Functional status decline as a measure of adverse events in home health care: an observational study.

Tanya Pollack Scharpf,John F P Bridges,Natalie Colabianchi,Timothy Peng,Penny H Feldman,Duncan Neuhauser,Elizabeth A Madigan

doi:10.1186/1472-6963-6-162

Abstract

BackgroundResearch that examines the quality of home health care is complex because no gold standard exists for measuring adverse outcomes, and because the patient and clinician populations are highly heterogeneous. The objectives in this study are to develop models to predict functional decline for three indices of functional status as measures of adverse events in home health care and determine which index is most appropriate for risk-adjusting for future quality research.MethodsData come from the Outcomes and Assessment Information Set (OASIS) from a large urban home health care agency and other agency data. Prognostic data yields 49,437 episodes, while follow-up data yields 47,684 episodes. We tested three indices defined as substantial decline in three or more (gt3_ADLs), two or more (gt2_ADLs), and one or more (gt1_ADLs) ADLs. Multivariate logistic regression determines the performance of the models for each index as measured by the c-statistic and Hosmer-Lemeshow chi square (χ2).ResultsFrequencies for gt3_ADLs, gt2_ADLs, and gt1_ADLs are 212 (0.43%), 783 (1.58%), and 4,271 (8.64%) respectively. Follow-up results are comparable with frequencies of 218 (0.46%), 763 (1.60%), and 3,949 (8.28%) for each index. Gt3_ADLs does not produce valid models. The model for gt2_ADLs consistently yields a higher c-statistic compared to gt1_ADLs (0.754 vs. 0.679, respectively). Both indices' models yield non-significant Hosmer-Lemeshow chi square indicating reasonable model fit. Findings for gt2_ADLs and gt1_ADLs are consistent over time as indicated by follow-up data results.ConclusionGt2_ADLs yields the best models as indicated by a high c-statistic and a non-significant Hosmer-Lemeshow χ2, both of which exhibit exceptional consistency. We conclude that gt2_ADLs may be preferable in defining ADL adverse events in the context of home health care.

Highlights

Research that examines the quality of home health care is complex because no gold standard exists for measuring adverse outcomes, and because the patient and clinician populations are highly heterogeneous
The end of a given episode of care is defined as the first discharge Outcomes and Assessment Information Set (OASIS) assessment occurring on or before 60 days following the start of the episode; if no discharge has occurred by 60 days, the closest OASIS assessment available at or before 60 days is used
Gt3_ADLs, which is based on the current Center for Medicare and Medicaid Services (CMS) definition of an activities of daily living (ADL) adverse event, was too conservative, yielding few episodes experiencing functional decline and numerous 'floor' episodes as compared to the alternative indices

Summary

Introduction

Research that examines the quality of home health care is complex because no gold standard exists for measuring adverse outcomes, and because the patient and clinician populations are highly heterogeneous. The objectives in this study are to develop models to predict functional decline for three indices of functional status as measures of adverse events in home health care and determine which index is most appropriate for risk-adjusting for future quality research. Research that examines the quality of home health care is complex because no gold standard exists for measuring adverse events, and because the patient and clinician populations are highly heterogeneous. As part of its outcomes based quality initiative, CMS identifies 13 potential adverse events for patients in home health care. The adverse events cover four main areas: emergency care, serious unexpected events, unmet care needs, and declines in health or physical functioning [3]

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