Underreporting of nursing home utilization on the CMS-2728 in older incident dialysis patients and implications for assessing mortality risk

• Authors: Christopher Bowling, Emory University; Rebecca Zhang, Emory University; Harold Franch, Emory University; Yijian Huang, Emory University; Anna Mirk, Emory University; William McClellan, Emory University; Theodore Johnson II, Emory University; Nancy Kutner, Emory University
• Journal Title: BMC Nephrology
• Volume: Volume 16, Number 1
• Publisher: BioMed Central | 2015-03-21, Pages 32-32
• Type of Work: Article | Final Publisher PDF
• Publisher DOI: http://doi.org/10.1186/s12882-015-0021-9
• Subjects: Health Sciences, Public Health
• Keywords: Science & Technology; Life Sciences & Biomedicine; Urology & Nephrology; Nursing home; End-stage renal disease; Frail elderly; STAGE RENAL-DISEASE; PATIENTS INITIATING DIALYSIS; MEDICARE CLAIMS DATA; UNITED-STATES; VALIDATION; ADULTS; FRAILTY; HEALTH; CARE; CKD

Abstract

Background: The usage of nursing home (NH) services is a marker of frailty among older adults. Although the Centers for Medicare & Medicaid Services (CMS) revised the Medical Evidence Report Form CMS-2728 in 2005 to include data collection on NH institutionalization, the validity of this item has not been reported. Methods: There were 27,913 patients ≥ 75 years of age with incident end-stage renal disease (ESRD) in 2006, which constituted our analysis cohort. We determined the accuracy of the CMS-2728 using a matched cohort that included the CMS Minimum Data Set (MDS) 2.0, often employed as a "gold standard" metric for identifying patients receiving NH care. We calculated sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for the CMS-2728 NH item. Next, we compared characteristics and mortality risk by CMS-2728 and MDS NH status agreement. Results: The sensitivity, specificity, PPV and NPV of the CMS-2728 for NH status were 33%, 97%, 80% and 79%, respectively. Compared to those without the MDS or CMS-2728 NH indicator (No MDS/No 2728), multivariable adjusted hazard ratios (95% confidence interval) for mortality associated with NH status were 1.55 (1.46-1.64) for MDS/2728, 1.48 (1.42-1.54) for MDS/No 2728, and 1.38 (1.25-1.52) for No MDS/2728. NH utilization was more strongly associated with mortality than other CMS-2728 items in the model. Conclusions: The CMS-2728 underestimated NH utilization among older adults with incident ESRD. The potential for misclassification may have important ramifications for assessing prognosis, developing advanced care plans and providing coordinated care.