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Nursing Home Quality Measures: Do They Accurately Reflect Quality?
There are currently >17,000 nursing homes (NHs) in the United States, which cumulatively care for approximately 1.8 million residents.1 An NH is the last resort for patients whose cognitive abilities and function have declined as a result of multiple chronic and comorbid illnesses, such as long-standing diabetes mellitus, stroke, moderate to severe dementia, neurological diseases (eg, Parkinson’s disease), coronary artery disease, neuropathy, and chronic renal failure. Common reasons for NH admission include recurrent falls from deconditioning; moderate to severe dementia with abnormal behaviors, including sundowning; and the need for 24-hour care, which cannot be adequately met at home and is overwhelming for the caregiver. In many cases, indicators of end-stage diseases and syndromes are also present, including urinary or fecal incontinence, dysphagia, and total dependence on caregivers for activities of daily living (ADLs).2
Because NHs are recipients of Medicare and Medicaid funding, they are heavily regulated by the federal government and state agencies. Historically, these regulations have been implemented to ensure NH residents receive quality care. In 2004, the National Quality Forum (NQF; www.qualityforum.org), a voluntary consensus standards-setting organization, endorsed an initial set of nursing home quality measures, developed by the Centers for Medicare & Medicaid Services (CMS; www.cms.gov), for publicly reporting care in NHs. According to the NQF, it endorsed these quality measures because they provide patients and their families with reliable information on the quality of care being provided in skilled nursing facilities, enabling them to make informed decisions on where to go or send their loved ones for short- (length of stay ≤100 days) or long-term care (LTC; length of stay >100 days).3 The quality data derived from these measures provide information on the care experiences and general health of residents in NHs across the country. In June 2011, NQF endorsed CMS’s latest nursing home quality measures, which included 5 measures for short-stay residents and 12 measures for long-stay residents4; these measures are outlined in Table 1. In the spring of 2012, these measures will become the enhanced set of publicly reported quality measures available on Medicare’s Nursing Home Compare Website (www.medicare.gov/NHCompare). On the Website, five stars represents the highest quality care and one star represents the lowest quality care, enabling consumers to easily compare how the facilities they are interested in measure against the >17,000 NHs throughout the United States.
Medical directors of NHs should be quite familiar with the NH quality measures, as they regularly participate in executive-level and regularly scheduled quality improvement meetings. Practitioners who care for patients in the NH setting, however, may not be as familiar with them. This article provides a review of some of the latest NQF-endorsed NH quality measures, which are outlined in a CMS draft document dated May 20, 2011.5 Although these measures have not yet been finalized and more changes are anticipated this fall, these modifications are not expected to significantly change these quality indicators, which largely remain unrealistic. This article outlines deficiencies with some of the calculations CMS uses to determine quality care in the NH setting and explains how various measures could be fine-tuned to provide a more accurate reflection of care. The discussion includes recommendations on which variables should be used as the numerator (the term of a fraction, usually above the line, indicating the number of equal parts that are to be added together) and which should be used as the denominator (the term of a fraction, usually below the line, indicating the number of equal parts into which the unit is divided); see Table 2 . The major measures reviewed include falls and fractures, depressive symptoms, indwelling catheter use, urinary tract infections (UTIs), weight loss, pain, and pressure ulcers.
