Quality of care in one Italian nursing home measured by ACOVE process indicators.

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Quality of Care in One Italian Nursing Home Measured by ACOVE Process Indicators Claudia Pileggi, Benedetto Manuti, Rosa Costantino, Aida Bianco, Carmelo G. A. Nobile, Maria Pavia* Department of Health Sciences, University of Catanzaro ‘‘Magna Græcia’’, Catanzaro, Italy Abstract Objectives: To adapt the Assessing Care of Vulnerable Elders Quality Indicators (ACOVE QIs) for use in Italy, to assess the adherence to these indicators as reported in the medical records of residents in a nursing home (NH), to compare this adherence for general medical and geriatric conditions, and eventually, to identify the relationships between patients’ characteristics and reported processes of care. Methods: Two physicians collected the data by reviewing medical records of all NH residents in the previous 5 years, for a period of one year. Patients aged ,65 years were excluded. A total of 245 patients were reviewed during the study period. The ACOVE QIs set, developed for NH processes of care, was used to assess the quality of care. Multivariate analysis was performed to identify and to assess the role of patients’ characteristics on quality of processes of care by several domains of care in general medical and geriatric conditions. Results: With the exception of diabetes management, quality of processes of care for general medical conditions approached adequate adherence. Care falls substantially short of acceptable levels for geriatric conditions (pressure ulcers, falls, dementia). On the contrary, the recommended interventions for urinary incontinence were commonly performed. Adherence to indicators varied for the different domains of care and was proven worse for the screening and prevention indicators both for geriatric and general medical conditions. Statistical analysis showed disparities in provision of appropriate processes of care associated with gender, age, co-morbidities, level of function and mobility, length of stay and modality of discharge by NHs. Conclusions: Adherence to recommended processes of care delivered in NH is inadequate. Substantial work lies ahead for the improvement of care. Efforts should focus particularly on management of geriatric conditions and on preventive healthcare. Citation: Pileggi C, Manuti B, Costantino R, Bianco A, Nobile CGA, et al. (2014) Quality of Care in One Italian Nursing Home Measured by ACOVE Process Indicators. PLoS ONE 9(3): e93064. doi:10.1371/journal.pone.0093064 Editor: Antony Bayer, Cardiff University, United States of America Received September 6, 2013; Accepted March 1, 2014; Published March 27, 2014 Copyright: ß 2014 Pileggi et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: This work was supported by the following Research Grants: Italian Ministry of University and Research (MIUR/PRIN-2008. Prot H8YFRE). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: The authors have declared that no competing interests exist. * E-mail: pavia@unicz.it Introduction In recent decades an exponential growth in numbers of vulnerable elders has led to the concept of emerging new needs associated with their increasing disabilities, and concomitantly an increasing but transformative new demand for health care requiring formal long-term support. Long-term care represents a program of health care, personal care and social services delivered over time to persons who have lost or never acquired some nominal degree of functional capacity [1]. These services may be provided in a variety of settings, largely accounted for in Nursing Homes (NHs). Older patients, as highlighted in a recent review article, do not receive appropriate care [2], so innovative quality improvement strategies still need to be designed, developed and implemented in settings now delivering suboptimal care [3,4]. To explore where, when and for which conditions quality deficiencies exist, Rand Corporation developed a comprehensive set of indicators for assessing the quality of the processes of care, rather than of the outcomes, namely the Assessing Care Of Vulnerable Elders (ACOVE) quality indicators (QIs) [5,6]. These QIs represent minimum care rather than optimal care to be provided for general medical and geriatric conditions to the vulnerable elders, and are meant to assess and ultimately improve the quality of care [5,6]. In Italy there is limited experience about the use of standardized indicators to assess the quality of care provided to NH resident elders, and no study has examined quality of processes of care delivered to prevent, diagnose and