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Nursing home quality of care improved during the early 1990s

Based on a substantial decline in the rate of pressure ulcers experienced by nursing home residents, nursing home quality of care has improved, according to a study supported by the Agency for Healthcare Research and Quality (HS09768). Pressure ulcers are a standard measure of nursing home quality because avoiding these skin wounds requires coordinated care efforts to turn and take care of bedridden residents.

Pressure ulcers range from stage 1 (persistent area of skin redness that does not disappear when pressure, usually from the resident's mattress, is relieved) to stage 4 (severe and gaping wounds that expose muscle and/or bone). The study found that between 1991 and 1995, pressure ulcer rates declined by over 25 percent (after adjusting for patients' risk of developing ulcers).

The researchers evaluated pressure ulcer preventive care among residents in 107 nursing homes that were part of a for-profit nursing home chain operating in nine States. During the 5-year period, nurses assessed 30,510 nursing home residents (77 percent were women; average age 82.4) for the presence of pressure ulcers at admission, every 90 days in stable patients, and whenever there was a significant change in health status. Nearly 60 percent of residents had difficulty with bed mobility, and 69 percent needed help to transfer from their bed to a chair or other location. The nurses used the federally mandated Minimum Data Set (MDS) to record the results of their assessments. The MDS is a comprehensive resident assessment instrument that contains detailed information describing the clinical, behavioral, and socioeconomic status of residents.

The study revealed that the proportion of new stage 3 or 4 ulcers declined from 30 percent to 22 percent between 1991 and 1995, so ulcers in more recent years were less apt to be severe. Furthermore, it would have cost an estimated $800,000 to treat the 127 additional ulcers that would have occurred in this group of nursing home residents in 1995 if the rate had not changed since 1991. Finally, if these results are generalized to the more than 1.5 million nursing home residents across the Nation, they suggest that tens of thousands fewer patients are developing pressure ulcers each year. This demonstrates improved quality of care in nursing homes from 1991 to 1995, concludes principal investigator Dan R. Berlowitz, M.D., M.P.H., of Boston Medical Center and the Bedford VA Hospital.

Improving pressure ulcer care has long been a priority. AHRQ supported the development of two clinical practice guidelines in the early 1990s on the prevention and treatment of pressure ulcers. The authors of this study suggest that these guidelines may have contributed to the improvements in care they found.

See "Are we improving the quality of nursing home care? The case of pressure ulcers," by Dr. Berlowitz, Herminio Q. Bezerra, M.D., Gary H. Brandeis, M.D., and others in the January 2000 Journal of the American Geriatrics Society 48, pp. 59-62.

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