Falls and Fractures
Falls and fractures often are not preventable in an NH resident with multiple comorbid illnesses. A classic and common example of a resident for whom preventing falls is almost impossible is the resident with dementia and osteoarthritis with disuse atrophy of the lower extremities; cataracts, glaucoma, or another problem that impedes vision; and diabetic retinopathy.6 The prevalence of dementia and osteoarthritis in the frail elderly NH population ranges from 60% to ≥80%.7 Visual difficulties and diabetes are also common and often occur concomitantly. Because of the high prevalence of multiple morbidities in NH residents, the CMS measure of assessing the percentage of long-stay residents who experience one or more falls that leads to a major injury is unrealistic. A better quality measure may be the percentage of residents with falls who do not have an adequate care plan in place to prevent serious injuries during a fall, as noted by documentation in the chart. An adequate care plan for falls may include use of a low bed, placing a mat on the floor, establishing a toileting program, ensuring adequate lighting, reducing administration of antipsychotics, conducting an environmental assessment on admission and after each fall to assess for hazards, and providing bed and chair alarms. With an adequate care plan in place, the fact that a resident fell and even sustained a serious injury does not necessarily imply that the facility was at fault or should be penalized.8
Another problem with the CMS measure for falls is the exclusion criteria. Incidences of falls are excluded from the calculation if the fall occurrence was not assessed or the number of falls with major injury was not assessed. These exclusions potentially provide staff with an incentive not to assess falls, making the rationale for these exclusions unclear. CMS should further clarify these exclusion criteria to ensure they are not misunderstood or abused.
Depressive Symptoms
Depressive symptoms have been reported to occur in 12% of residents with major depression and in 30% of residents with minor, subsyndromal, or subthreshold depression, making it a fairly common problem in NHs.9,10 CMS’s proposed quality measure is the percentage of long-stay residents who have symptoms of depression during the 2-week period preceding the MDS 3.0 target assessment date.5 The problem with this measure is that it is too general, failing to take into account the reasons that the depressive symptoms are still present. For example, a patient may have refused to take an antidepressant or has recently been started on a new agent and is not yet benefiting from the drug’s full effects. Although it would be impossible to account for every factor that can affect depressive symptoms, pharmacological interventions are a crucial consideration. Therefore, a more accurate measure may be the percentage of residents during the evaluation period who have depressive symptoms, yet have not been offered antidepressant therapy or another intervention to treat their symptoms.
Indwelling Catheter Use
Some residents may require lifelong use of an indwelling catheter because of dilated uropathy from diseases in their end stages, such as multiple sclerosis, diabetes, and chronic musculoskeletal or neurological diseases. Other residents may have obstructive uropathy, yet are unable to receive operative intervention because of a high risk of postoperative complications. A common example of this is the older man who cannot undergo prostatic surgery to treat his benign prostatic hypertrophy because he has multiple chronic comorbid illnesses. While patients with obstructive uropathy and a neurogenic bladder are rightfully excluded from CMS’s quality measure regarding use of catheters, the measure implies that there is a problem with keeping catheters in the bladder5; however, removal of indwelling catheters when not indicated can result in stasis of urine, urosepsis, and obstructive uropathy.11 In addition, long-term catheter use may be necessary for patients with stage III or IV pressure ulcers until they heal; for patients who need input or output monitoring, such as those with congestive heart failure or dehydration; or for patients with a terminal illness. The CMS exclusion criteria for catheter use do not account for certain patient populations, like those who do not have a neurogenic bladder or obstructive uropathy, yet still require long-term catheter use. Therefore, instead of assessing the percentage of long-stay residents who have had a catheter inserted and left in their bladder for 7 days, a more appropriate quality measure may be the percentage of residents who should not have had their catheter removed. For this calculation, the numerator would include the number of patients who underwent a simple bedside assessment (ie, urinalysis, culture, and post-void residual urine determination) several hours after removal of their indwelling urinary catheter to determine whether removal was appropriate and, if so, received proper bladder training. A urological referral may be needed to make the determination.
