White Nursing Home Residents Research Articles

Geospatial Distribution of Racial Disparities in Influenza Vaccination in Nursing Homes

ObjectivesThis study aimed to assess the distribution of racial disparities in influenza vaccination between White and Black short-stay and long-stay nursing home residents among states and hospital referral regions (HRRs). DesignRetrospective cohort study. Setting and ParticipantsWe included short-stay and long-stay older adults residing in US nursing homes during influenza seasons between 2011 and 2018. Included residents were aged ≥65 years and enrolled in Traditional Medicare. Analyses were conducted using resident-seasons, whereby residents could contribute to one or more influenza seasons if they resided in a nursing home across multiple seasons. MethodsOur comparison of interest was marginalized vs privileged racial group membership measured as Black vs White race. We obtained influenza vaccination documentation from resident Minimum Data Set assessments from October 1 through June 30 of a particular influenza season. Nonparametric g-formula was used to estimate age- and sex-standardized disparities in vaccination, measured as the percentage point (pp) difference in the proportions of individuals vaccinated between Black and White nursing home residents within states and HRRs. ResultsThe study included 7,807,187 short-stay resident-seasons (89.7% White and 10.3% Black) in 14,889 nursing homes and 7,308,111 long-stay resident-seasons (86.7% White and 13.3% Black) in 14,885 nursing homes. Among states, the median age- and sex-standardized disparity between Black and White residents was 10.1 percentage points (pps) among short-stay residents and 5.3 pps among long-stay residents across seasons. Among HRRs, the median disparity was 8.6 pps among short-stay residents and 5.0 pps among long-stay residents across seasons. Conclusions and ImplicationsOur analysis revealed that the magnitudes of vaccination disparities varied substantially across states and HRRs, from no disparity in vaccination to disparities in excess of 25 pps. Local interventions and policies should be targeted to high-disparity geographic areas to increase vaccine uptake and promote health equity.

Preference Importance Ratings among African American and White Nursing Home Residents

ABSTRACT Objectives The Preferences for Everyday Living Inventory (PELI-NH) assesses psychosocial preferences of nursing home (NH) residents. This study explored the association of race with importance ratings of self-dominion preferences (i.e., preferences for control). Methods PELI-NH interviews were conducted with 250 NH residents. Tests of mean differences compared African American (n = 57) and White (n = 193) residents on demographic (age, gender, education, length of stay) and clinical attributes (self-rated health, depressive symptoms, anxiety, functional limitations, hearing, vision, cognition). Stepwise multiple regression accounted first for associations of demographic and clinical attributes then for the unique association of race with total importance of self-dominion preferences to determine whether African American and White residents differ. For between group demographic/clinical differences, interaction effects were tested. Results African Americans were younger and more functionally impaired. After accounting for the effects of gender (female), age (younger), anxiety (greater), and functional impairment (less) with higher reports of importance of self-dominion preferences, race was significant. There were no significant moderating effects. Conclusions African American residents reported greater importance of self-dominion preferences than Whites. Clinical Implications Cultural sensitivity is critical; it may be more important to provide opportunities for autonomous decision-making for African American than for White residents.

Racial Disparities in Care Interactions and Clinical Outcomes in Black Versus White Nursing Home Residents With Dementia.

With the increase in Black nursing home residents, racial and ethnic disparities in quality of care have been raised. The purpose of this study was to evaluate racial disparities in care and outcomes over 12 months. This was a secondary data analysis using data from the Evidence Integration Triangle for Behavioral and Psychological Symptoms of Dementia study. A total of 553 residents, 24% Black residents and 76% White residents, from 55 nursing homes were included. Differences favoring Black resident were noted in agitation, quality of life, inclusion of person-centered care approaches in care plans, and fewer falls and hospitalizations. Differences in quality-of-care interactions favored White residents. There were no differences in depression, resistiveness to care, function, pain, or transfers to the emergency department. Disparities in clinical outcomes were small and generally favored Black versus White residents except for quality-of-care interactions.

