All Publications

  • Perceived Patient Safety Culture in Nursing Homes Associated With "Nursing Home Compare" Performance Indicators. Medical care Li, Y., Cen, X., Cai, X., Temkin-Greener, H. 2019


    BACKGROUND: The safety and quality of care provided to nursing home residents is a significant concern. Little is known whether fostering patient safety culture helps improve the safety and quality of nursing home care.METHODS: This study determined the associations of nursing home patient safety culture performance, as reported by administrators, directors of nursing, and unit leaders in a large national sample of free-standing nursing homes, with several "Nursing Home Compare" performance indicators. We conducted the survey in 2017 using the Agency for Healthcare Research and Quality Survey on Patient Safety Culture for nursing homes to collect data on 12 core domains of safety culture scores. Survey data were linked to other nursing home files for multivariable regression analyses.RESULTS: Overall, 818 of the 2254 sampled nursing homes had at least 1 completed survey returned for a response rate of 36%. After adjustment for nursing home, market, and state covariates, every 10 percentage points increase in overall positive response rate for safety culture was associated with 0.56 fewer health care deficiencies (P=0.001), 0.74 fewer substantiated complaints (P=0.004), reduced fines by $2285.20 (P=0.059), and 20% increased odds of being designated as 4-star or 5-star (vs. 1 to 3 star) facilities (odds ratio roughly=1.20, P<0.05).CONCLUSIONS: Efforts to improve nursing home performance in patient safety culture have the potential to improve broad safety and quality of care measures encapsulated in the Nursing Home Compare publication.

    View details for DOI 10.1097/MLR.0000000000001142

    View details for PubMedID 31259786

  • Preventable Hospitalizations Among Nursing Home Residents With Dementia and Behavioral Health Disorders. Journal of the American Medical Directors Association Temkin-Greener, H., Cen, X., Hasselberg, M. J., Li, Y. 2019


    Nursing home (NH) residents with Alzheimer's disease/related dementias (ADRD) and/or behavioral health disorders (BHD) are at high risk of hospitalizations, many of which are potentially avoidable. Empirical evidence regarding potentially avoidable hospitalizations (PAHs) among these residents is quite sparse and mixed. The objectives of this study were to (1) examine the risk of PAH among residents with ADRD only, BHD only, ADRD and BHD compared to residents with neither and (2) identify associations between individual- and facility-level factors and PAH in these subgroups.Retrospective, CY2014-2015.Long-term residents age 65+ (N = 807,630) residing in 15,234 NHs.We employed the Minimum Data Set, MedPAR, Medicare beneficiary summary, and Nursing Home Compare. Hospitalization risk was the outcome of interest. Individual-level covariates were used to adjust for health conditions. Facility-level covariates and state dummies were included. Multinomial logistic regression models were fit to estimate the risk of PAH and non-potentially avoidable hospitalizations (N-PAH).Compared to residents without ADRD or BHD, those with ADRD had at least a 10% lower relative risk ratio (RRR) of N-PAH and a significantly lower risk of PAH, at 16% (P < .0001). Residents with BHD only had a statistically higher, but clinically very modest (RRR = 1.03) risk of N-PAH, with no difference in the risk of PAH. Focusing on specific BHD conditions, we found no difference in N-PAH or PAH among residents with depression, lower PAH risk among those with schizophrenia/psychosis (RRR = 0.92), and an increased risk of both N-PAH (RRR = 1.15) and PAH (RRR = 1.09) among residents with bipolar disorders.We observed a lower risk of PAH and N-PAH among residents with ADRD, with the risk for residents with BHD varying by condition. Substantial variations in PAH and N-PAH were evident across states. Future research is needed to identify state-level modifiable factors that explain these variations.

    View details for DOI 10.1016/j.jamda.2019.03.006

    View details for PubMedID 31043354

  • Aggressive Behaviors Among Nursing Home Residents: Association With Dementia and Behavioral Health Disorders. Journal of the American Medical Directors Association Cen, X., Li, Y., Hasselberg, M., Caprio, T., Conwell, Y., Temkin-Greener, H. 2018; 19 (12): 1104?9.e4


    We measured the prevalence and severity of aggressive behaviors (ABs) among nursing home (NH) residents and examined whether individuals with behavioral health disorders were more likely to exhibit aggressive behaviors than others.The analytical sample included 3,270,713 first Minimum Data Set (MDS) assessments for residents in 15,706 NHs in 2015.Individuals were identified as having (1) behavioral health disorders only (hierarchically categorized as schizophrenia/psychosis, bipolar disorder, personality disorder, substance abuse, depression/anxiety); (2) dementia only; (3) behavioral health disorders and dementia; or (4) neither. The Aggressive Behavior Scale (ABS) measured the degree of aggressive behaviors exhibited, based on 4 MDS items (verbal, physical, other behavioral symptoms, and rejection of care). The ABS scores ranged from 0 to 12 reflecting symptom severity as none (ABS score = 0), mild (ABS score = 1-2), moderate (ABS score = 3-5), and severe (ABS score = 6-12). Bivariate comparisons and multinomial logistic regressions were performed.Residents with behavioral health disorders and dementia had the highest prevalence of ABs (23.1%), followed by dementia only (15.3%), behavioral health disorders only (9.3%), and neither (5.3%). After controlling for individual risk factors and facility covariates, the relative risk of exhibiting severe ABs was 2.47, 5.50, and 9.42 for residents with behavioral health disorders only, dementia only, and behavioral health disorders and dementia, respectively, with a similar pattern for moderate or mild ABs.Residents with behavioral health disorders were less likely than residents with dementia to exhibit aggressive behaviors in nursing homes. Thus, anecdotally reported concerns that aggressive behaviors are primarily an issue for residents with behavioral health disorders, rather than those with dementia, were not empirically justified.

