Approaching cross-national comparisons of nursing home residents - Continuing and Rehabilitative Care for Elderly People: A Comparison of Countries and Settings

Age and Ageing, Nov, 1997 by Brant E. Fries, Marianne Schroll, Catgerine Hawes, Ruedi Gilgen, Palmi V. Jonsson, Pil Park

Introduction

The development and implementation of the national nursing home Resident Assessment Instrument (RAI) in the USA provided opportunities for experimentation and adoption elsewhere in the world. While many of these applications are in their early stages, they represent considerable potential both for the host nation and for more global understanding of long-term institutional care through cross-national comparisons. In the following we describe the background for and results from these early applications that provide preliminary comparisons among the continuing care facility populations of seven long-term care systems.

The RAI was mandated nation-wide in the USA to improve the quality of care in nursing homes. The underlying assumption was that improved assessment of a resident will improve the comprehensiveness and appropriateness of the care plan, and thus improve the quality of care provided. The RAI system encourages these linkages by providing not only for the assessment, using the RAI's Minimum Data Set (MDS), but also through care planning guidelines (Resident Assessment Protocols) [1]. An evaluation of the US system has shown that as early as 2 years after its introduction, improvements in the processes and outcomes of care were observed [2-6].

The US government has recently mandated a national RAI database. Such an archive would permit a variety of research and regulatory efforts which could include examining relationships between cost and quality, and tracking regional and temporal differences in the US nursing home population. Anticipating these uses, we have assembled an archive of over 2.7 million MDS assessments from the 12 states that have already mandated submission of computerized data. Work with these data has helped identify data issues, guide the structure of the national system, address complexities in the development of analytic files (such as those representing longitudinal changes for individual residents), and perform policy-relevant research. This database has also been the cornerstone for cross-national comparisons, both by representing the US population and by providing the structures for such comparisons.

Overall, the MDS has been translated into 11 languages (Danish, Dutch, French, Icelandic, Italian, Spanish, Swedish, German, Czech, Finnish and Norwegian), while the Resident Assessment Protocols and training manual have been translated into eight languages (first on the prior list). In most cases, a reverse-translation of the MDS back to English has been accomplished. The comparisons of the original and twice-translated instruments helped identify possible sources of unreliability or incompatibility for cross-national comparisons. For example, in the Swedish back-translation, preference for `exercise/sports' became `gymnastics.' It is unlikely that many elders would be assessed, at least in the USA, with an interest in gymnastics. Also, `failure to eat' was translated back from Japanese as `refusal to eat'. Although even an exact translation does not ensure compatibility, we have relied heavily on the expertise that bi-lingual, trained practitioners/gerontologists have in geriatric assessment. Across multiple nations, we have seen similar and good inter-observer reliabilities [7].

Differing goals across the several nations experimenting with the RAI have lead to a variety of strategies for and levels of implementation. We discuss here six countries other than the USA for which standardized MDS data are available. In Denmark, the RAI has been adopted for use in an entire community (Copenhagen) and in Iceland for the entire nation. In Japan, it is being tested prior to potential national adoption. In contrast, the initial use of the MDS in Sweden has been primarily for research, while in Italy much of the impetus has been educational: to improve training of nursing home staff. The French experiment in a limited number of nursing homes was to demonstrate the RAI's effect on quality of care.

Despite these differences, there is consistency of the MDS across these seven data sets (US, European and Japanese). This, together with the richness of the MDS to describe institutionalized elders, creates new opportunities for cross-national comparisons. The comparisons provide initial background to the companion articles in this supplement. Further, they demonstrate large international and intra-national differences in long-term care facilities. For comparisons to be drawn, therefore, studies must be performed with an abundance of comparable data and must address this variability in their design.

Methods

The data used in this comparative study derive from multiple projects using the RAI to describe elderly people institutionalized for chronic or rehabilitative care. [We considered both somatic and psycho-geriatric facilities, as appropriate, but have not considered institutions providing primarily care for chronic psychiatric illnesses (excluding dementias) or acute hospitals. The reader is referred to each of the country-specific reports for a fuller description of the facilities included. We use the term `resident' throughout the work, although some may use the term `patient'.