ICELANDIC NURSING HOME RESIDENTS: THEIR MORTALITY, HEALTH, FUNCTIONAL PROFILE, AND CARE QUALITY, USING THE MINIMUM DATA SET OVER TIME

Sammanfattning: The overall aim of this thesis was to investigate trends over time in residents’ health status, functional profile and predictors of mortality at admission to Icelandic nursing homes and in addition to determine upper and lower thresholds for Minimum Data Set (MDS) Quality Indicators, to investigate the prevalence of quality indicators over time and their association with the health status and functional profile of residents in Icelandic nursing homes. Studies I and II included 2,206 persons assessed over 11 years (1996-2006). In study III a modified Delphi method and a panel of 12 members were used to determine the thresholds for Minimum Data Set Quality Indicators. Data from residents (N=2,247 representing 47 nursing homes) were analysed, applying the thresholds developed. In study IV the sample was 11,034 MDS assessments of 3,694 residents (2003-2009) and in the framework the sample was 11,912 MDS assessments of 3,704 residents (1999-2009). Study I showed that 28.6-61.4% of residents had intact cognitive performance and 42.5-68% were independent in ADL performance. A weak, but significant, linear trend over the eleven years was seen in residents' health becoming less stable, their cognitive performance improving, more pain being reported and greater participation in social activities. Study II showed that the median survival time was 31 months. No significant difference was detected in the mortality rate between cohorts. Age, gender (HR 1.52), place admitted from (HR 1.27), ADL functioning (HR 1.33-1.80), health stability (HR 1.61-16.12) and ability to engage in social activities (HR 1.51-1.65) were significant predictors of mortality. In study III upper and lower thresholds for 20 Minimum Data Set Quality Indicators were established. Residents not having a quality indicator present numbered from 32.5-99.3% depending on the indicator in question. The quality indicators with the median value above the upper threshold, indicating poor care, were: depression (49.4%); symptoms of depression without antidepressant (18.2%); use of 9 or more medications (63.8%); anti-anxiety or hypnotic drug use (69.2%); little or no activity (52.5%). Findings from study IV showed that 16 out of 20 quality indicators increased in prevalence, indicating a decline in quality of care (p< 0.05) over the study period. In 12 out of 20 indicators the prevalence was lower than 25%. One quality indicator showed improvement, i.e. ‘Bladder and bowel incontinence without a toileting plan’ from 17.4% in 2003 decreasing to 11.5% in 2009 (p<0.001). Residents’ health and functional status partially explained the increased prevalence of the quality indicators over time. At admittance many residents had a relatively high level of independence, the mortality rate did not change over the study period and health stability and ADL performance were strong predictors of mortality. More than 50% died within 3 years, and almost a third of the residents may have needed palliative care within a year of admission. Pain management, social engagement and palliative care are areas where more staff knowledge seems to be needed. The thresholds established aims for Icelandic nursing homes, uncovering areas of care requiring improvement. Icelandic nursing homes seem to be doing best in handling incontinence and nutritional care, and in several quality indicators the prevalence was quite low. The areas of care that indicated poor care and needed improvement included treatment of depression, number of medications and resident activity level. Quality Indicator results and trends over time can be used for improvement, planning of services and staff knowledge.