treat the main general medical conditions compared to the geriatric ones. The aims of our study were to adapt the ACOVE QIs in a specific geographic area of Italy, to assess the adherence to these indicators as reported in medical records of residents in a NH, to compare this adherence for general medical and geriatric conditions, and eventually, to identify the relationships between patients’ characteristics and reported processes of care. Our data may contribute to implement QIs on a large scale, thus promoting the adoption of best practices in NHs. PLOS ONE | www.plosone.org 1 March 2014 | Volume 9 | Issue 3 | e93064 ACOVE Indicators’ Use in Nursing Home in Italy Materials and Methods The study was undertaken in one 40-bed NH facility located in the area of Catanzaro (Italy). The catchment area of Catanzaro encompasses about 240.000 inhabitants and 1.635 sq km. It is served by six NHs for a total of 194 beds. Two previously trained physicians, who were not involved in care, collected the data by reviewing medical records of NH residents. A detailed protocol has been used to train reviewers to extract data from medical records. In the protocol, simulations of the most common situations that the reviewers would find in the medical records were also included. Finally, the first 30 medical records were reviewed together by two physicians and all discrepancies were resolved through discussion, re-reading and the possible intervention of a third reviewer. Data were collected for all patients who had been NH residents for at least one year in the previous 5 years (2001 to 2006). If patients were admitted for more than one year, the previous 12 months of stay were evaluated; patients aged less than 65 were excluded. The following data were collected for each patient: socio-demographics, mode of admission to NH, cognitive and functional health status, and delivered processes of care. To assess the clinical conditions of patients, we collected the individual diagnoses and the Cumulative Illness Rating Scale for Geriatrics (CIRS-G index) [7,8], a clinician-rated scale of cumulative medical burden in geriatric patients. Two CIRS-G indices were used: the 14 CIRS-G severity index, represented by the disease severity mean (ranging from 1, no problem, to 5, extremely severe) in each of 14 organ systems, and the 14 CIRS-G comorbidity index, computed by counting the number of items for which a score of 3 or more was reported. Cognitive status was assessed using the Short Portable Mental Status Questionnaire (SPMSQ) [9], and the level of function and mobility using the Barthel index [10]. The ACOVE QI set, developed for NH processes of care, and covering 11 general medical conditions [11] and 6 geriatric syndromes [12] was used to assess the quality of care. The ACOVE QIs have been subjected to a cross-cultural translation and adaptation process into the Italian language. The process of cross-cultural adaptation involved several steps: 1) translation from English to Italian; 2) establishment of an expert committee that included two experienced researchers in internal medicine and geriatrics, three researchers proficient in survey design and cross-validation method, one language professional and one translator; 3) meeting of the expert committee to produce the first Italian draft; 4) pilot-testing on a focused group of charts; 5) meeting of the expert committee to produce a new consensus version; 6) back-translation to English; 7) re-evaluation by the committee members and production of the final draft. Then, a pilot study was conducted in order to test the final draft of the tool. Subsequently, the translated version of the tool was submitted to a group of experts who were senior researchers in public health, in internal medicine and geriatrics. They reviewed the format and content of the items, as well as the content validity of the tool as a whole. Eventual disagreement between physicians in reviewing medical records was resolved by discussion. We selected 4 medical conditions (hypertension, diabetes mellitus, heart failure, pneumonia and influenza) (Appendix S1) and 4 geriatric syndromes (dementia, urinary incontinence, falls and mobility disorders and pressure ulcers) (Appendix S2); the clinical conditions were selected since they were the most frequently encountered ones in the study population. Several indicators were assessed for each condition (Hypertension = 13, Diabetes mellitus = 11, Heart failure = 9, Pneumonia and Influ- enza = 8, Dementia = 13, Urinary incontinence = 6, Falls and mobility disorders = 6, Pressure ulcer = 7). The ACOVE QIs are constructed in an IF/THEN format. The "IF" portion of the QI defines the eligible patient for a specific process of care, and the "THEN" portion defines the recommended care. So, "IF" in the patient’s medical record that specific clinical characteristic was reported (eg. that NH resident had diabetes), "THEN" it was necessary to check whether the procedure described by the QI had been performed or not (eg. his or her glycosylated hemoglobin levels had been measured at least every 12 month). Therefore, each NH resident has been considered eligible in relation to one or more clinical conditions reported in the medical record. Whenever the condition described by one of the QI appeared in the medical record, a score of 1 was assigned if the process of care had been performed in adherence to the indicator, otherwise a score of 0 was attributed. For each patient the same indicator could be measured several times according to the recurrence of the condition in the medical record. If the patient had an identified contraindication to a process of care, the related indicator was not included in the scoring process. If feasibility of any indicator was questionable, it was not considered [12,13]. For each clinical condition, scores were calculated at the patient level as the percentage of adherence to the recommended process of care. For example, a patient who had 1 medical conditions (hypertension), and 1 geriatric syndrome (dementia), might have been eligible for all 13 hypertension QIs, and for 11 of the 13 dementia QIs. If 7, and 4 QIs, respectively, were satisfied, the patient’s mean quality score for hypertension would be calculated as 7:13 = 54%, and for dementia as 4:11 = 36%. Moreover, the scores were also calculated by domain of care, categorized into three groups: screening and prevention, diagnosis and treatment. For instance, of the 13 indicators related to hypertension 3 belonged to the screening and prevention domain of care, 4 to the diagnosis, and 6 to the therapy. If the 7 QIs satisfied were divided as the following: 1 QI in screening and prevention, 2 QIs in diagnosis and 4 QIs of therapy, the patient’s mean quality score for each domain of care related to hypertension would be calculated as 1:3 = 33% for screening and prevention, as 2:4 = 50% for diagnosis, and as 4:6 = 67% for therapy. Therefore we provided one QI score for each eligible clinical condition and for each domain of care. The Ethics Committee of the "Mater Domini" Hospital of Catanzaro (Italy) approved the protocol of the study. As a matter of course, written consent was always requested when admission to the NH occurred, and only the patients who had given permission for their personal data to be used for research were included in the study. Statistical analysis In the primary analysis, we used t-test to compare the mean level of the QIs scores for general medical and geriatric conditions in the three domains of care. Six multiple linear regression models were developed to evaluate the relationship of baseline independent characteristics with: QIs scores calculated in the three domains of care (screening and prevention, diagnosis and therapy), separated for general medical and geriatric conditions. In all 6 models the explanatory variables included were the following: age (#75 years = 1, 76–85 years = 2, $86 years = 3), sex (male = 0, female = 1), marital status (single/divorced/widowed = 0, married = 1), education level (no formal education = 0, $5 years = 1), referral to NH (hospital/residential care services = 0, home = 1), length of NH stay (#18 months = 0, 19–36 months = 1, $37 months = 2), outcome of NH stay (categorical, discharge = 1, death = 2, transfer to another facility = 3, NH PLOS ONE | www.plosone.org 2 March 2014 | Volume 9 | Issue 3 | e93064 ACOVE Indicators’ Use in Nursing Home in Italy attendance = 4), 14 CIRS-G comorbidity index (continuous), 14 CIRS-G severity index (continuous), Barthel index (total independence = 0, dependence: mild = 1, moderate = 2, severe = 3, total = 4), SPMSQ (cognitive function impairment: no = 0, borderline or mild = 1, moderate = 2, severe = 3), medical/surgical examinations (no = 0, yes = 1), referral to emergency department (no = 0, yes = 1), hospital admission (no = 0, yes = 1). Regression coefficients (b), standard errors (SE) and 95% confidence intervals (CI) were calculated. All of the tests for significance were two-sided and p-values #0.05 were considered statistically significant. All analyses were conducted using the Stata software program, version 11 [14]. Results Medical records for 245 patients were reviewed during the study period, and their main characteristics are presented in Table 