The Diagnosis of Schizophrenia Among Nursing Home Residents With ADRD: Does Race Matter?

To examine racial differences in the frequency of schizophrenia diagnosis codes used among nursing home (NH) residents with Alzheimer's Disease and Related Dementias (ADRD), pre and post the implementation of public reporting of antipsychotic use in NHs. The 2011-2017 Minimum Data Set and Medicare Master Beneficiary Summary File were linked. We identified long-stay NH residents (i.e., those who had quarterly or annual assessments) with ADRD aged 55 years and older (N=7,734,348). Outcome variable was defined as the diagnosis of schizophrenia documented in the MDS assessments. Main variables of interest included individual race (black versus white), the percent of blacks in a NH and time trend. Multivariate regressions were estimated. The frequency of schizophrenia diagnosis codes among NH residents with ADRD steadily increased over the study period, and blacks experienced a greater increase than their white counterparts. For example, the overall likelihood of having schizophrenia diagnosis increased 1.9 percentage points (95% confidence interval [CI]: 0.019, 0.020, p < 0.01) from 2011 to 2017 among whites, while blacks had an addition 1.3 percentage points increase (95% CI: 0.011, 0.015, p < 0.01). The increase in the likelihood of having schizophrenia diagnosis code was higher in NHs with higher percent of blacks: the increase from 2011 to 2017 was 2.6 percentage point (95% CI: 0.023, 0.029, p < 0.01) higher in NHs with the highest percent of blacks, compared to NHs with lowest percent of blacks. Racial differences in the growth of schizophrenia diagnosis also existed within a NH after accounting for NH factors. Following the implementation of public reporting of antipsychotic use in NH, black residents experienced a greater increase in the likelihood of having schizophrenia diagnosis than white NH residents. NHs with a higher proportion of blacks had a greater increase in schizophrenia diagnosis, and blacks experienced an increased likelihood of schizophrenia diagnosis than whites within a NH. Further research is needed to determine a causal relationship between the federal policy mandating public reporting and disparities in schizophrenia diagnostic coding.

Patterns of preference importance ratings among African-American and White nursing home residents

Background: The Preferences for Everyday Living Inventory (PELI) was developed to assess the psychosocial preferences of older adults receiving home care (PELI-HC) and then revised for nursing home residents (PELI-NH). While the PELI-HC has been tested to identify patterns in preference ratings by race, the PELI-NH has not. We sought to explore whether the PELI-NH tool captures differences in preference ratings of African-American and White NH residents. Methods: Preference assessment interviews were conducted with NH residents (n = 317). Analysis via a Mann-Whitney U test, results show that 46 of 72 (63.88%) a preference importance items were not statistically different between African-American and White NH residents. Additionally, African-Americans reported greater importance than White older adult NH residents in 26 of 72 (36%) preference importance items. Conclusion/Implications: It appears that the PELI-NH can test group differences in preference importance among African-American and White NH residents; implications for practice will be discussed. Part of a symposium sponsored by the Research in Quality of Care Interest Group.

From Micro to Macro: Exploring Preference-Based Person Centered Care from Multiple Perspectives

