Developing a Set of Indicators to Assess End-of-Life Care in Massachusetts Nursing Homes: Final Report

Nursing homes are often the final residence for many people. Studies have estimated that as many as 20 to 25 percent of deaths due to chronic illness in the U.S. occur in nursing homes. In recognition of the trend of increasing utilization of nursing homes as a setting for the end of life, and the opportunities and challenges for end-of-life care in nursing homes, in July 2004, Commonwealth Medicine (a division of the UMass Medical School) awarded an internal grant to the study team to develop a set of indicators that can be used to assess and evaluate the appropriateness of end-of-life care for residents of nursing homes in Massachusetts. The indicators and the results of the analysis are a basis from which future research can be conducted, and from which quality improvement programs can be initiated. This report presents the project’s results. The project was guided by an advisory group of researchers, nursing home administrators, directors of nursing, geriatricians, advocates, and policy makers. First, a comprehensive literature review was conducted to inform the project. Second, a set of indicators were developed within seven domains of end of life care: 1) structure and processes of care; 2) physical and emotional aspects of care; 3) advanced care planning; 4) ethical and legal aspects of care; 5) aggressive care near death; 6) family satisfaction; and 7) provider continuity, skill, and satisfaction. Third, the indicators were prioritized by the advisory group using a structured prioritization process in order to determine which indicators had the most relevance to assessing end-of-life care in the nursing home setting. Fourth, baseline data were collected for a small set of indicators. Data were collected from Massachusetts Medicaid claims data and a family survey. A total of 44 indicators were developed in the seven domains. The indicators within each domain were prioritized and the results of the structured prioritization process are provided in the body of the report. Baseline data were collected for five of the indicators: death in hospital; overall hospice use; length of stay on hospice; total Medicaid resource use at the end of life; and family satisfaction. This project sets forth a slate of indicators that can be used by nursing homes, coalitions, community groups, state agencies, and researchers to evaluate the quality of end-of-life care in nursing homes. With long histories of providing care to this vulnerable population, nursing homes can be well-positioned in the future to provide symptom management, advance care planning support, appropriate care to the imminently dying, and emotional support to staff and other residents. However, nursing homes face many challenges to providing high-quality end-of-life care. With continuing attention on the strengths of nursing homes and the needs of dying residents, improvements in the processes of care and the policy environment to support high-quality end-of-life care are possible. Moreover, the indicators presented in this report can provide the critical tools in evaluating the success of future interventions to improve the end-of-life care for nursing home residents

The Use of “Effect Size” in Augmenting the Results of Significance Testing: A Comparison of Pre/Post Data from a Geriatric Interclerkship

Most research in medical education, when examining the impact of an intervention, report findings based primarily on significance testing despite the controversy of its appropriate use. Moreover, the p-value used to determine rejection or acceptance of the null hypothesis tells nothing about the magnitude of the significance. Using a pre/post assessment of a Geriatric Interclerkship as a case study, this study examines the utility of effect size measures in augmenting significance testing results. Presented at the AAMC (Association of American Colleges) Annual Meeting, RIME (Research in Medical Education) Program, November 2004

The Effectiveness of a Geriatrics Curriculum

With support from the AAMC/John A. Hartford Foundation the University of Massachusetts Medical School developed a Geriatrics curriculum and faculty development that would be integrated across all four years. Beginning in Fall 2001, these were implemented over the next two academic years in both preclinical and clinical areas and are highlighted on the timeline above. Would implementation of this new Geriatrics curriculum and faculty development impact students’ ratings of instruction time in Geriatrics? Presented at the AAMC (Association of American Colleges) Annual Meeting, RIME (Research in Medical Education) Program, November 2005

Nursing Students Teaching Medical Students: An Interdisciplinary Teaching Experience

