AMDA Foundation - Assessing the Study’s Impact

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Assessing the Study’s Impact

Vol XXVIII, Sep `07

The LTC-QI Partnership aimed to evaluate the impact of the AMDA pain and pressure ulcer clinical practice guidelines (CPGs) on care processes. The study began with six nursing homes in Fall 2004—and by Spring 2007, it included 48 nursing homes in five states.

The study team is excited to describe the results of this three-year intervention, below. Please keep these results confidential, as these results are not published.

Study Design

Each nursing home was randomized to receive either the pain management or pressure ulcer prevention CPG and implementation toolkit. After CPG and data collection training, the nursing homes spent nine months implementing their assigned CPG.

Each arm of the study served as the ‘control’ for the other arm by collecting process of care data on both clinical topics. Nursing homes collected data at three time points: baseline (Month 1), remeasurement (Month 9), and follow-up (Month 15).

Results

Table 1 (p. 2) presents the process measure score trends from baseline to remeasurement among the 22 nursing homes that completed data collection at these time points. Among the pressure ulcer care process measures, the difference between improvement in the two study arms neared significance (p<0.10) for two measures and was significant (p<0.05) for one. Among the pain care process measures, the difference between improvement in the two study arms was significant (p<0.05) for one measure.

Eight nursing homes (50.0%) responded to a survey was administered to the 16 nursing homes that completed the study. Seven (87.5%) nursing homes formed teams to implement their assigned CPG. The composition and size of these teams varied, with teams ranging from three to 12 members and all representing an interdisciplinary approach (nursing staff, data coordinators, nursing home leadership, etc.).

Discussion

Interestingly, the process measures improved most among the arm of the study focusing on the other clinical topic; e.g., facilities randomized to the pain CPG improved most for the pressure ulcer care processes. All facilities collected data for both topics, and this self-audit may be an intervention that dilutes the effect of the CPGs.

While the results indicate that facilities may need additional assistance to adopt the CPGs, limitations include the fact that significant attrition—from 48 to 16 facilities over 15 months—meant the study was not powered to detect differences in improvement between the arms of the study.

Table 1: Trends between baseline (Month 1) and remeasurement (Month 9), by study arm

Process Measure	Pressure Ulcer Arm	Pain Ulcer Arm	Sign.

Pressure Ulcer
1. Pressure-reducing support surface on bed			*
2. Pressure-reducing support surface on chair			*
3. Pressure ulcer evaluation: complete wound description			NS
4. Pressure ulcer evaluation: Weekly update on wound healing			NS
5. Residents repositioned every two hours during the day			NS
6. Timely risk assessment for recently admitted residents			NS
7. Timely risk assessment for residents with pressure ulcers			**
8. Timely addressing of pressure ulcer risk factors in plan of care			NS
9. Unidentified / missed pressure ulcers in high-risk residents	NA	NA	NS
10. Weekly complete skin examination			NS
Pain
1. Change in medication regimen			NS
2. Complete pain assessment			NS
3. MD, NP, or PA notification of daily, moderate to severe pain			NS
4. Non-drug therapy as part of care			NS
5. Pain diagnosis			NS
6. Pain intensity scale			NS
7. Regularly-scheduled pain medications for daily pain			NS
8. WHO II or III pain medications for moderate-to-severe pain			**

Sign.: Significance; NS: Not significant; NA: Nursing homes submitted data for only one of the two time points * p<0.10; ** p<0.05. Note: If both arms improved or declined, darker color arrows indicate which arm improved or declined most