Advancing our knowledge related to honoring nursing home resident preferences is a cornerstone of person-centered care (PCC). While there are multiple approaches to providing PCC, we focus on resident preferences as assessed via the Preferences for Everyday Living Inventory (PELI). The PELI is an evidenced-based, validated instrument that can be used to enhance the delivery of PCC. In this symposium, we explore the perspectives of a variety of stakeholders including nursing home residents, staff, and the impact of preference-based care on provider level regulatory outcomes. First, we present a comparative study of preference importance among n=317 African America and White nursing home residents that found more similarities than differences between the two groups. Second, a content analysis of the responses from n=196 interviews with nursing home residents details the barriers and facilitators connected to their levels of satisfaction with their preferences being fulfilled. Third, perspectives from n=27 direct care workers explore the concept of pervasive risk avoidance to the delivery of PCC. Fourth, systems-level practices, such as shift assignments and provider schedules are identified as barriers to successfully fulfilling resident preferences from the perspectives of n=19 staff within assisted living. Our final presentation utilizes a fixed-effects panel regression analysis with n=551 Ohio nursing home providers to explore the impact of PELI use on regulatory outcomes such as substantiated complaints and deficiency scores reported in the CMS Nursing Home Compare data. Discussant Dr. Kristi Williams will integrate findings, highlighting implications for policy, practice, and future directions. Research in Quality of Care Interest Group Sponsored Symposium.

Challenges of Increased Diabetes Prevalence: Implications of Cardio and Renal Comorbidities for Hispanic and White Middle-Aged Nursing Home Residents Diagnosed with Diabetes in Texas, 1999 and 2009

Increased prevalence of diabetes and related comorbidities has emerged as a major challenge for community resilience in the United States. While attention has been directed towards the impacts of this development for the general population, the nursing home population has received little examination. This research analyzes change in the prevalence of particular cardio and renal comorbidities for Hispanic and Non-Hispanic White nursing home residents in Texas aged 50–64 diagnosed with diabetes for 1999 and 2009 using data from the federal Minimum Data Set. Comparisons are made by ethnicity and gender to identify trends and possible disparities. Important findings include that the prevalence of congestive heart failure increased for all groups, and the changes were statistically significant for Hispanic Women and Non-Hispanic White Men. Statistically significant differences were found in the prevalence of peripheral vascular disease as rates were higher for Hispanics of both genders for both years, indicating substantial and ongoing disparities. Disturbingly high rates for renal failure were found for Hispanics that indicate substantial disparities. Recommendations for meeting this challenge include emphasizing prevention measures and updating for models regarding the dynamics nursing home admission.

Non-Hispanic Black-White disparities in pain and pain management among newly admitted nursing home residents with cancer.

BackgroundRacial disparities in pain management persist across health care settings and likely extend into nursing homes. No recent studies have evaluated racial disparities in pain management among residents with cancer in nursing homes at time of admission.MethodsUsing a cross-sectional study design, we compared reported pain and pain management between non-Hispanic White and non-Hispanic Black newly admitted nursing home residents with cancer (n=342,920) using the de-identified Minimum Data Set version 3.0. Pain management strategies included the use of scheduled analgesics, pro re nata analgesics, and non-pharmacological methods. Presence of pain was based on self-report when residents were able, and staff report when unable. Robust Poisson models provided estimates of adjusted prevalence ratios (aPR) and 95% CIs for reported pain and pain management strategies.ResultsAmong nursing home residents with cancer, ~60% reported pain with non-Hispanic Blacks less likely to have both self-reported pain (aPR [Black versus White]: 0.98, 95% CI: 0.97–0.99) and staff-reported pain (aPR: 0.89, 95% CI: 0.86–0.93) documentation compared with Non-Hispanic Whites. While most residents received some pharmacologic pain management, Blacks were less likely to receive any compared with Whites (Blacks: 66.6%, Whites: 71.1%; aPR: 0.98, 95% CI: 0.97–0.99), consistent with differences in receipt of non-pharmacologic treatments (Blacks: 25.8%, Whites: 34.0%; aPR: 0.98, 95 CI%: 0.96–0.99).ConclusionLess pain was reported for Black compared with White nursing home residents and White residents subsequently received more frequent pain management at admission. The extent to which unequal reporting and management of pain persists in nursing homes should be further explored.

Analysis of Racial and Ethnic Disparities as Possible Risk Factors for Development of Incontinence by Nursing Home Residents.

