Changes in Antipsychotic Drug Use Following Shifts in Policy

This case study of antipsychotic drug use in nursing homes illustrates the potential benefits and limits of multilevel hierarchical linear analysis in long-term care research. Multilevel (MLn) logistic regression models were used to assess changes in exposure and average daily dose and their associations with resident and facility characteristics following implementation of the 1987 Omnibus Budget Reconciliation Act regulations. Data were obtained for 8,158 elderly Oregon Medicaid residents residing in 128 facilities between July 1991 and December 1994. Findings support the general hypothesis that resident characteristics are the main determinants of drug use and that drug use decreased over time among some resident populations and some facility types. Although challenges were encountered in the use of the MLn software, hierarchical modeling has advantages that make it attractive for long-term care multilevel applications such as the drug use study reported here.

Effect of Person-Centered Showering and the Towel Bath on Bathing-Associated Aggression, Agitation, and Discomfort in Nursing Home Residents with Dementia: A Randomized, Controlled Trial

OBJECTIVES

To evaluate the efficacy of two nonpharmacological techniques in reducing agitation, aggression, and discomfort in nursing home residents with dementia. The techniques evaluated were person-centered showering and the towel bath (a person-centered, in-bed bag-bath with no-rinse soap).

DESIGN

A randomized, controlled trial, with a usual-care control group and two experimental groups, with crossover.

SETTING

Nine skilled nursing facilities in Oregon and six in North Carolina.

PARTICIPANTS

Seventy-three residents with agitation during bathing (69 completed the trial) and 37 nursing assistants who bathed them.

MEASUREMENTS

Agitation and aggression were measured using the Care Recipient Behavior Assessment; discomfort was measured using a modification of the Discomfort Scale for Dementia of the Alzheimer Type. Raters who were blinded to subject status coded both from videotaped baths. Secondary measures of effect included bath duration, bath completeness, skin condition, and skin microbial flora.

RESULTS

All measures of agitation and aggression declined significantly in both treatment groups but not in the control group, with aggressive incidents declining 53% in the person-centered shower group (P<.001) and 60% in the towel-bath group (P<.001). Discomfort scores also declined significantly in both intervention groups (P<.001) but not in the control group. The two interventions did not differ in agitation/aggression reduction, but discomfort was less with the towel bath (P=.003). Average bath duration increased significantly (by a mean of 3.3 minutes) with person-centered showering but not with the towel bath. Neither intervention resulted in fewer body parts being bathed; both improved skin condition; and neither increased colonization with potentially pathogenic bacteria, corynebacteria, or Candida albicans.

CONCLUSION

Person-centered showering and the towel bath constitute safe, effective methods of reducing agitation, aggression, and discomfort during bathing of persons with dementia.

The validity of medicaid pharmacy claims for estimating drug use among elderly nursing home residents: The Oregon experience

This study compared computerized Medicaid pharmacy claims data for nursing home residents with chart data to establish how well the claims data identified those receiving drugs within three different psychoactive drug classes (yes/no for each class) and how well the claims estimated total within-class average daily dose. Percent agreement, positive predictive value (PPV), and negative predictive value (NPV) for drug exposure were over 85% for each class. Kappas were excellent for antipsychotics and antidepressants, and good for anxiolytics. Correspondence was lower for average daily dose. Using an algorithm that credits some but not all doses associated with overlapping claims, correlations ranged from 0.97 to 0.66. Agreement on therapeutic dose was excellent for antipsychotics (kappa = 0.81) and fair to good for antidepressants and anxiolytics (kappa = 0.63, and kappa = 0.52, respectively). The findings suggest that Medicaid pharmacy claims data are reasonably accurate for quality assurance and accreditation purposes.

A proposed prototype for identifying and correcting sources of measurement error in classification systems

Because many raters are generally involved in the implementation of a patient classification system, interrater reliability is always a concern in the development and use of such a system. In this article, a case example is used to demonstrate a prototype for identifying measurement error introduced at each step in the classification process (assessment, creating summary item responses, and use of these responses for categorization) and to illustrate how this identification may lead to error reduction strategies. The methods of analyses included percent agreement, Kappa, and visual inspection of contingency tables displaying interrater responses to assessment items, summary items, and the placement category. The extent to which raters followed instructions was analyzed by comparing their responses with computer-generated responses across the classification steps. In addition, raters were interviewed regarding their use of the system.

Alberta Assessment and Placement Instrument. Description and interrater reliability

There is a clear need for increased standardization of placement and therefore greater equity among long-term-care patients with similar clinical needs and environmental constraints. This article describes a multidimensional instrument that incorporates a decision rule for placement recommendations across 4 levels of care. Interrater reliability for the assessment items as well as the placement levels are reported.