Purpose. To determine if nursing homes that score in the lower 25th percentile (low prevalence) versus the upper 75th percentile (high prevalence) on each of two Minimum Data Set (MDS) incontinence quality indicators provide different incontinence care processes.
Design. Cross-sectional.
Subjects. 347 long-term residents in 14 skilled nursing facilities for the MDS prevalence of incontinence indicator and 432 residents in 16 skilled nursing facilities for the MDS prevalence of incontinence without a toileting plan indicator.
Measures. Nine care processes related to incontinence were defined and operationalized into clinical indicators. Research staff assessed implementation of each care process on 3 consecutive 12-hour days (7 am to 7 pm ). The assessment included resident interviews, physical performance evaluations, and chart abstraction using standardized protocols.
Results. Homes with lower prevalence rates on both MDS incontinence quality indicators (good outcomes) had a significantly higher proportion of participants with chart documentation of two relevant care processes: 1 an evaluation of the resident's incontinence history and 2 toileting assistance rendered by staff. However, interviews with incontinent residents capable of accurately reporting care activity occurrence showed no difference in toileting assistance frequency between homes in the upper and lower quartiles for either MDS incontinence indicator. Participants reported an average of 1.8 toileting assists per day across all homes with a narrow average frequency range between homes (1.6-2.0). These frequencies of toileting assistance are not sufficient to improve urinary incontinence. There was also no difference in the frequency of toileting assistance received by incontinent participants rated on the MDS as receiving scheduled toileting (n = 75, mean = 1.9 ± 1.24) compared to incontinent residents rated on the MDS as not receiving scheduled toileting (n = 131, mean = 1.8 ± 1.22). None of the homes provided chart documentation that supported staff decisions to place or not place a resident on a scheduled toileting program.
Conclusions. The quality of incontinence assessment and treatment as documented by scheduled toileting interventions was poor across all homes, and the MDS incontinence quality indicators were not associated with clinically important differences in related care processes. Chart documentation that a resident was on a scheduled toileting program or received toileting assistance was not related to resident reports of the frequency of received assistance.
Quality indicators are calculated from resident assessment data generated by nursing home (NH) staff in the federally-mandated Minimum Data Set (MDS) reporting system. 1 The MDS quality indicator information is provided to all NHs in the nation and is available in publicly accessible reporting systems with flags that signal unusually high or low quality indicator scores for individual homes. 2 The development and dissemination of the MDS quality indicators represent the most visible effort by the Centers for Medicare Services (CMS) to improve NH care at the national level, and new indicators continue to be developed and tested as part of this effort. 3,4 However, there is controversy about the accuracy of the facility-generated MDS data, which are used to score the quality indicators.
One assumption is that differences in MDS quality indicator scores reflect differences in care process implementation and thus provide useful information for NH improvement, consumer decision making, and external survey purposes (eg, survey staff can focus efforts on homes with outlying incontinence quality indicator scores). However, there has been no verification by investigators, independent of those who developed the MDS and the associated quality indicators, that the indicators reflect real differences in the quality of care provided. Despite this dearth of information, policy decisions have been made to use the indicators in a variety of projects to improve NH care quality and to inform long-term care consumers. 4,5
The purpose of this study is to begin to test the assumption that differences in MDS quality indicator scores reflect real differences in the quality of related care processes. Of the many care processes addressed by the quality indicator scores, this study focuses on incontinence care largely because there exists already valid and reliable methods for evaluating incontinence care processes apart from using MDS data. 6,7 Such assessment methods, which provide an independent benchmark for comparison purposes, are a prerequisite for evaluating the association between MDS quality indictor scores and the care processes they are intended to measure. One recent study by a research team that developed new MDS quality indicators reported an association between facilities' overall score on an incontinence prevalence quality indicator derived from the MDS and unspecified care processes. 5 This report, however, provided limited information about the measurement of incontinence care quality. The study reported here avoids this limitation by using a standardized, rigorously defined measurement methodology.
This study evaluated nine incontinence care processes determined by expert consensus to be related to positive outcomes (ie, valid) and feasible to implement in NHs. The methodology used to define the incontinence care process indicators has been described elsewhere. 8,9,10,11 Nursing home staff implementation of each care process was measured by resident interview and chart abstraction using standardized protocols. Homes with MDS quality indicator scores that placed them in either the lower (25th percentile-low prevalence or good outcome) or upper (75th percentile-high prevalence or poor outcome) quartile on two separate MDS-generated incontinence quality indicators were compared on the nine care process measures.
The only two currently used MDS incontinence quality indicators are: (1) prevalence of incontinence and (2) prevalence of incontinence without a toileting plan. The prevalence of incontinence indicator is calculated for each NH by dividing all residents rated on the MDS as incontinent (MDS item H1a or H1b rated as 3 or 4) by all residents in the facility. Presumably, a high prevalence of incontinence among residents reflects potentially poor resident care. There is a risk adjustment for this indicator (eg, prevalence of incontinence in residents who differ on mobility and cognitive impairment levels) that this study did not evaluate.
The second indicator, incontinence without a toileting plan, is calculated by dividing all residents rated on the MDS (items H3a and H3b) as being on a scheduled toileting or bladder retraining program by the number of residents rated as occasionally or frequently incontinent (MDS items H1a or H1b rated as 2 or 3). Presumably, a high prevalence of incontinent residents who are not on a toileting or bladder retraining program reflects poor incontinence care due to under-utilization of interventions known to improve incontinence among a substantial proportion of NH residents. 12
The purpose of this study was to evaluate whether homes that scored in the extreme quartiles on these two MDS incontinence quality indicators also provided different incontinence care processes that could be interpreted as reflecting differences in care quality.