U.S. Department of Veterans Affairs Public Access Author manuscript J Am Geriatr Soc. Author manuscript; available in PMC 2016 January 20. Published in final edited form as: J Am Geriatr Soc. 2016 January ; 64(1): 151–155. doi:10.1111/jgs.13879.
VA Author Manuscript
Longitudinal pressure ulcer rates since the adoption of culture change in Veterans Health Administration nursing homes Christine W. Hartmann, Ph.D.a,b, Michael Shwartz, Ph.D.c,d, Shibei Zhao, M.S.a, Jennifer A. Palmer, M.S.a, and Dan R. Berlowitz, M.D.a,b aCenter
for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, MA bDepartment
of Health Policy and Management, Boston University School of Public Health,
Boston, MA cCenter
for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA
VA Author Manuscript
dBoston
University School of Management, Boston, MA
Christine W. Hartmann, Ph.D. 200 Springs Road (152), Bedford, MA 01730, Phone: 781-687-2738; Fax: 781-687-2227, [email protected]. Jennifer A. Palmer, M.S. (alternate corresponding author), 200 Springs Road (152), Bedford, MA 01730, Phone: 781-687-2855; Fax: 781-687-3106, [email protected] Data were previously presented at the 2014 Gerontological Society of America Annual Scientific Meeting. Conflict of Interest Disclosures:
Elements of Financial/Personal Conflicts
*CWH
VA Author Manuscript
Yes
No
MS
Yes
SZ
No
Yes
JP
No
Yes
DB
No
Yes
No
Employment or Affiliation
X
X
X
X
X
Grants/Funds
X
X
X
X
X
Honoraria
X
X
X
X
X
Speaker Forum
X
X
X
X
X
Consultant
X
X
X
X
X
Stocks
X
X
X
X
X
Royalties
X
X
X
X
X
Expert Testimony
X
X
X
X
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Board Member
X
X
X
X
X
Patents
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X
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X
X
Personal Relationship
X
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Author Contributions: The corresponding author affirms that she has listed everyone who contributed significantly to the work. Hartmann: study concept and design; data collection, analysis, and interpretation; manuscript preparation. Shwartz: study concept and design; data analysis and interpretation; manuscript preparation. Zhao: data collection, analysis, and interpretation; manuscript preparation. Palmer: data collection; manuscript preparation. Berlowitz: study concept and design; data interpretation; manuscript preparation.
Hartmann et al.
Page 2
Abstract Objective—To examine facility-level pressure ulcer development rates and variations in these rates after a system-wide adoption of culture change in Veterans Health Administration (VHA) nursing homes.
VA Author Manuscript
Design—4-year retrospective longitudinal design. Setting—109 VHA facilities representing 132 nursing homes, known as Community Living Centers (CLCs). Measurements—Pressure ulcers were identified using FY08-11 Minimum Data Set (MDS) data. Pressure ulcer development was defined as a stage 2 or larger pressure ulcer on an MDS assessment with no pressure ulcer on the previous assessment. A risk adjustment model was developed using 105,274 MDS observations to predict the likelihood of pressure ulcers (c statistic = 0.72). A Bayesian hierarchical model that adjusted for differences in the precision of pressure ulcer rates from differently sized facilities was used to calculate smoothed risk-adjusted (SRA) rates for each facility. The statistical significance of the trend over the 4 years was determined by examining the 95% interval estimate for the slope.
VA Author Manuscript
Results—Over the 4 year period, the beginning of which coincided with the VHA’s system-wide adoption of culture change as a performance measure, median SRA facility pressure ulcer development rates were fairly consistent at approximately 4%. The range in SRA rates declined from 14.8% to 10.1%. Some facilities had significantly improving SRA rates (e.g., declined steadily from 5.5% to 3.9%) and some had significantly worsening SRA rates (e.g., increased steadily from 5.1% to 7.9%). Seven sites had significantly improving rates (p
VA Author Manuscript
Longitudinal pressure ulcer rates since the adoption of culture change in Veterans Health Administration nursing homes Christine W. Hartmann, Ph.D.a,b, Michael Shwartz, Ph.D.c,d, Shibei Zhao, M.S.a, Jennifer A. Palmer, M.S.a, and Dan R. Berlowitz, M.D.a,b aCenter
for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, MA bDepartment
of Health Policy and Management, Boston University School of Public Health,
Boston, MA cCenter
for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA
VA Author Manuscript
dBoston
University School of Management, Boston, MA
Christine W. Hartmann, Ph.D. 200 Springs Road (152), Bedford, MA 01730, Phone: 781-687-2738; Fax: 781-687-2227, [email protected]. Jennifer A. Palmer, M.S. (alternate corresponding author), 200 Springs Road (152), Bedford, MA 01730, Phone: 781-687-2855; Fax: 781-687-3106, [email protected] Data were previously presented at the 2014 Gerontological Society of America Annual Scientific Meeting. Conflict of Interest Disclosures:
Elements of Financial/Personal Conflicts
*CWH
VA Author Manuscript
Yes
No
MS
Yes
SZ
No
Yes
JP
No
Yes
DB
No
Yes
No
Employment or Affiliation
X
X
X
X
X
Grants/Funds
X
X
X
X
X
Honoraria
X
X
X
X
X
Speaker Forum
X
X
X
X
X
Consultant
X
X
X
X
X
Stocks
X
X
X
X
X
Royalties
X
X
X
X
X
Expert Testimony
X
X
X
X
X
Board Member
X
X
X
X
X
Patents
X
X
X
X
X
Personal Relationship
X
X
X
X
X
Author Contributions: The corresponding author affirms that she has listed everyone who contributed significantly to the work. Hartmann: study concept and design; data collection, analysis, and interpretation; manuscript preparation. Shwartz: study concept and design; data analysis and interpretation; manuscript preparation. Zhao: data collection, analysis, and interpretation; manuscript preparation. Palmer: data collection; manuscript preparation. Berlowitz: study concept and design; data interpretation; manuscript preparation.
Hartmann et al.
Page 2
Abstract Objective—To examine facility-level pressure ulcer development rates and variations in these rates after a system-wide adoption of culture change in Veterans Health Administration (VHA) nursing homes.
VA Author Manuscript
Design—4-year retrospective longitudinal design. Setting—109 VHA facilities representing 132 nursing homes, known as Community Living Centers (CLCs). Measurements—Pressure ulcers were identified using FY08-11 Minimum Data Set (MDS) data. Pressure ulcer development was defined as a stage 2 or larger pressure ulcer on an MDS assessment with no pressure ulcer on the previous assessment. A risk adjustment model was developed using 105,274 MDS observations to predict the likelihood of pressure ulcers (c statistic = 0.72). A Bayesian hierarchical model that adjusted for differences in the precision of pressure ulcer rates from differently sized facilities was used to calculate smoothed risk-adjusted (SRA) rates for each facility. The statistical significance of the trend over the 4 years was determined by examining the 95% interval estimate for the slope.
VA Author Manuscript
Results—Over the 4 year period, the beginning of which coincided with the VHA’s system-wide adoption of culture change as a performance measure, median SRA facility pressure ulcer development rates were fairly consistent at approximately 4%. The range in SRA rates declined from 14.8% to 10.1%. Some facilities had significantly improving SRA rates (e.g., declined steadily from 5.5% to 3.9%) and some had significantly worsening SRA rates (e.g., increased steadily from 5.1% to 7.9%). Seven sites had significantly improving rates (p
