Specialization in Nursing Home Care

疗养院护理专业

• 批准号: 9217536
• 负责人: DAVID C GRABOWSKI
• 金额: $ 27.8万
• 依托单位: HARVARD MEDICAL SCHOOL
• 依托单位国家: 美国
• 财政年份: 2015
• 资助国家: 美国
• 起止时间: 2015-02-15 至 2019-01-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9217536
• 关键词: Acute; Antidepressive Agents; Caring; Characteristics; Chronically Ill; Communities; Data; Data Set; Dementia; Exhibits; Growth; Health; Health Services Research; Healthcare; Home Nursing Care; Home environment; Hospitals; Impaired cognition; Impairment; Lead; Learning; Literature; Long-Term Care; Medicare claim; Mental Health; Mental disorders; Methods; Nursing Assessment; Nursing Homes; Outcome; Patients; Persons; Policies; Population; Prevalence; Procedures; Process Measure; Provider; Quality Indicator; Quality of Care; Randomized; Research; Research Personnel; Scientist; Series; Testing; Time; Variant; Vulnerable Populations; care seeking; disadvantaged population; experience; functional disability; functional improvement; high standard; improved; improved outcome; instrument; interest; medical specialties; public health relevance; severe mental illness; social; study population

DESCRIPTION (provided by applicant): Historically, nursing homes were functionally similar, caring for impaired residents with a range of underlying health conditions largely drawn from the local community. Over time, however, homes have specialized in the treatment of particular types of chronically ill residents. In particular, some homes now specialize in the treatment of residents with dementia and/or severe mental illness. This specialization occurs both by treating a high volume of residents with these conditions and also through dedicated units and facilities. The literature to date on specialization in nursing home care has largely been confounded by differential selection into more and less specialized settings. The type of resident who is admitted to a dementia special care unit (SCU), for example, may be quite different in many unobserved ways from the resident who is admitted to a non-SCU facility. If so, simple comparisons of quality of SCU and non-SCU settings, controlling for observable characteristics, may yield misleading estimates. When randomization is not feasible, as in this case, social scientists have applied instrumental variables methods to account for unobserved differences across study populations. One "instrument" that has been frequently and successfully used in health care, including in the PI's prior nursing home research, is the differential distance from the patient's home to different providers. Using instrumental variables methods, the research proposed here seeks to test hypotheses pertinent to the question of whether specialization by nursing homes in the treatment of mental illness or dementia improves outcomes. We focus on these two conditions because of their prevalence and the observed specialization by nursing homes in the treatment of these populations. Thus, these conditions provide an ideal opportunity to study the positives and negatives of nursing home specialization. In Aim 1, we investigate the within and between-facility variation in care for persons with dementia or mental illness in nursing homes. That is, across homes and within a home, do persons with dementia and mental illness receive comparable quality of care? Aim 2 focuses on the independent effect of specialization on quality. If specialization is associated with expertise, this specialization wll improve care, if it is associated with worse care being offered to a disadvantaged population, the effect of specialization will be negative. Aim 3 recognizes that the care of persons with mental illness or dementia may exhibit externalities. We quantify the spillovers in quality for car of other residents. In all three Aims, we focus on empirical indicators of quality of care, measured by process and outcome indicators, for both general and mental health care. We use the powerful national 1999-2011 Minimum Data Set (MDS) assessments of nursing home residents merged with Medicare claims data. By providing the best evidence to date on specialization in the treatment of residents with mental illness and dementia, this proposal has the potential to greatly improve the quality of care for the millions of residents with dementia an mental illness that will be treated in U.S. nursing homes in the coming decade.

描述（由申请人提供）：从历史上看，养老院在功能上是相似的，照顾受损的居民与一系列的基本健康状况主要来自当地社区。然而，随着时间的推移，疗养院专门治疗特定类型的慢性病患者。特别是，一些家庭现在专门治疗患有痴呆症和/或严重精神疾病的居民。这种专业化既通过治疗大量患有这些疾病的居民，也通过专门的单位和设施来实现。到目前为止，在疗养院护理专业化的文献在很大程度上被混淆的差异选择到更多和更少的专业设置。例如，入住痴呆症特别护理病房（SCU）的居民类型可能与入住非SCU设施的居民在许多未观察到的方面有很大不同。如果是这样，简单比较SCU和非SCU设置的质量，控制可观察到的特征，可能会产生误导性的估计。当随机化不可行时，如在这种情况下，社会科学家应用工具变量方法来解释研究人群中未观察到的差异。一个“工具”，已被频繁和成功地用于医疗保健，包括在PI的先前的疗养院研究，是从病人的家到不同的供应商的差异距离。使用工具变量的方法，这里提出的研究旨在测试相关的问题，是否专业化的疗养院在治疗精神疾病或痴呆症改善的结果的假设。我们专注于这两种情况，因为它们的患病率和观察到的专业化护理院在这些人群的治疗。因此，这些条件提供了一个理想的机会，研究养老院专业化的积极和消极的。在目标1中，我们调查了养老院中痴呆症或精神疾病患者的护理设施内和设施间的变化。也就是说，在不同的家庭和同一个家庭中，痴呆症和精神疾病患者是否得到了质量相当的护理？目标2侧重于专业化对质量的独立影响。如果专业化与专业知识有关，这种专业化将改善护理，如果它与向弱势群体提供的更差护理有关，专业化的效果将是负面的。目标3认识到，对精神病患者或痴呆症患者的护理可能具有外部性。我们量化了其他居民汽车质量的溢出效应。在所有三个目标，我们专注于护理质量的经验指标，衡量过程和结果指标，为一般和精神卫生保健。我们使用强大的国家1999-2011年最小数据集（MDS）评估养老院居民合并医疗保险索赔数据。通过提供迄今为止关于精神疾病和痴呆症患者治疗专业化的最佳证据，该提案有可能大大提高数百万痴呆症患者的护理质量，痴呆症是一种精神疾病，将在未来十年在美国疗养院接受治疗。