1. More than half were referred to NH by hospitals or residential care services (56.3%), and the mean length of stay was 27.3 months (standard deviation +15.8). Percentages of eligible patients varied for each clinical condition, ranging from 26.5 for heart failure to 100 for pneumonia and influenza. Adherence to quality processes of care according to clinical conditions investigated is found in Appendix S1 and Appendix S2. A detailed examination of the appropriateness of care for individual conditions revealed that, among general medical conditions (Appendix S1), the mean level QI score for recommended processes of care for hypertension was 77.6%; almost all subjects had regular follow-up checks and received appropriate pharmacological management, but orthostatic blood pressure was rarely checked. The mean level QI score for diabetes mellitus was 67.3%; almost all diabetics received regular blood pressure checks, annual foot examination and glycosylated haemoglobin checks, but fewer than 25% received an ophthalmologic examination. The mean level QI score for heart failure management was 81.8%; high compliance to specific physical examinations and complete medical history was found, but appropriate beta blockers prescriptions were provided only to 31% of those eligible. Mean adherence rates for pneumonia and influenza, even though all patients were eligible, was 75.1%; almost all recommended interventions showed high compliance for patients with pneumonia. Formal strategies to increase vaccinations were usually adopted (85%), but influenza vaccine was administered three times more often than pneumococcal vaccine (90% vs 29%). Concerning geriatric conditions (Appendix S2), the mean level QI score for dementia reached 57%. In more than 90% of residents with cognitive impairment a validated cognitive assessment was performed, but only 34% were screened for depression. No medical records were found to indicate the registration of any bracelet identification. The mean level QI score for recommended interventions to prevent falls and treat mobility disorders was 72.7%. Of eligible subjects, 96% were examined for balance or gait disturbances at admission, and more than two-thirds enrolled in exercise programs; however, hypotension screening was documented in only 14%. The mean level QI score for pressure ulcers was 63.2%. Appropriate risk assessment at admission and at recommended intervals was performed in 40% of eligible subjects, whereas 84% of residents with a pressure ulcer received this type of evaluation. For more than 90% of subjects appropriate topical therapy was applied, but adequate nutritional assessment was performed in only 22%. Compliance with urinary incontinence indicators was 82.7%. Among recommended interventions for urinary incontinence, the risk assessment at admission, the appropriateness of indications and documentation for catheteri- Table 1. Selected Characteristics of the Study Population. Characteristic Sex Male Female Age group, years #75 76–85 $86 Educational level, years of schooling None 5 8 $13 Marital status Single/Divorced/Widowed Married Access to NHb care Hospital/Residential care services Home Length of stay in the NHb, months #18 19–36 $36 Outcome of NHb stay Discharge Death Transferred to another facility Still in NHb Access to the Emergency Department None $1 Medical/Surgical investigation received No Yes Cognitive function impairment (SPMSQc) Intact mental functioning Borderline or mild impairment Moderate impairment Severe impairment Level of function and mobility (Barthel index) Totally independent Mild dependence Moderate dependence Severe dependence Total dependence 14 CIRS-Gd Comorbidity Index 14 CIRS-Gd Severity index N % Mean+SDa 105 42.9 140 enfocar la importancia de la producción mediática de los niños en su descubrimiento del mundo, sobre todo utilizando el periódico escolar y la imprenta. Asimismo las asociaciones de profesores trabajaron en esta línea e incluso la enseñanza católica se comprometió desde los años sesenta realizando trabajos originales en el marco de la corriente del Lenguaje Total. Páginas 43-48 45 Comunicar, 28, 2007 En el ámbito de los medios, también desde el principio del siglo XX hay ciertas corrientes de conexión. Pero es a lo largo de los años sesenta cuando se constituyeron asociaciones de periodistas apasionados por sus funciones de mediadores, que fomentaron la importancia ciudadana de los medios como algo cercano a los jóvenes, a los profesores y a las familias. Así se crearon la APIJ (Asociación de Prensa Información para la Juventud), la ARPEJ (Asociación Regional de Prensa y Enseñanza para la Juventud), el