Incontinence is a common health problem among nursing home (NH) residents. Differences between black and white NH residents in incontinence prevalence have been reported. Although reducing health disparities is a principal objective of the national health care agenda, little is known about disparities in incidence of new incontinence in NHs. The purpose of this study was to assess whether there were racial/ethnic disparities in the time to development of incontinence in adults over age 65 who had been continent on NH admission. If no racial or ethnic disparities in time to incontinence were found, other predictors of time to incontinence would be explored. Three national databases were sources of data on 42,693 adults over 65 admitted to 446 for-profit NHs in a national chain. Multi-level predictors of time to any type of incontinence were analyzed, using Cox proportional hazards regression for white Non-Hispanic NH admissions and the Peters-Belson method for minority NH admissions: American Indians/Alaskan Natives, Asians/Pacific Islanders, Black non-Hispanics, and Hispanics. No racial/ethnic disparities in time to incontinence were found. Approximately 30% of all racial/ethnic groups had developed incontinence by 6 months. Those who developed incontinence sooner were older and had greater deficits in activities of daily living (ADL) and cognition. Results were consistent with past evidence and suggest that interventions to maintain continence from the time of admission should be applied across racial/ethnic groups.

Racial Disparities in Receipt of Hospice Services Among Nursing Home Residents

This study examined the relationship between race and advance care planning, hospitalization, and death among nursing home residents receiving hospice care. Secondary data analysis using the 2007 Minimum Data Set (MDS) was used to identify documentation of these activities for White, Black, Hispanic, and Asian residents with linear regression models fitted to each dependent variable. Across different types of advance directives, compared to White nursing home residents, Black, Hispanic, and Asian residents who received hospice services were significantly less likely overall to have documented advance directives. All racial groups were also more likely to experience hospitalization while on hospice, regardless of whether they had a documented "do not hospitalize" order. As nursing homes become more diverse, recognizing differences in hospice use and end-of-life planning will continue to increase in importance.

Hospice use among urban Black and White U.S. nursing home decedents in 2006.

Medicare hospice is a valuable source of quality care at the end of life, but its lower use by racial minority groups is of concern. This study identifies factors associated with hospice use among urban Black and White nursing home (NH) decedents in the United States. Multiple data sources are combined and multilevel logistic regression is utilized to examine hospice use among urban Black and White NH residents who had access to hospice and died in 2006 (N = 288,202). In NHs, Blacks are less likely to use hospice than Whites (35.4% vs. 39.3%), even when controlling for covariates, interactions, and clustering of decedents in NHs and counties (adjusted odds ratio = 0.81, 95% confidence interval = 0.77-0.86). Variation in hospice use is greater among subgroups of Blacks than between Blacks and Whites, and these variations are predominantly due to individual-level factors, with some influence of NH-level factors. Hospice use is higher for Blacks versus Whites with do-not-resuscitate orders and lower for Blacks versus Whites with congestive heart failure (CHF). Additionally, hospice use is greater among Blacks with versus without do-not-resuscitate or do-not-hospitalize orders or cancer and those in low-tier versus other NHs. There was also lower hospice use among Blacks with versus without CHF. Efforts to reduce racial differences in hospice use should attend to individual-level factors. Heightening use of advance directives and targeting Blacks with CHF for hospice could be particularly helpful.

Pressure Ulcer Prevalence Among Black and White Nursing Home Residents in New York State