Urinary Tract Infections
UTIs are the most common infection in the NH setting due in part to older age and waning immune defenses. In addition, sphincter laxity secondary to urethral or bladder obstruction from prostatic hyperplasia or other obstructing pathology is often associated with residual urine in the bladder after emptying, which increases the risk of UTI, even if the residual is below 200 cc. Sphincter laxity and the presence of bacteria beyond the urinary sphincter are common findings in the frail elderly, particularly women, whose urine may also be contaminated by vaginal flora. Other factors associated with an increased risk of UTI in older frail patients include alterations in certain neurotransmitters, immobility, use of medications that affect bladder emptying (eg, antispasmodics), and poor perineal hygiene.12 Therefore, development of a UTI in an older frail resident should not necessarily imply that he or she is receiving poor care, provided adequate perineal cleaning and hygiene are being administered. Instead of assessing the percentage of long-stay residents with a UTI,5 a better quality measure would be the percentage of residents with a UTI who did not receive regular perineal hygiene or catheter care (ie, changing) and for whom antibiotic treatment was not documented. However, caution is needed when factoring antibiotic treatment into the equation because the literature indicates that UTIs, bacteriuria, or the presence of significant pyuria should not be treated unless symptoms develop, as a means of preventing resistant organisms from emerging.12 The urinary incontinence guidelines of the AMDA–Dedicated to Long Term Care (AMDA) should be used to define UTI in the LTC setting. According to the guidelines, UTI is present if three of the following four conditions are met: (1) change in the character or color of the urine; (2) presence of back or suprapubic pain; (3) alteration in the level of consciousness; or (4) fever of 101°F.13
Weight Loss
Weight is one of the major indicators of nutritional status in NHs, with malnutrition being a common problem.14 Risk factors for malnutrition include advanced age, dysphagia, dementia, depression, and total dependence on staff for feeding. Weight loss and poor nutritional status in many cases may be unavoidable because of a terminal illness, carcinoma, failure to thrive, chronic infections (eg, HIV), or advanced dementia. The AMDA guidelines for altered nutritional status define unavoidable weight loss as weight loss that occurs despite an appropriate interdisciplinary care plan that includes these steps: (1) monitoring of food intake; (2) laboratory monitoring of serum albumin and prealbumin levels; (3) making nutritional and dietary recommendations; (4) supplementing intake with additional calories and protein whenever possible; (5) treating the chronic infection or a carcinomatous process to the extent possible; (6) addressing artificial means of nutritional intervention when applicable and documenting refusals by the resident or his or her family; (7) notifying the attending physician and family of all recommendations and their impact; (8) updating the care plan as necessary; and (9) documenting any changes in the chart.15 The problem with CMS’s quality measure regarding excessive weight loss is that it does not account for unavoidable weight loss. It focuses on determining the percentage of long-stay residents with weight loss ≥5% of body weight in 1 month or ≥10% of body weight in 6 months despite not being on a physician-prescribed weight-loss regimen.5 A more appropriate quality measure would be the percentage of long-stay residents with this level of weight loss who did not receive an adequate evaluation, re-evaluation, and work-up of their weight loss as per the AMDA guidelines for altered nutritional status.15
Pain
Chronic pain is common among NH residents and can be attributable to any number of causes, such as metastatic carcinoma, neuropathy, osteoarthritis, pressure ulcers, and muscle spasticity states. Pain can also be magnified by chronic anxiety and depression. Determining the cause of pain may be difficult in NH residents due to communication problems secondary to dementia, stroke, or other progressive neurological diseases; the complexity of the disease process being treated (eg, terminal carcinoma); the practice style and beliefs of the attending physician; and the beliefs of the resident and his or her family. An appropriate work-up for pain requires assessing patients to determine the cause(s) of their pain and implementing pharmacological and nonpharmacological interventions that are appropriate and in accordance with the AMDA chronic pain guidelines.16 CMS’s quality measure for pain in long-stay residents assesses the percentage of residents who reported almost constant pain or frequent episodes of moderate to severe pain in the 5 days preceding the MDS 3.0 target assessment date, or who reported any episode of severe or horrible pain during this same period. The problem with this measure is that uncontrolled pain in an NH resident does not always indicate that pain is not being addressed, as long as a care plan for pain control is in effect and being updated regularly. A more accurate quality measure may be the percentage of long-stay residents whose chronic pain has not been addressed through pharmacological and nonpharmacological interventions according to the AMDA chronic pain guidelines or who have not received a pain consultation. The quality measure also does not take into account hindrances that prevent the practitioner from adequately addressing pain in the NH setting, such as the current status of narcotic prescribing, which requires that prescriptions be written separately rather than just in the chart, necessitating additional time and supplies (eg, prescription pads) and contributing to the potential disruption and delay of care for the resident.17
Pain is one of the five quality measures for short-stay residents. For these residents, CMS proposes assessing the percentage of individuals who self-reported at least one episode of moderate to severe pain or any horrible or excruciating pain with any frequency in the 5 days preceding the MDS 3.0 target assessment date. Patients who are readmitted to the NH are not excluded from the assessment, despite being more likely to be using a pain medication to control moderate to severe pain from an acute illness or injury. A more appropriate quality indicator may be the percentage of short-stay residents with new-onset moderate to severe pain who are not provided with around-the-clock access to pain medications for breakthrough pain.