CIPE (Comité Interprofesional para la Prensa en la Escuela) o la APE (Asociación de Prensa y Enseñanza), todas ellas para la prensa escrita Estas asociaciones fueron precedidas por movimientos surgidos en mayo de 1968, como el CREPAC que, utilizando películas realizadas por periodistas conocidos, aclaraba temas que habían sido manipulados por una televisión demasiado próxima al poder político y realizaba encuentros con grupos de telespectadores. cipio del siglo XX, y nos han legado textos fundadores muy preciados, importantes trabajos de campo y muchos logros educativos y pedagógicos. La educación en medios ha tenido carácter de oficialidad de múltiples maneras, aunque nunca como una enseñanza global. Así la campaña «Operación Joven Telespectador Activo» (JTA), lanzada al final de los años setenta y financiada de manera interministerial para hacer reflexionar sobre las prácticas televisuales de los jóvenes, la creación del CLEMI (Centro de Educación y Medios de Comunicación) en el seno del Ministerio de Educación Nacional en 1983, la creación de la optativa «Cine-audiovisual» en los bachilleratos de humanidades de los institutos en 1984 (primer bachillerato en 1989) y múltiples referencias a la educación de la imagen, de la prensa, de Internet. La forma más visible y rápida de evaluar el lugar de la educación en medios es valorar el lugar que se le ha reservado en los libros de texto del sistema educa- 2. Construir la educación en los medios sin nombrarla El lugar que ocupa la edu- La denominación «educación en medios», que debería cación en los medios es muy ambiguo, aunque las cosas están cambiando recientemente. entenderse como un concepto integrador que reagrupase todos los medios presentes y futuros, es a menudo percibida En principio, en Francia, co- por los «tradicionalistas de la cultura» como una tendencia mo en muchos otros países, la educación en los medios no es hacia la masificación y la pérdida de la calidad. una disciplina escolar a tiempo completo, sino que se ha ido conformado progresivamente a través de experiencias y reflexiones teóricas que han tivo en Francia. Una inmersión sistemática nos permi- permitido implantar interesantes actividades de carác- te constatar que los textos oficiales acogen numerosos ter puntual. Se ha ganado poco a poco el reconoci- ejemplos, citas, sin delimitarla con precisión. miento de la institución educativa y la comunidad es- colar. Podemos decir que ha conquistado un «lugar», 3. ¿Por qué la escuela ha necesitado casi un siglo en el ámbito de la enseñanza transversal entre las dis- para oficilializar lo que cotidianamente se hacía en ciplinas existentes. ella? Sin embargo, la escuela no está sola en esta aspi- Primero, porque las prácticas de educación en me- ración, porque el trabajo en medios es valorado igual- dios han existido antes de ser nombradas así. Recor- mente por el Ministerio de Cultura (campañas de foto- demos que no fue hasta 1973 cuando aparece este grafía, la llamada «Operación Escuelas», presencia de término y que su definición se debe a los expertos del colegios e institutos en el cine ), así como el Minis- Consejo Internacional del Cine y de la Televisión, que terio de la Juventud y Deportes que ha emprendido en el seno de la UNESCO, definen de esta forma: numerosas iniciativas. «Por educación en medios conviene entender el estu- Así, esta presencia de la educación en los medios dio, la enseñanza, el aprendizaje de los medios moder- no ha sido oficial. ¡La educación de los medios no apa- nos de comunicación y de expresión que forman parte rece oficialmente como tal en los textos de la escuela de un dominio específico y autónomo de conocimien- francesa hasta 2006! tos en la teoría y la práctica pedagógicas, a diferencia Este hecho no nos puede dejar de sorprender ya de su utilización como auxiliar para la enseñanza y el que las experiencias se han multiplicado desde el prin- aprendizaje en otros dominios de conocimientos tales Páginas 43-48 46 Comunicar, 28, 2007 como los de matemáticas, ciencias y geografía». A pe- mente en todas las asignaturas. Incluso los nuevos cu- sar de que esta definición ha servido para otorgarle un rrículos de materias científicas en 2006 para los alum- reconocimiento real, los debates sobre lo que abarca y nos de 11 a 18 años hacen referencia a la necesidad no, no están totalmente extinguidos. de trabajar sobre la información científica y técnica y En segundo lugar, porque si bien a la escuela fran- el uso de las imágenes que nacen de ella. cesa le gusta la innovación, después duda mucho en Desde junio de 2006, aparece oficialmente el tér- reflejar y sancionar estas prácticas innovadoras