Changes in hospitalization associated with introducing the resident assessment instrument

Vincent Mor, Orna Intrator, Brant E. Fries, Charles Phillips, Joan Teno, Jeffrey Hiris, Catherine Hawes, John Morris

Research output: Contribution to journalArticle

117 Citations (Scopus)

Abstract

OBJECTIVE: To compare the rates of hospitalization among cohorts of nursing home residents assembled before and after the implementation of the federally mandated Resident Assessment Instrument (RAI). SAMPLE: Subjects were nursing home residents chosen from 268 facilities in major Metropolitan Statistics Areas in 10 states and representing more than 1500 facilities and 60,000 residents. Two resident cohorts (1990 and 1993) were sampled (8 to 16 residents per facility, depending upon facility size) as part of an evaluation of the impact of implementing the RAI. METHODS: Research nurses reviewed records, interviewed staff, observed patients, and completed an RAI at baseline and 6 months later. All transitions during this interval (hospital admissions, nursing home transfers, returns home, death, etc.) were tracked. Using polytomous logistic regression, we tested the effect of cohort on the probability of being hospitalized in light of the competing risks of dying or remaining in the home, controlling for demographic and case-mix variables, and having a DNR order in the chart. RESULTS: A total of 4196 residents were studied, 2118 in 1990 (age 81.3, female 77.7%, LOS 6+ months 49.8%) and 2078 in 1993 (age 81.7, females 75.5%, LOS 6+ months 50.2%). The unadjusted probability of hospitalization dropped from .205 to .151. Multivariate analyses revealed a significant adjusted odds of hospitalization of .74 (95% CI .60-.91) and no cohort effect on home discharge or death. Among severely cognitively impaired residents, the adjusted odds of hospitalization in 1993 compared with the 1990 cohort was 0.74 (.53-1.03). Finally, among survivors in both cohorts who had a follow-up MDS performed, and whose ADL remained stable, 15.9% were hospitalized in 1990, whereas only 10.9% were hospitalized in 1993. On the other hand, ADL decliners were more likely to have been hospitalized in 1993 than in 1990 (40.6% vs 25.2%). CONCLUSIONS: Although other changes in the industry, clinical practice, and health care policy may have influenced hospitalization of nursing home residents, the substantial reductions observed among the cognitively impaired and those with stable ADL suggest superior and uniform assessment information in the form of the RAI contributed significantly to this decline.

Original languageEnglish (US)
Pages (from-to)1002-1010
Number of pages9
JournalJournal of the American Geriatrics Society
Volume45
Issue number8
DOIs
StatePublished - Jan 1 1997
Externally publishedYes

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Nursing Homes
Hospitalization
Activities of Daily Living
Cohort Effect
Diagnosis-Related Groups
Health Policy
Survivors
Industry
Multivariate Analysis
Logistic Models
Nurses
Demography
Delivery of Health Care
Research

ASJC Scopus subject areas

  • Geriatrics and Gerontology

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Changes in hospitalization associated with introducing the resident assessment instrument. / Mor, Vincent; Intrator, Orna; Fries, Brant E.; Phillips, Charles; Teno, Joan; Hiris, Jeffrey; Hawes, Catherine; Morris, John.

In: Journal of the American Geriatrics Society, Vol. 45, No. 8, 01.01.1997, p. 1002-1010.

Research output: Contribution to journalArticle

Mor, Vincent ; Intrator, Orna ; Fries, Brant E. ; Phillips, Charles ; Teno, Joan ; Hiris, Jeffrey ; Hawes, Catherine ; Morris, John. / Changes in hospitalization associated with introducing the resident assessment instrument. In: Journal of the American Geriatrics Society. 1997 ; Vol. 45, No. 8. pp. 1002-1010.
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AU - Mor, Vincent

AU - Intrator, Orna

AU - Fries, Brant E.

AU - Phillips, Charles

AU - Teno, Joan

AU - Hiris, Jeffrey

AU - Hawes, Catherine

AU - Morris, John

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N2 - OBJECTIVE: To compare the rates of hospitalization among cohorts of nursing home residents assembled before and after the implementation of the federally mandated Resident Assessment Instrument (RAI). SAMPLE: Subjects were nursing home residents chosen from 268 facilities in major Metropolitan Statistics Areas in 10 states and representing more than 1500 facilities and 60,000 residents. Two resident cohorts (1990 and 1993) were sampled (8 to 16 residents per facility, depending upon facility size) as part of an evaluation of the impact of implementing the RAI. METHODS: Research nurses reviewed records, interviewed staff, observed patients, and completed an RAI at baseline and 6 months later. All transitions during this interval (hospital admissions, nursing home transfers, returns home, death, etc.) were tracked. Using polytomous logistic regression, we tested the effect of cohort on the probability of being hospitalized in light of the competing risks of dying or remaining in the home, controlling for demographic and case-mix variables, and having a DNR order in the chart. RESULTS: A total of 4196 residents were studied, 2118 in 1990 (age 81.3, female 77.7%, LOS 6+ months 49.8%) and 2078 in 1993 (age 81.7, females 75.5%, LOS 6+ months 50.2%). The unadjusted probability of hospitalization dropped from .205 to .151. Multivariate analyses revealed a significant adjusted odds of hospitalization of .74 (95% CI .60-.91) and no cohort effect on home discharge or death. Among severely cognitively impaired residents, the adjusted odds of hospitalization in 1993 compared with the 1990 cohort was 0.74 (.53-1.03). Finally, among survivors in both cohorts who had a follow-up MDS performed, and whose ADL remained stable, 15.9% were hospitalized in 1990, whereas only 10.9% were hospitalized in 1993. On the other hand, ADL decliners were more likely to have been hospitalized in 1993 than in 1990 (40.6% vs 25.2%). CONCLUSIONS: Although other changes in the industry, clinical practice, and health care policy may have influenced hospitalization of nursing home residents, the substantial reductions observed among the cognitively impaired and those with stable ADL suggest superior and uniform assessment information in the form of the RAI contributed significantly to this decline.

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