older people during the course of illness is of increasing importance when addressing questions of the appropriate and inappropriate use of medical technology.

Targeting and quality of nursing home care. A five-nation study

The objective of this study was to demonstrate that appropriate targeting and quality monitoring of institutional care of the elderly is possible using person-based information on residents of nursing homes. This cross-sectional study used Minimum Data Set (MDS) assessments of nursing home residents in 6 US states, Copenhagen, Reykjavik, and selected locations in Italy and Japan. The outcome measures were life expectancy at age 65, population over 65, percentage over 65's in nursing homes, and clinical characteristics of nursing home residents from a multinational database of RAI/MDS assessments. We found that Japan has the highest life expectancy, and the second lowest expenditure on health care. The United States has the highest expenditure on health care and intermediate life expectancy. Italy has the highest proportion of population over 65 and the lowest proportion of over 65's in nursing homes. Iceland, a relatively young country, has the highest proportion of over 65's in nursing homes. Residents in Italy and the United States had the most severe physical, cognitive and clinical characteristics, those in Iceland the least. There was wide variation in markers of quality of care, with no country either uniformly good or bad across multiple measures. In conclusion, headline statistics comparing nations' percentage of Gross Domestic Product (GDP) spent on health care, age structure of the population, percentage of over 65's in nursing homes and clinical characteristics bear no consistent relationship. Local policy and practice also affect quality of care. Standardized assessment enables comparisons at local, national and international levels making possible further research on targeting and the appropriate use of institutional care, thus permitting a range of efficiency measures to be developed to inform policy.

RUG-III and resource allocation: comparing the relationship of direct care time with patient characteristics in five countries

BACKGROUND

resource use by different types of patients is of increasing interest to health care services all over the world. Case-mix systems that group together individuals with similar patterns of resource use have been developed to address these questions. Resource Utilization Groups version III (RUG-III) was developed in the USA to address the issue in the care of elderly people and has been validated in a number of countries.

METHOD

this paper synthesizes the results of RUG-III validation studies performed in the USA, Japan, Spain, Sweden and England and Wales, showing the consistency of the system in spite of different skill-mix and total time spent with patients. Data from the validation studies of five countries were compared. Percentage of time given by trained nurses and mean nursing time per patient was compared overall and between selected RUG-III groups.

RESULTS

mean time per patient ranged from 84.4 min per day in Japan, to 155.6 min in England and Wales. Trained nurse time ranged from 7.5% of total time in the USA to 53.2% of total time in England and Wales. The inter-group relationship was very similar in all countries. The RUG-III system appears robust in a wide variety of settings and countries. Future research should address the relationship between skill-mix and total time spent with patients with respect to outcome and quality of care.

Transitions across various continuing care settings

PURPOSE

to compare cross-nationally the sources and rates of admission and discharge in nursing homes.

METHODS

data on admission were used from the Minimum Data Set of the Resident Assessment Instrument as collected in a multi-nation database at the University of Michigan. Additional data containing longitudinal episodes were used from databases in the Netherlands, Switzerland and the USA.

RESULTS

the sources and rates of admission and discharge in nursing homes vary widely between countries. In Japan 47.5% of the sample was admitted from another long-term care setting, in Italy and the USA 36% and 42% respectively were admitted directly from hospital, while in Denmark and Iceland more than 60% came from home. The longitudinal data show that in the Netherlands, residents' return to home was much more likely than in Geneva or the USA (27% vs 5% vs 10%) and that in the USA a relatively large number of nursing home residents (>45%) was discharged (intermittently) to a hospital within 180 days after first admission as compared to the Netherlands (10%).

CONCLUSIONS

there are large differences between countries in admission and discharge to and from nursing homes. Various policies, payment schemes, care patterns and routine referrals influence this and can be studied with cross-national data now available.

Rehabilitation in nursing homes: a cross-national comparison of recipients

OBJECTIVE

to examine the prevalence of therapy use in nursing homes in selected countries and to describe the characteristics of nursing home residents who receive therapy. DESIGN and

SAMPLING

the design of the study is cross-sectional, using Minimum Data Set (MDS) assessments of nursing home residents. The sample includes all nursing home residents in six US states (n = 273491), in Copenhagen, Denmark (n = 3451), Reyjkavik, Iceland (n = 1254), and selected locations in Italy (n = 1089) and Japan (n = 1255).

METHOD

we determined who had received physical or occupational therapy treatments in the last 7 days. Demographic and clinical characteristics of recipients were compared relative to other nursing home residents within each country.

RESULTS

in the five countries, the prevalence of receiving therapy was 31% (Iceland), 30% Japan), 23% (Denmark), 14% (Italy) and 11% (USA). Substantial proportions of the recipients were over the age of 85, were clinically stable and had been in the nursing home for longer than 90 days. Across all countries, residents with poorer activities of daily living (ADL) scores but good cognitive scores were more likely to receive therapy than other residents. Rehabilitation nursing, an adjunct to therapy, was concentrated on residents with poor ADL scores.

CONCLUSIONS

substantial numbers of long-stay residents receive therapy in nursing homes, including those over the age of 85 years and those with cognitive impairment. Hence, future rehabilitation outcome studies can involve these previously understudied patient populations.

Comprehensive clinical assessment in community setting: applicability of the MDS-HC

OBJECTIVE

To describe the results of an international trial of the home care version of the MDS assessment and problem identification system (the MDS-HC), including reliability estimates, a comparison of MDS-HC reliabilities with reliabilities of the same items in the MDS 2.0 nursing home assessment instrument, and an examination of the types of problems found in home care clients using the MDS-HC.

DESIGN

Independent, dual assessment of clients of home-care agencies by trained clinicians using a draft of the MDS-HC, with additional descriptive data regarding problem profiles for home care clients.