For a number of years, Advanced Practice Nursing ( APN) students have taught interested 1st year medical students to perform intramuscular injections prior to their participation in community flu clinics. When several 4th year medical students needed documentation of competency in intravenous (IV) cannulation prior to participating in an elective rotation at another institution, the Director of Interdisciplinary Partnerships in the Graduate School of Nursing requested assistance from the medical school\u27s Dean of Students. In fact, all medical students need IV therapy training prior to graduation, not just those who seek out elective rotations at other medical schools. Integration of IV therapy training into the Undergraduate Medical Education Surgery Clerkship curriculum supports the clinical objectives of the Surgery Clerkship along with the developing use of simulation within the medical school. This need led to the development of this interprofessional simulation education initiative. Presented at the AAMC (Association of American Colleges) Annual Meeting, RIME (Research in Medical Education) Program, November 2008

Setting the Standard for a High-Stakes End of Third Year Assessment

Purpose: - Conduct modified Angoff standard setting procedure due to planned move to “high-stakes” End of Third Year Assessment (EOTYA) - Assess the result of applying cutoffs to EOTYA student performance data - Analyze judges’ perceptions and confidence in setting cutoffs for three skill areas across seven Objective Structured Clinical Examinations (OSCEs) Presented at the AAMC (Association of American Colleges) Annual Meeting, RIME (Research in Medical Education) Program, November 2007

Using a Targeted OSCE Station to Measure Unprofessional Behavior

Standardized patients are widely used in medical education but their use to assess professionalism is limited. With grant support from the Edward J. Stemmler, MD Medical Education Research Fund (“Stemmler Fund”) of the National Board of Medical Examiners (NBME), the usefulness of standardized patients (SPs) in the assessment of professional behavior was investigated. A targeted professionalism OSCE station featuring a values conflict was written. A professionalism instrument was developed and subsequently revised during the course of the study, with the final version containing various components of American Board of Internal Medicine (ABIM) core set of eight professionalism attributes and several other scales in recent medical research. Presented at the Ottawa Conference, 2006

Measuring Unprofessional Behavior During an 8-Station OSCE

Standardized patients (SPs) are widely used in medical education but their use to assess professionalism is limited. This study investigated the utility of SPs assessing unprofessional behavior during an annual end of third year Objective Structured Clinical Examination (OSCE). Presented at the AAMC (Association of American Colleges) Annual Meeting, RIME (Research in Medical Education) Program, November 2006

A Price Worth Paying: The Case for Controlling Marine Emissions in the Pearl River Delta

The Pearl River Delta (PRD) is a region with a single airshed, but different administrative and legal practices for controlling air quality. Under the Regional Cooperation Plan on Building a Quality Living Area (QLA Plan) released in June 2012 the Governments of Hong Kong, Guangdong and Macau have outlined a strategy to collaborate in reducing emissions from vessels throughout the PRD. This report provides evidence designed to assist policymakers in the region with this objective. It focuses on regulating toxic exhaust emissions from ocean-going vessels (OGVs) -- the most significant contributors of marine emissions. The findings show that marine sources of sulphur dioxide (SO2) emissions currently account for 519 premature deaths per annum in the PRD. These deaths could be reduced by 91% should an Emission Control Area (ECA) mandating the use of fuels with lower sulphur content be introduced. The report also demonstrates that three less comprehensive control measures would also reduce OGV emissions and associated public health impacts by 41-62%. Policymakers are encouraged to introduce these measures as stepping-stones on the way to establishment of an ECA for the PRD

Rolling Out a State-of-the-Art Simulation Center: Early Experiences

The Simulation Center, opened in the Fall 2006, contains state-of-the-art simulation technology (e.g., high-fidelity adult and pediatric mannequins, task trainers, and real-time/recorded observation and scenario review via audio-visual equipment) that provides an interactive learning environment designed to replicate the clinical setting. It is available to the School of Medicine, Graduate Medical Education, the School of Nursing, and the Graduate School of Biomedical Sciences. Event facilitators (i.e., faculty or residents) were asked to assess their initial perception and utilization of the center. Presented at the 2008 Society on Simulation in Healthcare Conference