Annals of Long Term Care

Predictors of Adherence to the Use of Hip Protectors in Nursing Home Residents
Andrea Warnke, PhD, Gabriele Meyer, Ralf Bender, PhD, and Ingrid Mühlhauser, MD.

Objectives: To assess predictors of hip-protector use in nursing home residents under usual-care conditions and after intervention consisting of structured education of nurses and nursing home residents and provision of free hip protectors.

Design: Nested cohort analyses within a cluster randomized, controlled trial with 18 months follow-up.

Setting: Forty-nine nursing home clusters in Hamburg, Germany.

Participants: Residents with at least one fall during the study period (intervention group, n=237; usual-care group, n=274).

Measurements: Use of hip protector while falling. Regression analyses were performed for each of the two cohorts of fallers using the time to the first fall without hip protector as the dependent variable. Predefined nursing home cluster-related parameters (center, staffing ratio, proportion of registered nurses in nursing staff, hip-protector use before study period) and resident-related parameters (sex, history of falls and fractures, fear of falling, urinary incontinence, use of walking aid, degree of disablement) were considered as explanatory variables.

Results: Under usual care, 97% of fallers (n=266), compared with 62% (n=148) in the intervention group, experienced at least one fall without hip protection. Using Cox proportional hazards models with and without frailty parameter (random cluster effect), the following predictors were identified: intervention group: use of walking aid, hazard ratio (HR)=1.53 (95% confidence interval (CI):0.98-2.39) and no urinary incontinence, HR= 1.47 (95% CI:1.03-2.09); usual care: nursing staff per 10 residents, HR= 0.78 (95% CI=0.63-0.96); high degree of disablement, HR=1.38 (95% CI= 1.06-1.80); strong fear of falling, HR=0.78 (95% CI=0.60-1.02). The nursing home cluster was a significant predictor in the control group (P=.029), but not in the intervention group (P=.100).

Conclusion: Only a few and weak predictors of hip-protector use of questionable relevance could be identified in both groups. Future research should concentrate on the implementation of interventions of proven efficacy, such as provision of hip protectors combined with structured education of staff and residents. J Am Geriatr Soc 2004;52(3): 340-345.

Effect of State Medicaid Reimbursement Rates on Hospitalizations from Nursing Homes
Orna Intrator, PhD, and Vincent Mor, PhD

Objectives: To estimate the effect of state Medicaid nursing home reimbursement rates on hospitalizations of nursing home residents.

Design: Cross-sectional sample of nongovernment-owned nursing homes with 25 beds or more in one Metropolitan Statistical Area in each of 10 states in 1993, with 6 months follow-up on mortality and hospitalizations.

Setting: Two hundred fifty-three nursing homes.

Participants: Eight to 16 randomly selected residents from each facility, totaling 2,080.

Measurements: Minimum Data Set assessments conducted by research nurses at baseline. A three-category 6-month outcome was defined as (1) any hospitalization; for those not hospitalized, (2) death versus (3) alive in the facility.

Results: Using multinomial logistic regression, adjusted to survey design, controlling for resident and facility characteristics, a $10 increase in 1993 Medicaid reimbursement rate above the mean rate of approximately $75 resulted in a 9% reduction in a resident’s risk of hospitalization (P<.05).

Conclusion: State Medicaid reimbursement rates appear to affect clinical decisions regarding the need for hospital admission and thresholds for nursing home use. The findings from this study reemphasize the importance of properly aligning state Medicaid and federal Medicare long-term care policies because, currently, states have no incentive to increase reimbursement rates to avoid hospitalization.