It is estimated that 1.6–3.8 million infections occur among U.S. nursing home (NH) residents each year,1 although healthcare-associated infections (HAI) may be largely preventable.2 To reduce HAI, the Centers for Medicare and Medicaid Services (CMS) monitors NH infection control (IC) practices as part of the annual inspection survey that determines certification eligibility. Non-compliant NHs are issued a citation (i.e., F-tag or “deficiency”). State Departments of Health (DOH) have also responded to these problems through a variety of activities, information and policies, which include IC training resources for NH providers, advisories, formal working groups, or collaboratives to advise NH providers regarding IC and mandatory or voluntary HAI reporting by NHs to the DOH.3 To our knowledge, the effects of these activities have not been evaluated. Hence, our objective was to determine associations between specific state DOH activities with NH IC citation rates.
Information regarding state activities to reduce infections in NHs was systematically collected from 50 states and the District of Columbia’s DOH websites between November 2012 and January 2013. Details regarding data collection were previously described.3 Data from the Certification and Survey Provider Enhanced Reporting (CASPER) system from 2013 (93.9%) or 2014 (6.1%) were used, as were data from the Area Health Resource File (AHRF). CASPER contains information collected during CMS annual NH inspections, including citations and facility characteristics.4 AHRF contains county-level socioeconomic, demographic and health descriptions.5
Multivariable logistic regression with regional and urbanicity fixed-effects and state clustering was used to test associations between IC-related citations and the presence of the following state DOH activities: 1) voluntary or mandatory reporting of NH infections; 2) an advisory board, working group or collaborative focused on reducing infections in NHs; and 3) IC training available through the DOH website (excluding inspection-related information). The models included covariates to control for facility, resident population and market characteristics similarly to other studies.6,7 Relationships between overall care quality citations and DOH activities were also evaluated to assess specificity. A significance level of 5% was set a priori. All analyses were conducted using Stata 13 statistical software.
Data were available from 14,276 NHs; 91.3% of facilities were in states that provided IC training, 70.4 % were in states with an advisory group or collaborative, and 9.7% were in states with mandatory or voluntary HAI reporting. In this sample, 37.6% and 64.3% of facilities received an IC-related or a care quality citation, respectively. In the multivariable analyses, NHs in states that had mandatory or voluntary HAI reporting were less likely to receive IC-related citations (OR: 0.61; 95% CI: 0.49, 0.75) or overall care quality citations (OR: 0.75; 95% CI: 0.55, 0.95). NHs in states that provided IC training were less likely to receive IC-related citations (OR: 0.67; 95% CI: 0.48, 0.86), and training was not related to overall care quality citations. The presence of a state advisory or collaborative was not associated with either IC-related or care quality deficiency citations (see Table).
Table.
Associations between state Department of Health policies and activities and deficiency citations in nursing homes
| Policy/Activity | Infection control citations | Care quality citations | ||||
|---|---|---|---|---|---|---|
|
| ||||||
| OR | 95% CI | p-value | OR | 95% CI | p-value | |
| Advisory group or collaborative | 0.91 | 0.70, 1.12 | 0.434 | 1.19 | 0.85, 1.54 | 0.231 |
| Infection control training or materials | 0.67 | 0.48, 0.86 | 0.006 | 0.80 | 0.45, 1.45 | 0.333 |
| Mandatory or voluntary HAI reporting | 0.61 | 0.49, 0.75 | <0.001 | 0.75 | 0.55, 0.95 | 0.036 |
Note. Estimates produced using logistic regression models with regional and urbanicity fixed-effects and state clustering, adjusting for facility, resident population and market characteristics similar to other studies.6,7 OR = Odds Ratio; CI = Confidence Interval; HAI = Healthcare Associated Infection.
The association between provider access to IC training and fewer IC-related citations was specific and strong. Using qualitative methods, we previously found the need for increased training opportunities for NH staff members, particularly for those in charge of IC programs.8 It is logical that state DOH-provided IC training would improve IC and result in an inverse relationship with IC-related citations.
Inverse correlations between the presence of HAI reporting and both general care quality citations and IC-related citations may indicate that HAI reporting impacts quality generally. At the time of data collection, only five states had HAI reporting, of which three implemented reporting within the previous year.3 Other factors coinciding with NH HAI reporting in those states and that were not accounted for in our study may have affected care quality citations. Furthermore, the relationship was stronger with IC citations suggesting specificity. Future research should reassess these relationships.
It was surprising that there was no association between presence of advisory groups or collaboratives and citations. As these groups may be initiated by an entity other than the state DOH (e.g., county-led), they may not have been identified on the state DOH website and therefore were not accounted for in the current analysis. Further research regarding regional initiatives to reduce infections in NHs would be helpful to interpret the impact of these initiatives as well as isolate effects of state policies.
We found a IC-related citations rate similar to Ye et al. (2015),9 which was higher than previously reported.7 A factor contributing to this difference is that previously there were five IC-related citations (441–445) that were combined into one citation (441) in September 2009. Another factor may be that the rate of NHs receiving IC citations rose 12.87–17.31% from 2000–2007.7 It is plausible that this trend continued to increase through data used in this study.
Given these findings, clinicians may wish to seek out NH-specific IC training as a means to improve practice and reduce IC citations. As IC training resources generated by state DOH and HAI reporting is different across states, further research should determine which training methods are most effective and whether HAI reporting improves care. Policymakers and state DOHs should provide or increase IC training to NH providers.
Acknowledgments
Financial support. Funding for this study was generously provided by the National Institute of Nursing Research (NINR, R01 NR013687). CCC was also supported by NINR (F31 NR015176).
Footnotes
The authors have no conflicts of interest to report.
Contributor Information
Catherine C. Cohen, Email: chc2144@columbia.edu, 630 West 168th Street, Mail Code 6, Columbia University School of Nursing, Center for Health Policy, New York, NY, USA, Phone: (212) 305-3431, Fax: (212) 305-3639.
John Engberg, RAND Corporation, Pittsburgh, PA, USA.
Carolyn T.A. Herzig, Columbia University School of Nursing, Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA.
Andrew W. Dick, RAND Corporation, Boston, MA, USA.
Patricia W. Stone, Columbia University School of Nursing, Center for Health Policy, New York, NY, USA.
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