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How computers will keep tabs on nursing homes someday.

Today, the nursing home fields is on the verge of a revolution in quality assessment: the use of OBRA's basic care planning tool, the MDS, in computerized outcome studies. If done properly, these promise to offer nursing homes (and, yes, their regulators) an unprecedented amount of information on which facilities really are high-quality performers, which are not, and what the laggards have to do to catch up. Nursing homes with computerized clinical data systems already have the technology they need to implement this, it's just a matter (no small matter!) of getting it organized. Many nursing homes, though, might be excused for feeling alarm at this, particularly considering the regulatory environment in which they function these days. But outcome studies could, in fact, prove to be good news for nursing homes, suggests Barty Fogel, MD, in this interview with NURSING HOMES Editor Richard L. Peck. Dr. Fogel, who is with Brown University's Center for Gerontology and Health Care Research, and is a pioneering investigator in nursing home outcome studies, explains how this computerized data can, and should, be used.

Peck: Would you briefly describe the state-of-the-art of computerized outcome studies for the nursing home?

Dr. Fogel: Right now these are being done in the research and demonstration context. Certain prominent facilities, such as Boston's Hebrew Rehabilitation Center for the Aged, are doing this, but that's because one of the developers of the MDS is a researcher there. A couple of nursing homechains--notably, the national Health Corporation of Tennessee--are doing this, and HCFA's Multi-State Case-mix Reimbursement project involving nursing homes in six states is developing data for outcome studies. Generally, though, the facilities that I have visited are not set up to do this yet. In fact, their implementation of the MDS for care planning itself is quite widely variable from facility-to-facility.

Peck: Still, for nursing homes that might be interested in developing outcome studies using their computerized clinical data systems, how might they proceed?

Dr. Fogel: One way would be to organize into a consortium of nursing homes feeding the data to someone with expertise in developing studies comparing their performance and identifying high-quality care. Nursing homes will have to collect the MDS data in a comparable manner so that the comparative studies will means something. Several colleagues and I are, in fact, developing just such a consortium approach which we plan to make available to nursing homes in the near future.

As for individual nursing homes doing this on their own, though I question whether the smaller facilities -- say, 50 to 80 beds -- would be able to amass sufficient useful data for valid outcome results, there are possibilities for monitoring outcomes for very common problems. The facility would have to make sure that the studies are appropriately designed, and that if the facility's case mix changes markedly over time, appropriate adjustments are made.

Peck: What are ways in which individual nursing homes might use such studies?

Dr. Fogel: You need to have a clear idea as to what you want to measure, at what interval, and toward what goals. For example, you might look at how you are implementing the MDS mood scale and RAP for depression. How many residents with symptoms are receiving treatment? What sorts of treatment do they receive, and how often? Which treatments are producing improvement? Or you could track your incontinence assessment procedures: Which residents received RAPs? What follow-up procedures are used and how often? What effect did assessment and care planning have in reducing incontinence?

Peck: You have indicated in other research that you have done that these outcome studies must be interpreted cautiously, and that they have the potential for being seriously misinterpreted. Would you elaborate on that?

Dr. Fogel: The key thing to remember is that MDS analyses focus on outcomes, not on processes. If the outcomes are good, we have to take a close look at the processes, rather than make assumptions about them.

I'll explain. Much of the geriatric literature emphasizes that long-acting benzodiazepines are not recommended for the elderly, to the risk of drug accumulation and drug-related falls. Yet this does not necessarily mean that geriatric patients receiving long-acting benzodiazepines are getting poor care. It depends on the patient's function. I know of a man in his 80s still playing competitive tennis even though he has been on Valium for some time. If the patient is functioning well with such a drug, there really is no problem.

This raises the question: Why was the patient given such-and-such a drug? It could be that this is the best drug to give for the patient's particular indication, if he or she can tolerate it.

In preliminary work, we found that some nursing home residents on the anti-depressant amitriptyline (Elavil) -- which many experts tell us is contraindicated because it is so sedating -- were actually doing better -- were more active and independent -- than residents on the supposedly preferable alternatives. Similarly, we found some patients doing better on thioridazine Mellaril) than on haloperidol (Haldol), even though many authorities prefer Haidol in the elderly. The key to this finding was the activities section of the MDS which allowed comparison of residents' spontaneous activity levels, controlling for ADL status.

The question is raised (though it hasn't been answered, as yet): Was this, in fact, rational prescribing -- that is, residents receiving the medications that the physician knew worked best for them? Or was it a matter of the physician's prescription happening to be a fortunate one?

This is where I think the OBRA regulations for prescribing didn't go far enough. They require the physician to justify use of a drug, but they don't require the physician to supply the reasons for the prescription -- the symptoms, for example, he or she was trying to address. Use of haloperidol may be justifiable, but if the patient loses all mobility and initiative, its use is probably not appropriate in that case. And if the patient on thioridazine goes from being totally dependent and agitated to completely independent in all ADLs, you have suspect it was helpful, no matter what the regulations say.

The conservative interpretation of all this is that the "bad" drugs may not be bad for everyone, and you have to respect individual differences. If the physician truly is individualizing treatment for the patient's good, outcome studies will show it. Likewise, if the claim of individualized treatment is really a cover-up for sloppy care, outcome studies will show that, too.

Peck: So, in essence, by focusing on outcome rather than process, such studies may yield a great deal of information about what really constitutes quality care.

Dr. Fogel: That's the point. In doing this, perhaps we can move away the micromanagement of the process of care, which is the more typical approach today.
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Title Annotation:interview with Barry Fogel
Author:Peck, Richard L.
Publication:Nursing Homes
Article Type:Interview
Date:Jan 1, 1993
Previous Article:Computerization: where do we go from here?
Next Article:Medicolegal liability and clinical software.

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