The occurrence of pressure ulcers (PUs) in nursing homes is a marker for poor quality of care. We examine whether differences in PU prevalence between black and white residents are due to within- or across-facility disparities. Minimum Data Sets (2006-2007) are linked with the Online Survey Certification and Reporting database. Long-term care residents with high risk for PUs are identified. The dependent variable is dichotomous, indicating PU presence/absence. Individual race and facility race-mix are the main variables of interests.The sample includes 59,740 long-term care high-risk residents (17.4% black and 82.6% white) in 619 nursing homes. We fit 3 risk-adjusted logit models: base, conditional fixed-effects, and random-effects. Unadjusted PU prevalence is 14.5% (18.2% for blacks and 13.8% for whites). Overall, blacks are more likely to have PUs than whites, controlling for individual risk factors. We find no such effect within facilities after additional accounting for facility fixed effects. The effect of race is significantly different between the base and the conditional fixed-effects logit model. The random-effects and conditional fixed-effects logit models show similar results, demonstrating that higher PU presence among blacks is associated with greater facility-specific concentration of black residents. Greater PU occurrence among blacks may not result from differential within-facility treatment of blacks versus whites. Rather, blacks are more likely to reside in facilities with poorer care quality. To improve PU care for blacks, efforts should focus on improving the overall quality of care for facilities with high proportion of black residents.

Influenza Vaccine in African‐American and White Nursing Home Residents: Is There a Gap?

Influenza Vaccine in African‐American and White Nursing Home Residents: Is There a Gap?

Religious Activities, Strength from Faith, and Social Functioning Among African American and White Nursing Home Residents

ABSTRACT This study explored the effects of having a preference for religious activities in the nursing home, and of drawing strength from faith on social functioning in a random sample of 1,595 White and 172 African American residents from 270 nursing homes. Nurses assessed residents using the Minimum Data Set (MDS). Utilizing Ordinary Least Squares (OLS) regression, in the sub-sample of Whites we found that activities of daily living (ADL), cognitive, and vision impairments, depression, and no contact with family or friends were negatively related to social functioning, while being female, preferring religious activities, and drawing strength from faith were positively related to social functioning. Among African Americans, we found that ADL, cognitive impairment, and depression were negatively related to social functioning, while religious activity preference and strength from faith were positively related to social functioning. Among Whites, faith moderated the negative effects of having no contact with family or friends and religious activity preference exacerbated the negative effects of cognitive impairment on social functioning. Among African Americans, faith moderated the negative effects of depression. These findings suggest that Durkheim's hypothesis of religion's influence on social solidarity is supported in the nursing home setting. The positive effects of religious activities and strength from faith operated primarily through a distress-deterrent model, but there was also some support for moderation effects. Theoretical, research design, and nursing home practice implications of the findings are discussed.

Environmental Contexts of Ultimate Decisions: Why White Nursing Home Residents Are Twice as Likely as African American Residents to Have an Advance Directive

The purpose of this study was to determine the extent to which observed differences between White and African American nursing home residents in having an advance directive are attributable to differences between the groups in personal characteristics, the organizational environment of the nursing home, and the geographical environment of the counties in which the nursing homes are located. By using the Medical Expenditure Panel Survey Nursing Home Component matched with county-level measures from the Area Resource File, we modeled the probability of having an advance directive as a function of nursing home resident, facility, and county characteristics for African American and White residents. The probability of having an advance directive was 27.0% for African American residents and 63.6% for White residents. Nearly half of this 36.6 percentage point gap could be explained by group differences in personal, facility, and county characteristics. County characteristics play a more prominent role than do personal or facility measures in explaining the observed ethnic gap in the prevalence of advance directives. Additional studies should focus further on geographic, health status, and attitudinal variations among nursing home residents that may account for the remaining ethnic difference in the prevalence of advance directives among nursing home residents.

Pressure Ulcer Prevention in Black and White Nursing Home Residents:

To determine if educating nursing home staff about pressure ulcer prevention reduces the differential risk of pressure ulcer development in black and white nursing home residents. Subanalysis of a study designed to monitor the emergence of all pressure ulcers in nursing home residents during 12-week baseline and intervention periods. All residents and staff of a not-for-profit, 136-bed nursing home in urban western Pennsylvania. The quality improvement intervention, featuring a computer-based interactive video education program on pressure ulcer prevention and early detection, consisted of 3 components: (1) staff ability enhancement, (2) staff financial incentives, and (3) real-time management feedback. Three specific outcome measures were monitored for differential risk of pressure ulcer development in black and white nursing home residents: (1) the rate of emergent Stage I-IV pressure ulcers identified, (2) the rate of emergent Stage II-IV pressure ulcers identified, and (3) the rate of individual residents developing at least 1 pressure ulcer (Stages II-IV). At baseline, black residents demonstrated a higher rate of Stage II-IV pressure ulcer emergence. Black residents with any pressure ulcer were also more likely to have multiple Stage II pressure ulcers compared with white residents. During the baseline period, 31.8% of the pressure ulcers detected in white residents were Stage I, whereas no Stage I pressure ulcers were detected in black residents. During the intervention period, the rate of emergence of all pressure ulcers declined for both groups in similar trends. Black residents were more likely to have multiple Stage II-IV pressure ulcers and were less likely to have Stage I pressure ulcers identified at baseline compared with white residents. The education intervention effectively reduced the rate of pressure ulcers for all residents and eliminated the racial disparity noted during the baseline period.

End-of-Life Hospitalization for African American and Non-Latino White Nursing Home Residents: Variation by Race and a Facility's Racial Composition

Hospitalization of nursing home residents at the end of life is common, more so among African Americans. Whether a nursing home's racial mix is associated with hospitalization is unknown. This study examined the association between race, a nursing home's racial mix, and end-of-life hospitalization. This was a retrospective cohort study. Studied were nursing home residents in New York (n = 14,159) and Mississippi (n = 1481) who died in 1995-1996 and had a minimum data set (MDS) assessment within 120 days of death. The outcome measure was the odds of hospitalization in the last 90 days of life. A variable reflecting a nursing home's proportion of African American residents (in 1995-1996) represented a nursing home's racial mix. Forty-six percent of African Americans and 32% of whites were hospitalized in the last 90 days of life. After controlling for demographics, diagnoses, function, patient preferences (do-not-resuscitate [DNR]), and facility resources, nursing home residents in facilities having higher proportions of African American residents had greater odds of hospitalization (adjusted odds ratio [AOR] 1.14; 95% confidence interval [CI] 1.10, 1.18 in New York and AOR 1.35; 95% CI 1.24, 1.46 in Mississippi). Age and frailty interacted with race; older African Americans had a 16% greater likelihood (95% CI 1.08, 1.24) of hospitalization, and African Americans with more functional limitations had a 37% (95% CI 1.24, 1.51) greater likelihood of hospitalization than did comparable whites. It appears higher end-of-life hospitalization rates for African American residents are attributable to the facilities where most reside, and to differential hospitalization of older or more functional limited residents.

Similarities and Differences in Depression Among Black and White Nursing Home Residents

Similarities and Differences in Depression Among Black and White Nursing Home Residents

Similarities and Differences in Depression Among Black and White Nursing Home Residents

The authors examined racial similarities and differences in depressive symptomatology, diagnosis, and the predictors of depression in four independent nursing homes, conducting analyses across all sites and separately for the nursing home with the greatest racial balance (NH4). All-site data indicated that white residents showed more depression than black residents. There were no racial differences in the depression diagnosis derived from a structured interview of DSM-III-R. At NH4, there were no statistically significant racial differences in any of the measures of depression. Across sites, functional disability was the strongest predictor of both Geriatric Depression Scale (GDS) and DSM-III-R diagnosis of depression in both blacks and whites. Cognitive impairment and use of antidepressants were predictive of medical chart diagnosis of depression across sites, but not of depression measured by GDS or DSM-III-R criteria. At NH4, functional disability was predictive of GDS depression, but only among whites. Age was not an important predictor of depression. Results indicate the importance of considering the method used to diagnose depression and the necessity of controlling for the nursing home setting when examining racial differences in depression.

Perspective: a molecular approach to tuberculosis control-- an idea that might work.

Perspective: a molecular approach to tuberculosis control-- an idea that might work.