The prevention of undesirable events, such as falls, bone fractures, aspiration pneumonia, pressure ulcers, dehydration, and fever, is considered a quality indicator of geriatric care facilities (18,19).
This study’s first purpose was to report the effect of preadmission incidence on postadmission incidence. In most of the accidents, previous accidents were an indicator of postadmission incidence, except for bone fractures and dehydration, because of the lower frequency of these events postadmission. Obtaining preadmission incidence is a simple way to select high-risk patients.
If a history of undesirable events is adequately collected in the long-term care facility and shared among the healthcare professionals working in the facility, a three-step measure can be considered to reduce these undesirable events and hence improve the quality of the facilities.
The second purpose of this paper was to analyze the effect of care-management using previous risk events. The first step was to introduce a standardized risk management process using the Plan-Do-Check-Analysis (PDCA) cycle by collecting adequate information, including the history of undesirable events, and by performing adequate risk prevention planning and follow-up. The second step was to educate the health professionals about the risk management process and to share information about risk factors. The third step was to share information among the multidisciplinary team to adequately implement measures to prevent undesirable events (9).
To the authors’ knowledge, this is the first study to analyze the relative effectiveness of care management and multidisciplinary intervention for these events; many previous studies focused only on single risks. We compared the effectiveness of care management stratified by the presence of previous events. Most of the existing studies have focused on a single risk factor, such as falls. This study analyzed the relative effectiveness of prevention across multiple risk factors to understand the relative effectiveness of the intervention.
In this study, a reduction in risk events was not observed when all patients were included. However, the frequency of risk events decreased after selecting patients at high risk for pressure ulcers, an observation that was somewhat less noticeable for aspiration pneumonia. As shown in Table 2, pressure ulcers and aspiration pneumonia recurrence were reduced by approximately one-half with risk management. Using these data, we analyzed the NNT of risk management intervention.
Many studies have used single risk events, such as falls, have and shown higher effectiveness. For example, a meta-analysis by Chang et al. showed an odds ratio of 0.82 and NNT of 11 for a multidisciplinary fall prevention program (20). In this study, the NNT of fall prevention was much larger. This may be because we targeted fall prevention as well as many other undesirable risk events. Care management in real clinical settings must cope with multiple risks, and this figure may be close to reality.
This study is the first to show the relative effects of risk management. Risk management towards pressure ulcers and aspiration pneumonia was more effective, and few effects were observed in other events, including falls, dehydration and fever.
Although the incidence of pressure ulcers was reduced in the intervention group, these events did not completely cease. Therefore, sharing information about risk events between patients and their family is a crucial step in risk management.
Our study has several weaknesses. First, the observation period was short; if there were longer observation periods, the odds ratio and NNT could have been larger.
Second, this was not a truly randomized study. However, the prevalence and odds ratios for undesirable events were similar to those of previous studies.
Thirdly, the recall bias on admission may have also influence on the result. However, relatively short three-month period of history, and also direct interview to the patients and/or proxy family member may have contributed to decrease the recall bias.
Lastly, the result is obtained from LTCIs and may not the same with other settings such as home-based care and other type of facilities, because they may have different type of disability and combabilities.
Additionally, intervention did not significantly decrease all risk events. Thus, more specific interventions or classification approaches may be required to reduce undesirable events.
Our next step is to introduce these more specific interventions for the effective prevention of risk events in nursing homes. Also, it is important to inform not all patients will benefit from preventive measures. Adequate explanation to unpreventable risks on admission is also necessary.