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

Spring Calving Suckler Beef Systems: Influence of Grassland Management System on Herbage Availability, Utilisation, Quality and Cow and Calf Performance to Weaning

Suckler beef systems in Ireland are primarily based on grass. Suckler systems vary in intensity but many operate low input systems and participate in REPS (Rural Environmental Protection Scheme). As there is a considerable cost associated with second-cut silage this research compared a two-cut system with a simplified low input one-cut system

Waste Corn as a Source of Inoculum of Aspergillus Flavus, the Cause of Aflatoxin

Aspergillus Flavus occurs worldwide in diverse habitats on a variety of plant and animal substrates. In the United States, contamination of susceptible crops particularly maize, peanuts, cottonseed, and tree nuts has become a major health concern because of the development of the carcinogen, aflatoxin. Extensive research into all aspects of the biology of A. flavus over the past twenty years still has left many unanswered but very basic questions about the ecology of this important organism

Communication skills training in undergraduate medicine.

Good communication with patients is now recognised as the cornerstone in effective medical practice. Medical students do not automatically acquire the art of good communication through clinical training. A new course to promote the development of communication skills at undergraduate level is described. The course was provided at the juncture between pre-clinical and clinical training. Course evaluation illustrated the value of the course as perceived by students themselves and highlighted the areas of greatest need for students in communication skills training

Secular trends in child and adult sexual violence--one decreasing and the other increasing: a population survey in Ireland.

BACKGROUND: Sexual violence is a worldwide problem affecting children and adults. Knowledge of trends in prevalence is essential to inform the design and evaluation of preventive and intervention programmes. We aimed to assess the prevalence of lifetime sexual violence for both sexes and to document the prevalence of adult and child abuse by birth year in the general population. METHODS: National cluster-randomized telephone interview study of 3120 adults in Ireland was done. RESULTS: Child sexual abuse involving physical contact was reported by 20% of women and 16% of men. In adulthood, figures were 20% and 10% for women and men, respectively. Prevalence of any form of sexual violence across the lifespan was 42% (women) and 38% (men). Analysis by year of birth indicated a curvilinear pattern for child sexual abuse with lower prevalence in the oldest and youngest participants. Sexual violence in young adulthood showed a linear pattern with higher prevalence in the youngest participants. CONCLUSION: The trend of lower rates of experience of child sexual abuse in younger adults in the sample is in keeping with findings from other countries. The trend of higher rates of adult sexual violence in younger adults is worrying, particularly since the same participants reported less experience of child sexual abuse than the preceding generations. There is a paucity of international data addressing the issue of cohort differences in exposure to sexual violence. Within-study analysis, and follow-up studies designed to maximize replicability, are needed to inform discussion about societal trends in different types of sexual violence

Analysis of Fe2O3, TiO2 and Cr2O3 in Mullite by X-Ray Fluorescence

The basic theory and methods of X-ray fluorescence are briefly discussed. Pure synthetic mullite was made by mixing aluminum and silicon chlorides in non-aqueous solvent, coprecipitating as hydroxides, calcining to remove solvents and firing to 1600°C. Additions of Fe2O3, TiO2 and Cr2O3 to the high purity mullite were used to produce standard calibration curves for use in the analysis of unknowns. Experimental techniques are described and standard curves are presented. The method is rapid and results are comparable in accuracy to those of wet chemical analysis

Communication skills training in undergraduate medicine: attitudes and attitude change.

The importance of communication skills training in undergraduate medical education is now widely accepted. However little is known about student attitudes towards their own communication skills and whether their attitudes changes as a result of participating in communication skills courses. The aim of the present study was to identify these attitudes prior to commencing such a course and to further evaluate changes in these attitudes on completion of the course. Results demonstrated an improvement in perceived confidence regarding a number of specific communication skills. The study provides further evidence of the value of such courses in undergraduate medical training