title: Underreporting of nursing home utilization on the CMS-2728 in older incident dialysis patients and implications for assessing mortality risk.
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.
authors.affiliation: Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Atlanta Veterans Affairs Medical Center, 1670 Clairmont Road (11B), Decatur, GA, 30033, USA. cbbowli@emory.edu.|Division of General Medicine and Geriatrics, Department of Medicine, Emory University, Atlanta, GA, USA. cbbowli@emory.edu.
authors.forename: C Barrett
authors.initials: CB
authors.lastname: Bowling
authors.affiliation: United States Renal Data System, Rehabilitation/Quality of Life Special Studies Center, Emory University, Atlanta, GA, USA. hzang3@emory.edu.|Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA, USA. hzang3@emory.edu.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Zhang
authors.affiliation: Division of Renal Medicine, Department of Medicine, Emory University, Atlanta, GA, USA. hfranch@emory.edu.|Subspecialty Service Line, Atlanta Veterans Affairs Medical Center, Decatur, GA, USA. hfranch@emory.edu.
authors.forename: Harold
authors.initials: H
authors.lastname: Franch
authors.affiliation: United States Renal Data System, Rehabilitation/Quality of Life Special Studies Center, Emory University, Atlanta, GA, USA. yhuang5@emory.edu.|Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA, USA. yhuang5@emory.edu.
authors.forename: Yijian
authors.initials: Y
authors.lastname: Huang
authors.affiliation: Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Atlanta Veterans Affairs Medical Center, 1670 Clairmont Road (11B), Decatur, GA, 30033, USA. anna.mirk@va.gov.|Division of General Medicine and Geriatrics, Department of Medicine, Emory University, Atlanta, GA, USA. anna.mirk@va.gov.
authors.forename: Anna
authors.initials: A
authors.lastname: Mirk
authors.affiliation: Departments of Medicine and Epidemiology, Emory University, Atlanta, GA, USA. wmcclel@emory.edu.
authors.forename: William M
authors.initials: WM
authors.lastname: McClellan
authors.affiliation: Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Atlanta Veterans Affairs Medical Center, 1670 Clairmont Road (11B), Decatur, GA, 30033, USA. tmjohns@emory.edu.|Division of General Medicine and Geriatrics, Department of Medicine, Emory University, Atlanta, GA, USA. tmjohns@emory.edu.
authors.forename: Theodore M
authors.initials: TM
authors.lastname: Johnson
authors.affiliation: United States Renal Data System, Rehabilitation/Quality of Life Special Studies Center, Emory University, Atlanta, GA, USA. nkutner@emory.edu.
authors.forename: Nancy G
authors.initials: NG
authors.lastname: Kutner
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D014487:Centers for Medicare and Medicaid Services, U.S.; D015331:Cohort Studies; D005260:Female; D005568:Forms and Records Control; D016330:Frail Elderly; D006801:Humans; D015994:Incidence; D007676:Kidney Failure, Chronic / Q000453:epidemiology* / Q000401:mortality / Q000628:therapy; D008297:Male; D009735:Nursing Homes / Q000706:statistics & numerical data*; D010347:Patient Care Planning; D011379:Prognosis; D011996:Records / Q000592:standards*; D006435:Renal Dialysis / Q000706:statistics & numerical data*; D018570:Risk Assessment; D014481:United States / Q000453:epidemiology