    View details for DOI 10.1016/j.jamda.2018.09.010

    View details for PubMedID 30409493

  • Racial and Ethnic Differences in the Prevalence of Depressive Symptoms Among U.S. Nursing Home Residents. Journal of aging & social policy Li, Y., Cai, X., Harrington, C., Hasselberg, M., Conwell, Y., Cen, X., Temkin-Greener, H. 2018: 1?19


    This study aimed to examine racial and ethnic differences in significant depressive symptoms among long-term nursing home residents. We analyzed the 2014 national Minimum Data Set linked to a nursing home file and estimated multivariable logistic regressions to determine the associations of race and ethnicities with significant depressive symptoms (score ? 10 on the 9-item Patient Health Questionnaire [PHQ-9] scale) and whether associations were explained by resident and nursing home covariates. Stratified analyses further determined independent associations in subgroups of residents. We found that the prevalence rate of PHQ-9 scores ? 10 was 8.8% among non-Hispanic White residents (n = 653,031) and 7.4%, 6.9%, and 6.6% among Black (n = 97,629), Hispanic (n = 39,752), and Asian (n = 16,636) residents, respectively. The reduced likelihoods of significant depressive symptoms for minority residents compared to non-Hispanic Whites persisted after sequential adjustments for resident and nursing home covariates, as well as in stratified analyses. The persistently lower rate of significant depressive symptoms among racial and ethnic minority residents suggests that training of nursing home caregivers for culturally sensitive depression screening is needed for improved symptom recognition among minority residents.

    View details for DOI 10.1080/08959420.2018.1485394

    View details for PubMedID 29883281

    View details for PubMedCentralID PMC6286687

  • Trends and Hospital Variations in Surgical Outcomes for Cholangiocarcinoma in New York State. World journal of surgery Liu, H., Cen, X., Suo, T., Cai, X., Yuan, X., Shen, S., Liu, H., Li, Y. 2017; 41 (2): 525?37


    This population-based study examined surgical outcomes and hospital and post-acute care resource use after operations of cholangiocarcinoma during 2005-2012.Using New York State hospital claims, we identified subjects with intrahepatic tumor who underwent hepatectomy only (n = 2089), subjects with perihilar tumor who underwent hepatectomy and biliary-enteric anastomosis (BEA; n = 389) or BEA only (n = 3721), and subjects with distal cholangiocarcinoma undergoing pancreatectomy or pancreaticoduodenectomy (n = 228). We performed trend analyses for each group and calculated overall risk-adjusted mortality, complication, and 30-day readmission rates for hospitals using multivariable logistic regressions.Mortality rate was roughly 12 % over years for perihilar cases undergoing hepatectomy and BEA, significantly higher than the rates of other 3 groups (p = 0.000). The overall complication rate was 40 % for subjects undergoing both hepatectomy and BEA, more than doubling the rate for subjects undergoing hepatectomy or BEA alone (p = 0.000). Average LOS declined markedly for perihilar cases undergoing hepatectomy and BEA (from 21 days in 2005 to 16 days in 2012) and subjects with distal cholangiocarcinoma (from 22 days in 2005 to 16 days in 2012), but other outcomes did not change dramatically. Risk-adjusted hospital outcome rates varied substantially.Surgical patients with cholangiocarcinoma incur considerable mortality, postoperative complications, and resource uses, especially among those undergoing hepatectomy and BEA for perihilar tumors.

    View details for DOI 10.1007/s00268-016-3733-5

    View details for PubMedID 27785554

  • Medicare Advantage Associated With More Racial Disparity Than Traditional Medicare For Hospital Readmissions. Health affairs (Project Hope) Li, Y., Cen, X., Cai, X., Thirukumaran, C. P., Zhou, J., Glance, L. G. 2017; 36 (7): 1328?35


    We compared racial disparities in thirty-day readmissions between traditional Medicare and Medicare Advantage beneficiaries who underwent one of six major surgeries in New York State in 2013. We found that Medicare Advantage was associated with greater racial disparity, compared to traditional Medicare. After controlling for patient, hospital, and geographic characteristics in a propensity score based approach, we found that in traditional Medicare, black patients were 33 percent more likely than white patients to be readmitted, whereas in Medicare Advantage, black patients were 64 percent more likely than white patients to be readmitted. Our findings suggest that the risk-reduction strategies adopted by Medicare Advantage plans have not been successful in lowering the markedly higher rate of readmission among black patients, compared to white patients.

    View details for DOI 10.1377/hlthaff.2016.1344

    View details for PubMedID 28637771

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