Abstract
Objectives
Validated process measures that correlate with patient outcomes are needed for research
and quality improvement.
Design
Cross-sectional analysis within a cluster-randomized fall prevention study.
Setting
Nursing homes in North Carolina (n = 16).
Participants
Nursing home staff (n = 541) and residents with 1 or more falls in 6 months (n = 597).
Measurements
Fall-prevention process measures in 4 categories derived from Assessing Care of Vulnerable
Elders quality indicators were measured in 2 ways: (1) chart abstraction; and (2)
staff responses to clinical vignettes of hypothetical residents at risk for falls.
Recurrent fall rates (falls/resident/year) were measured. The proportion of the total
variation in falls rates explained by the scores for each method (chart abstraction
or vignette) was calculated using multilevel adjusted models.
Results
Chart and vignette measures of comorbidity management were moderately correlated (Pearson
correlation coefficient 0.43), whereas other process measure categories had low or
negative correlation between the 2 methods (psychoactive medication reduction 0.13,
environmental modification −0.42, and exercise/rehabilitation −0.08). Measures of
environmental modification and comorbidity management explained a moderate amount
of the total variation in recurrent fall fates, vignettes (7%–10% variation explained)
were superior to chart abstraction (2%–6% variation explained). Vignette responses
from unlicensed staff (nurse aides and rehabilitation aides) explained more variance
than registered nurses, licensed practical nurses, or other licensed staff in these
categories. Process measures for psychoactive medication reduction and exercise/rehabilitation
did not explain any of the variation in fall outcomes. Overall, vignette process measures
explained 3.9% and chart abstraction measures explained 0% of the variation in fall
outcomes.
Conclusions
Clinical vignettes completed by nursing home staff had greater association with resident
recurrent fall rates than traditional chart abstraction process measures.
Keywords
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References
- Development and testing of nursing home quality indicators.Health Care Financing Rev. 1995; 16: 107-127
- Inter-rater reliability of nursing home quality indicators in the U.S.BMC Health Serv Res. 2003; 3: 20
- The quality of quality measurement in U.S. nursing homes.Gerontologist. 2003; 43 (Spec No 2. pp 37-46)
- Nursing documentation in long-term care settings.Clin Nurs Res. 2014; 23: 442-461
- Association between skilled nursing facility quality indicators and hospital readmissions.JAMA. 2014; 312: 1542-1551
- The Minimum Data Set pressure ulcer indicator: Does it reflect differences in care processes related to pressure ulcer prevention and treatment in nursing homes?.J Am Geriatr Soc. 2003; 51: 1203-1212
- Clinical vignette-based surveys: A tool for assessing physician practice variation.Am J Med Qual. 2005; 20: 151
- Improving patient care. Measuring the quality of physician practice by using clinical vignettes: A prospective validation study.Ann Intern Med. 2004; 141: 771
- Comparison of vignettes, standardized patients, and chart abstraction: A prospective validation study of 3 methods for measuring quality.JAMA. 2000; 283: 1715-1722
- Adherence to advance directives in critical care decision making: vignette study.BMJ. 2003; 327: 1011
- Nursing home physicians' knowledge of and attitudes toward nonpharmacological interventions for treatment of behavioral disturbances associated with dementia.J Am Med Dir Assoc. 2008; 9: 491-498
- Eliciting medical care preferences from nursing home residents.Gerontologist. 1991; 31: 358-363
- CONNECT for quality: Protocol of a cluster randomized controlled trial to improve fall prevention in nursing homes.Implementation Sci. 2012; 7: 11
- The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities.in: Agency for Healthcare Research and Quality Emory University, Atlanta, GA2005
- Promoting effective staff interactions to improve fall prevention in nursing homes: A cluster-randomized trial.JAMA Int Med. 2017; (in press)
- Study of individualization and bias in nursing home fall prevention practices.J Am Geriatr Soc. 2017; 65: 815-821
- Quality indicators for falls and mobility problems in vulnerable Elders.J Am Geriatr Soc. 2007; 55: S327-S334
- The association between choice stepping reaction time and falls in older adults—A path analysis model.Age Ageing. 2010; 39: 99-104
- Barriers and facilitators in providing oral care to nursing home residents, from the perspective of care aides: A systematic review and meta-analysis.Int J Nurs Stud. 2017; 73: 34-51
- Connection, regulation, and care plan innovation: A case study of four nursing homes.Health Care Manage Rev. 2006; 31: 337-346
- Patterns of medical and nursing staff communication in nursing homes: Implications and insights from complexity science.Qual Health Res. 2006; 16: 173-188
- What is nursing home quality and how is it measured?.Gerontologist. 2010; 50: 426-442
- Quality indicators for the management of medical conditions in nursing home residents.J Am Med Dir Assoc. 2005; 6: S36-S48
Article info
Publication history
Published online: November 21, 2017
Footnotes
The authors declare no conflicts of interest.
This study was funded by 5R01NR003178-13. CCE is funded in part by 2P30AG028716-06 and K24 AG049077-01A1.
The sponsor played no role in the design, methods, subject recruitment, data collections, analysis, or preparation of this article.
Identification
Copyright
Published by Elsevier Inc. on behalf of AMDA - The Society for Post-Acute and Long-Term Care Medicine.
