title: A cross-sectional survey to investigate the quality of care in Tuscan (Italy) nursing homes: the structural, process and outcome indicators of nutritional care.
abstract: BACKGROUND
  Previous studies have investigated process and structure indicators of nutritional care as well as their use in nursing homes (NHs), but the relative weight of these indicators in predicting the risk of malnutrition remains unclear. Aims of the present study are to describe the quality indicators of nutritional care in older residents in a sample of NHs in Tuscany, Italy, and to evaluate the predictors of protein-energy malnutrition risk.
  
  
  METHODS
  A cross-sectional survey was conducted in 67 NHs. Information was collected to evaluate quality indicators of nutritional care and the individual risk factors for malnutrition, which was assessed using the Malnutrition Universal Screening Tool. A multilevel model was used to analyse the association between risk and predictors.
  
  
  RESULTS
  Out of 2395 participants, 23.7 % were at high, 11 % at medium, and 65.3 % at low risk for malnutrition. Forty-two percent of the NHs had only a personal scale to weigh residents; 88 % did not routinely use a screening test/tool for malnutrition; 60 % used some standardized approach for weight measurement; 43 % did not assess the severity of dysphagia; 12 % were not staffed with dietitians. Patients living in NHs where a chair or platform scale was available had a significantly lower risk of malnutrition (OR = 0.73; 95 % CI = 0.56-0.94). None of the other structural or process quality indicators showed a statistically significant association with malnutrition risk.
  
  
  CONCLUSIONS
  Of all the process and structural indicators considered, only the absence of an adequate scale to weigh residents predicted the risk of malnutrition, after adjusting for case mix. These findings prompt the conduction of further investigations on the effectiveness of structural and process indicators that are used to describe quality of nutritional care in NHs.
authors.affiliation: Department of Health Science, University of Florence, viale GB Morgagni 48, 50134, Florence, Italy. guglielmo.bonaccorsi@unifi.it.
authors.forename: Guglielmo
authors.initials: G
authors.lastname: Bonaccorsi
authors.affiliation: Regional Health Agency of Tuscany, Tuscany, Italy. francesca.collini@ars.toscana.it.
authors.forename: Francesca
authors.initials: F
authors.lastname: Collini
authors.affiliation: Regional Health Agency of Tuscany, Tuscany, Italy. mariangela.castagnoli@virgilio.it.
authors.forename: Mariangela
authors.initials: M
authors.lastname: Castagnoli
authors.affiliation: Research Unit of Medicine of Aging, Department of Experimental and Clinical Medicine, University of Florence-Unit of Geriatric Cardiology and Medicine, Florence, Italy. mauro.dibari@unifi.it.|Department of Heart and Vessels, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy. mauro.dibari@unifi.it.
authors.forename: Mauro
authors.initials: M
authors.lastname: Di Bari
authors.affiliation: Research Unit of Medicine of Aging, Department of Experimental and Clinical Medicine, University of Florence-Unit of Geriatric Cardiology and Medicine, Florence, Italy. mariachiara.cavallini@unifi.it.|Department of Heart and Vessels, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy. mariachiara.cavallini@unifi.it.
authors.forename: Maria Chiara
authors.initials: MC
authors.lastname: Cavallini
authors.affiliation: Research Unit of Medicine of Aging, Department of Experimental and Clinical Medicine, University of Florence-Unit of Geriatric Cardiology and Medicine, Florence, Italy. nicolettazaffarana@alice.it.
authors.forename: Nicoletta
authors.initials: N
authors.lastname: Zaffarana
authors.affiliation: Regional Health Agency of Tuscany, Tuscany, Italy. pasquale_pepe1@virgilio.it.
authors.forename: Pasquale
authors.initials: P
authors.lastname: Pepe
authors.affiliation: Department of Neuroscience, Psychology, Drug Research and Children's Health, University of Florence, viale Pieraccini 6, 50139, Florence, Italy. alessandro.mugelli@unifi.it.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Mugelli
authors.affiliation: Department of Neuroscience, Psychology, Drug Research and Children's Health, University of Florence, viale Pieraccini 6, 50139, Florence, Italy. ersilia.lucenteforte@unifi.it.
authors.forename: Ersilia
authors.initials: E
authors.lastname: Lucenteforte
authors.affiliation: Department of Neuroscience, Psychology, Drug Research and Children's Health, University of Florence, viale Pieraccini 6, 50139, Florence, Italy. alfredo.vannacci@unifi.it.
authors.forename: Alfredo
authors.initials: A
authors.lastname: Vannacci
authors.affiliation: Department of Health Science, University of Florence, viale GB Morgagni 48, 50134, Florence, Italy. chiara.lorini@unifi.it.
authors.forename: Chiara
authors.initials: C
authors.lastname: Lorini
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D007558:Italy; D008297:Male; D009735:Nursing Homes / Q000592:standards*; D015596:Nutrition Assessment; D010043:Outcome and Process Assessment, Health Care; D019984:Quality Indicators, Health Care / Q000592:standards*; D013222:State Medicine; D011795:Surveys and Questionnaires