Dossier n. 237/2014 [Abstract] Evaluation of the feasibility, accuracy and transferability of an integrated system for measuring quality of care in residential facilities for the elderly

An inter-regional research project called “Validation of an integrated and multidimensional set of quality ed equity oriented indicators, feasible and transferable to the national health service” was funded in 2010 by the Italian Center for diseases control and prevention (CCM - Centro controllo delle malattie del Ministero della salute). The Health and Social Regional Agency of the Emilia-Romagna has contributed with the Operating Unit 2 “Evaluation of the feasibility, accuracy and transferability of an integrated system for measuring quality of care in residential facilities for the elderly”. The aim was to evaluate the feasibility of a set of indicators for measuring quality of care, through harmonizing indicators already in use in five Local Health Trusts (LHTs) of Emilia-Romagna and evaluating indicators based on the regional administrative databases.

Forty six long-term care residential facilities were included in the study, located in five LHTs, ad accounting for 2.904 accredited beds and 417 non accredited beds overall. All facilities recorded a set of 10 indicators related to five dimensions perceived as priority (pressure ulcers, falls, urinary catheter, physical restraint, bath care) for a six months period (1 March - 31 August 2012). All the data for the indicators were obtained through the systems already in use among the participating LHTs: electronic information systems in two LHTs, ad hoc data collection in three LHTs. In the winter 2011-2012 a point prevalence study was conducted (in 38 facilities of the participating 46) aimed at collecting data on healthcare associated infections and antimicrobial use.

Indicators based on ad hoc collected data were integrated with additional indicators based on the analysis of the regional administrative databases: information system on elderly residential facilities (FAR- Flusso Assistenza Residenziale), hospital discharge forms (SDO - Scheda di Dimissione Ospedaliera), information systems on drug use in hospital, in the community and at hospital discharge (AFO, AFT, FED). Based on these databases, the following indicators were calculated: the general hospital admission rates, the avoidable hospital admissions rates, the mortality rate, the proportion of elderly deceased in the facility or in hospital, the overall drug use and that for specific categories of drugs. FAR was used to describe the characteristics of residents in the residential facilities (through a factorial analysis) and to identify cluster of facilities similar for their case-mix (through a cluster analysis).

On average, 17% of residents in the participating facilities developed a pressure ulcer (LDP) (acquired in the facility or in hospital), 8.3% of the residents acquired a LDP in the facility, but 56% of the residents were at high risk for LDP; 26% of the residents had a urinary catheter, 42% physical restraint (excluding bed rails); 13% of the residents fell, 3% had a fell associated with clinical consequences. On average, residents took four baths every month.

For all these indicators a significant variability across LHTs and facilities was detected: the indicators with the greatest variability (according to the variation coefficient) were total LDP per 1.000 days of residence (variation coefficient - CV 108) and facility-acquired LDP (both per 100 residents - CV 102,6 - and per 1,000 days of stay - CV 90,7); a significant variability was detected also for falls associated to clinical consequences (both per 100 residents - CV 107,5 - and per 100 days of stay - CV 132).

The prevalence of healthcare associated infections was 6% (158 infected residents of 2,695 studied residents) and that of systemic antibiotic use was 5% (131 residents treated with a systemic antimicrobial the days of the study). 56% of the infections involved the respiratory tract, followed by urinary tract infections (15%) and skin infections (13%). 91.5% of the antimicrobials were prescribed to treat an infection. For these two measures a significant variability among facilities was detected as well.

The hospital admission rate was 30.4/100 residents in the participating facilities (33.5/100 in residents of facilities in the whole Emilia-Romagna region); 10.9% of hospital admissions were repeated admissions in a 30-days period and 3.3% in a 7 days period. The hospital admission rate varied from 24.9% in one LHT to 45% in another LHT among the participating 5 LHTs. The proportion of hospital admissions considered as avoidable varied from 12.2% in one LHT to 19.9% in another among the participating 5 LHTs.

19.3% of the residents in the 49 facilities died in 2011 (19.5% of the institutionalized residents of the whole Emilia-Romagna Region): 60.4% of the deaths were in the facility, 10.7% in the facility but within 30 days from hospital stay, 28.8% in hospital. The proportion of institutionalized elderly dying in hospital varied from 21.6% in one LHT to 36.5% in another.

The drug consumption varied significantly both overall and for specific drug categories: the ranking of the first 10 categories of prescribed drugs per LHT show as in some LHT the most prescribed drugs are antithrombotics, in others diuretics. In some LHTs, psycholeptics and psychoanaleptics are located at the 4th or 5th rank, in other at the 8th.

Indicators of quality of care significantly varied in relation to the residents’ characteristics also: in the facilities characterized by a short length of stay and clinically complex residents the consumption of drugs was highest, as well as the exposure to urinary catheter and the rate of pressure ulcers per 1,000 days of stay. The hospital admission rate was lower in facilities characterized by non-autonomous long-stay residents.

In conclusion, the project has contributed to highlight the followings:

• some quality of care dimensions were perceived as critical by all the LHTs which have initiated quality of care monitoring activities;
• the monitoring of these dimensions is feasible in the practice, using different methodologies for data collection;
• the regional databases may be linked and used for monitoring the care profile of the residents of long term care facilities for the elderly; in particular:
• the link between FAR and SDO allows to monitor the rate of hospital admissions and that for avoidable hospital admissions;
• the link between FAR and drug use information systems allows to monitor the consumption of drugs, in general and for specific drug categories, such as psychodrugs;
• a dimension of quality of care, frequently undervalued, is the problem of healthcare associated infections and antimicrobial resistance in long-term care facilities, which is a frequent and relevant public health problem, needing specific intervention.