Pressure Ulcers
Residents at high risk for pressure ulcers include individuals with cognitive difficulties, mobility problems, altered nutritional status, sensory deficits, or urinary or fecal incontinence, and those on medications that may impair cognition. These residents are more likely to have progressive and irreversible clinical conditions, such as moderate to severe dementia, stroke, chronic spasticity, and other neurological conditions, making them totally dependent on caregivers for ADLs. The CMS quality measure seeks to capture the percentage of long-stay, high-risk residents with stage II to IV pressure ulcers, but this measure is misleading because it does not address the issue of unavoidability. Certain risk factors and disease processes prevent healing, including use of drugs such as steroids, resident noncompliance, sarcopenia, severe vascular compromise, terminal illness, metastatic cancer, multiple organ failure, and cachexia. Under such conditions a pressure ulcer may develop even though a facility has done all of the following: (1) evaluated the patient’s clinical condition and risk factors; (2) defined and implemented interventions consistent with patient needs and goals and recognized standards of practice; (3) monitored and evaluated the impact of these interventions; and (4) revised the approaches as appropriate. Therefore, instead of capturing the overall percentage of high-risk residents with pressure ulcers,5 a more appropriate quality indicator may be the percentage of residents with pressure ulcers for whom there was the lack of appropriate documentation to show that the ulcer was unavoidable and for whom there was also no care plan in place to prevent and treat the pressure ulcer.18
Pressure ulcers are also a quality measure for short-stay residents, with CMS assessing the percentage of short-stay residents with new or worsening stage II to IV pressure ulcers. After an extended complicated acute hospital stay, a significant number of short-stay residents may be admitted to the NH with pressure ulcers.18 In some cases, patients may have conditions that prevent healing, such as diabetes. Therefore, a more appropriate quality indicator may be the percentage of residents with new or worsening pressure ulcers during the evaluation period and no care plan in place for pressure ulcer prevention and treatment.
Concluding Thoughts
CMS’s quality measures have served as a point of contention in the LTC community. While consumers may find these measures useful, healthcare professionals caring for NH residents are frustrated by them because they are often unrealistic and counterproductive. In LTC, the philosophy of care is focused on mediating rather than curing disease, yet the revised quality measures do not seem to recognize that natural disease progression is often unavoidable in this population, and they have once again failed to capture realistic issues regarding geriatric syndromes and other clinical issues that plague LTC residents and their care providers on a daily basis. Because these issues are in the public domain, they will continue to haunt LTC providers and institutions, especially with regard to medicolegal risk. Rather than implementing the measures across the board, it would be more appropriate for CMS to engage in small grant-supported demonstration projects in several states to determine the validity and reliability of these new indicators. An alternative recommendation would be to enlist a subcommittee of American Geriatrics Society and AMDA representatives to encourage practicing clinicians and NH administrators to respond to CMS with appropriate modifications to these quality measures.
The author reports no relevant financial relationships.
Dr. Cefalu is professor and chief, Section of Geriatric Medicine, Louisiana State University Health Sciences Center, New Orleans, LA. He is also an Annals of Long-Term Care editorial advisory board member.
References
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