en sus mino «educación en medios» al publicar el Ministerio textos oficiales. Nos encontramos con una tradición de Educación los nuevos contenidos mínimos y las sólidamente fundada sobre una transmisión de conoci- competencias que deben adquirir los jóvenes al salir mientos muy estructurados, organizados en disciplinas del sistema educativo. escolares que se dedican la mayor parte a transmitir Este documento pretende averiguar cuáles son los conocimientos teóricos. La pedagogía es a menudo se- conocimientos y las competencias indispensables que cundaria, aunque los profesores disfrutan de una ver- deben dominar para terminar con éxito su escolaridad, dadera libertad pedagógica en sus clases. El trabajo seguir su formación y construir su futuro personal y crítico sobre los medios que estaba aún en elaboración profesional. Siete competencias diferentes han sido te- necesitaba este empuje para hacerse oficial. nidas en cuenta y en cada una de ellas, el trabajo con Aunque el trabajo de educación en los medios no los medios es reconocido frecuentemente. Para citar esté reconocido como disciplina, no está ausente de un ejemplo, la competencia sobre el dominio de la len- gua francesa definen las capa- cidades para expresarse oral- La metodología elaborada en el marco de la educación en mente que pueden adquirirse con la utilización de la radio e, medios parece incluso permitir la inclinación de la sociedad incluso, se propone fomentar de la información hacia una sociedad del conocimiento, como defiende la UNESCO. En Francia, se necesitaría unir el interés por la lectura a través de la lectura de la prensa. La educación en los medios las fuerzas dispersas en función de los soportes mediáticos y orientarse más hacia la educación en medios que al dominio adquiere pleno derecho y entidad en la sección sexta titulada «competencias sociales y cívi- técnico de los aparatos. cas» que indica que «los alum- nos deberán ser capaces de juz- gar y tendrán espíritu crítico, lo que supone ser educados en los las programaciones oficiales, ya que, a lo largo de un medios y tener conciencia de su lugar y de su influencia estudio de los textos, los documentalistas del CLEMI en la sociedad». han podido señalar más de una centena de referencias a la educación de los medios en el seno de disciplinas 4. Un entorno positivo como el francés, la historia, la geografía, las lenguas, Si nos atenemos a las cifras, el panorama de la las artes plásticas : trabajos sobre las portadas de educación en medios es muy positivo. Una gran ope- prensa, reflexiones sobre temas mediáticos, análisis de ración de visibilidad como la «Semana de la prensa y publicidad, análisis de imágenes desde todos los ángu- de los medios en la escuela», coordinada por el CLE- los, reflexión sobre las noticias en los países europeos, MI, confirma año tras año, después de 17 convocato- información y opinión rias, el atractivo que ejerce sobre los profesores y los Esta presencia se constata desde la escuela mater- alumnos. Concebida como una gran operación de nal (2 a 6 años) donde, por ejemplo, se le pregunta a complementariedad source of circulating FGF-21. The lack of association between circulating and muscle-expressed FGF-21 also suggests that muscle FGF-21 primarily works in a local manner regulating glucose metabolism in the muscle and/or signals to the adipose tissue in close contact to the muscle. Our study has some limitations. The number of subjects is small and some correlations could have been significant with greater statistical power. Another aspect is that protein levels of FGF-21 were not determined in the muscles extracts, consequently we cannot be sure the increase in FGF-21 mRNA is followed by increased protein expression. In conclusion, we show that FGF-21 mRNA is increased in skeletal muscle in HIV patients and that FGF-21 mRNA in muscle correlates to whole-body (primarily reflecting muscle) insulin resistance. These findings add to the evidence that FGF-21 is a myokine and that muscle FGF-21 might primarily work in an autocrine manner. Acknowledgments We thank the subjects for their participation in this study. Ruth Rousing, Hanne Willumsen, Carsten Nielsen and Flemming Jessen are thanked for excellent technical help. The Danish HIV-Cohort is thanked for providing us HIV-related data. 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(2010) Serum FGF21 levels are elevated in association with lipodystrophy, insulin resistance and biomarkers of liver injury in HIV-1-infected patients. AIDS 24: 2629–2637. PLOS ONE | www.plosone.org 7 March 2013 | Volume 8 | Issue 3 | e55632
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