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IIR 99-274 – HSR&D Study

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IIR 99-274
Evaluating Health Outcomes of Veterans in VA and Contract Nursing Homes
Dan R. Berlowitz MD MPH
Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA
Bedford, MA
Funding Period: July 2001 - June 2003

BACKGROUND/RATIONALE:
The quality of nursing home care is of substantial concern to patients, families, providers, and policy makers. Care is provided either in VA nursing homes (VANHs) or via contracts with community nursing homes (CNHs). The quality of care provided may be an important determinant in choosing between a VA nursing home or a CNH. This study will assist VA decision-makers in choosing individual patient placements, developing new or renewing existing contracts, and allocating resources to different program settings.

OBJECTIVE(S):
The objectives are: 1) to describe demographic and case mix differences between veterans residing in VANHs compared with those in CNHs; 2) to compare the demographic and case mix characteristics of the veteran and non-veteran populations residing in community nursing homes; 3) to identify predictors of five health outcomes considered quality indicators in long-term care, decline in functional status (as measured by activities of daily living (ADLs), development of pressure ulcers, mortality, behavioral changes since admission, and prevalence of dehydration; 4) to use these predictors to derive and validate new models or to modify risk adjustment models that we previously developed for predicting outcomes that can be applied across settings; and 5) to use these models to compare risk-adjusted outcomes among three populations--veterans in VANHs, veterans in CNHs, and non-veterans in community facilities.

METHODS:
The following 4 dependent outcome samples were used to address question 1 (veterans in VANHs versus veterans in New York State CNHs on VA contracts) of the analysis: (1) 2,877 veterans for behavioral decline; (2) 3,199 veterans for functional decline; (3) 3,202 veterans for pressure ulcers; and (4) 4,991 veterans for mortality. The statistical method used for all 4 dependent outcome models was multilevel random effects.

FINDINGS/RESULTS:
The behavioral decline model utilized 19 factors to predict behavioral decline. Statistically significant factors included uncomplicated dementia, dementia and psychosis, etc. The VANH variable was non-significant for indicating that CNH veterans were less likely to decline. The functional decline model utilized 9 factors to predict functional decline. Statistically significant factors included age, recency of admission, etc. The significant result of the VANH variable indicates that veterans in NYS CNHs with VA contracts are less likely to experience functional decline when compared to veterans in VANHs. The pressure ulcer model utilized 18 factors to predict pressure ulcer development. Significant factors included greater than stage 1 pressure ulcer, stasis ulcer, terminal illness, etc. The statistically significant value of the VANH variable indicates that veterans in VANHs are less likely to develop pressure ulcers when compared to veterans in NYS CNHs with VA contracts. The mortality model utilized 27 factors to predict mortality. Significant factors included age, intermittent supervision for eating, continual assistance for eating, etc. The VANH was non-significant for indicating that veterans in VANHs are less likely to die.

IMPACT:
This study is of major relevance to the VA regarding the provision of long-term care services to its growing elderly population. It will provide insights into differences between veterans cared for in these different settings, informing VA policymakers about the type of nursing home care that is most appropriate based on the case mix of the population. Finally, this study will help to identify subsets of residents who are at increased risk of poor outcomes and to suggest interventions appropriate for meeting their needs.

PUBLICATIONS:

Journal Articles

  1. Berlowitz DR, Rosen AK, Wang F, Tsilimingras D, Tariot PN, Engelhardt J, Kader B, Mukamel DB. Purchasing or providing nursing home care: can quality of care data provide guidance. Journal of the American Geriatrics Society. 2005 Apr 1; 53(4):603-8.
  2. Brandeis GH, Berlowitz DR, Katz P. Are pressure ulcers preventable? A survey of experts. Advances in Skin and Wound Care. 2001 Sep 1; 14(5):244, 245-8.
  3. Berlowitz DR, Young GJ, Brandeis GH, Kader B, Anderson JJ. Health care reorganization and quality of care: unintended effects on pressure ulcer prevention. Medical care. 2001 Feb 1; 39(2):138-46.
Book Chapters

  1. Berlowitz D, Rosen A. Risk adjustment for studying long-term care. In: Iezzoni L, editor. Risk Adjustment for Measuring Health Care Outcomes. 3 ed. Baltimore, MD: Health Administration Press; 2003. Chapter 16. 383-400 p.
Conference Presentations

  1. Berlowitz D. Risk Adjustment. Paper presented at: National Database of Nursing Quality Indicators Annual Conference; 2004 Nov 5; Palo Alto, CA.
  2. Rosen A, Wang F, Mukamel D, Kader B, Tsilimingras D, Bajorska A, Berlowitz D. Using Risk-Adjusted Outcomes to Measure Quality of Care in Nursing Homes. Paper presented at: American Geriatrics Society Annual Meeting; 2003 Nov 1; San Diego, CA.
  3. Wang F, Berlowitz D, Rosen A, Mukamel D, Kader B, Bajorska A. Using Hierarchical Models to Evaluate Nursing Home Care in the VA. Paper presented at: Health Policy Research Annual International Conference; 2003 Oct 17; Chicago, IL.
  4. Berlowitz D. Incidence and Prevalence of Pressure Ulcers: What the Numbers Mean. Paper presented at: Advances in Skin and Wound Care Clinical Annual Symposium; 2002 Sep 23; Dallas, TX.
  5. Berlowitz D. Case-mix Adjustment- ideal and Practical Limitations. Paper presented at: Budapest European Pressure Ulcer Advisory Panel Annual Meeting; 2002 Sep 20; Budapest, Hungary.
  6. Berlowitz D. Using Quality Improvements to Enhance Patient Safety and Pressure Ulcer Treatment. Paper presented at: Advanced Wound Care and Wound Healing Society (SAWC / WHS) Spring Symposium; 2002 Apr 29; Baltimore, MD.
  7. Berlowitz D. Pressure Ulcers. Paper presented at: Harvard Medical School on Geriatric Medicine Annual Review; 2002 Mar 5; Boston, MA.
  8. Berlowitz D. What is the Evidence that Pressure Ulcer Prevention is Effective. Paper presented at: National Pressure Ulcer Advisory Panel Biennial Conference; 2001 Nov 2; New York, NY.
  9. Berlowitz D. Using Quality Improvement to Enhance Patient Safety and Pressure Ulcer Prevention. Paper presented at: Advances in Skin and Wound Care Clinical Annual Symposium; 2001 Sep 22; Orlando, FL.
  10. Berlowitz D. Pressure Ulcers in America: Prevalence, Incidence, and Implications for the Future. Paper presented at: Advances in Skin and Wound Care Clinical Annual Symposium; 2001 Sep 21; Orlando, FL.
  11. Berlowitz D. Pressure Ulcers. Paper presented at: Harvard Medical School on Geriatric Medicine Annual Review; 2001 Mar 1; Boston, MA.


DRA: Health Systems, Aging, Older Veterans' Health and Care
DRE: Technology Development and Assessment
Keywords: Cost, Research measure, VA/non-VA comparisons
MeSH Terms: none

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