SETTING AND PARTICIPANTS

Reliability data from dual assessments of 241 randomly selected clients of home care agencies in five countries, all of whom volunteered to test the MDS-HC. Also included are an expanded sample of 780 home care assessments from these countries and 187 dually assessed residents from 21 nursing homes in the United States.

MEASUREMENTS

The array of MDS-HC assessment items included measures in the following areas: personal items, cognitive patterns, communication/hearing, vision, mood and behavior, social functioning, informal support services, physical functioning, continence, disease diagnoses health conditions and preventive health measures, nutrition/hydration, dental status, skin condition, environmental assessment, service utilization, and medications.

RESULTS

Forty-seven percent of the functional, health status, social environment, and service items in the MDS-HC were taken from the MDS 2.0 for nursing homes. For this item set, it is estimated that the average weighted Kappa is .74 for the MDS-HC and .75 for the MDS 2.0. Similarly, high reliability values were found for items newly introduced in the MDS-HC (weighted Kappa = .70). Descriptive findings also characterize the problems of home care clients, with subanalyses within cognitive performance levels.

CONCLUSION

Findings indicate that the core set of items in the MDS 2.0 work equally well in community and nursing home settings. New items are highly reliable. In tandem, these instruments can be used within the international community, assisting and planning care for older adults within a broad spectrum of service settings, including nursing homes and home care programs. With this community-based, second-generation problem and care plan-driven assessment instrument, disability assessment can be performed consistently across the world.

Casemix for inpatient care of elderly people: rehabilitation and post-acute care. Casemix for the Elderly Inpatient Working Group

BACKGROUND

defining contracts for the care of elderly people on the basis of the number of episodes is inappropriate as it fails to take account of the wide variation in their physical disability and rehabilitation needs. Resource use on a day-to-day basis can be estimated for patients using the Resource Utilization Groups version III (RUG-III) casemix system. For practical use, RUG-III assessments cannot be made daily and so assessments at different time intervals were evaluated in order to give an indication of resource use for an inpatient stay. This study describes how RUG-III assessments can be used to give an indication of resource use for an inpatient episode.

METHOD AND RESULTS

RUG-III assessments were completed for all admissions to elderly care rehabilitation wards in two Health Districts over a 10 week period. There were 336 patients and 965 RUG-III assessments. The average time required to make RUG-III assessments fell from 10 to 4 min by the end of the study period. Fortnightly assessment intervals including a discharge assessment correlated well with the average of weekly assessments (R2 = 0.88-0.91, P < 0.0001).

CONCLUSION

using the results from these assessments we propose a model for use of the RUG-III system in contracts for rehabilitation and post-acute care of elderly people which addresses the difficulty of combining clinical characteristics, rehabilitation, resource use and length of stay into a single useful meaningful casemix system.

Casemix for the elderly inpatient: Resource Utilization Groups (RUGs) validation project. Casemix for the Elderly Inpatient Working Group

Current methods of contracting for patient treatment in the health service are not suitable for elderly patients with multiple pathology and functional impairment. This study examines Resource Utilization Groups (RUGs) for use in geriatric medicine in England and Wales, based on 1675 patients from 26 hospitals in eight health districts in England and Wales. Nurses completed a questionnaire on the clinical characteristics of patients required to allocate them to one of 44 RUG groups. Nurse/patient contact times were recorded over a 24-hour period. Therapist/patient contact times were recorded for a week. Data were analysed using analysis of variance with time as independent and RUG group as dependent variable. Variance explanation in excess of 45% was achieved in acute and rehabilitation wards. In long-stay wards, variance explanation (23%) was no better than ADL score alone. RUG-III could form the basis of a casemix system for geriatrics in England and Wales in acute and rehabilitation settings.

Screening the elderly in the community: controlled trial of dependency surveillance using a questionnaire administered by volunteers

OBJECTIVE

To test the benefits of regular surveillance of the elderly at home using an activities of daily living questionnaire administered by volunteers.

DESIGN

Randomised controlled study.

PATIENTS

539 Subjects aged 75 and over from two general practices.

INTERVENTION

All subjects were visited at the beginning and end of the study by volunteers, who completed a scored activity of daily living questionnaire. The study group were revisited at regular intervals. Individuals with an increase in score greater than 5 were referred to their general practitioners. All interactions with social services and health authorities were recorded for both groups.

MAIN OUTCOME MEASURES

Mortality, activity of daily living score, total number of days in institutions, geriatric and psychogeriatric service contacts, primary health care team contacts, use of community support services.

RESULTS

The study group were admitted to hospital more often than the controls (335 occasions v 252), but the control group spent 33% more days in institutions, mainly in long term admissions to residential accommodation. The number of falls reported in the control group doubled (from 17 before the first interview to 36 before the last) and in the study group remained unchanged (12 before both interviews). The study group received community support services sooner than the control group. There was no difference between the groups in mortality or activity of daily living score.

CONCLUSION

Regular visiting of old people at home by non-professional volunteers using a simple activity of daily living questionnaire is a practical way of identifying problems and initiating action for this group.

Shoulder Subluxation in elderly inpatients

Examination of the plain chest radiographs of 300 patients consecutively admitted to a department of geriatric medicine revealed that 16 patients had subluxation of the shoulder. Subluxation and excursion of the humeral head were measured, and the results were correlated with with the range of movement and the ability to perform the activities of daily living. No significant relationship was found, but there was a tendency toward increased impairment of movement with increased excursion. The causes of shoulder subluxation include rheumatoid arthritis and previous injury, but subluxation may be no more than a reflection of the aging process, lax musculature, or an intrinsic mild abnormality of the joint structure. As it is of little practical significance, treatment should be undertaken only in the presence of troublesome pain.