Journal of Gerontological Nursing

Research Brief 

Validating MDS Data about Risk Factors for Perineal Dermatitis by Comparing with Nursing Home Records

Anna M. Toth, RN, BAN, MSN; Donna Z. Bliss, PhD, RN, FAAN; Kay Savik, MS; Jean F. Wyman, PhD, RN, FAAN

Abstract

Perineal dermatitis is one of the main complications of incontinence and increases the cost of health care. The Minimum Data Set (MDS) contains data about factors associated with perineal dermatitis identified in a published conceptual model of perineal dermatitis. The purpose of this study was to determine the validity of MDS data related to perineal dermatitis risk factors by comparing them with data in nursing home chart records. Findings indicate that MDS items defining factors associated with perineal dermatitis were valid and supported use of the MDS in further investigation of a significant, costly, and understudied health problem of nursing home residents.

Abstract

Perineal dermatitis is one of the main complications of incontinence and increases the cost of health care. The Minimum Data Set (MDS) contains data about factors associated with perineal dermatitis identified in a published conceptual model of perineal dermatitis. The purpose of this study was to determine the validity of MDS data related to perineal dermatitis risk factors by comparing them with data in nursing home chart records. Findings indicate that MDS items defining factors associated with perineal dermatitis were valid and supported use of the MDS in further investigation of a significant, costly, and understudied health problem of nursing home residents.

At the time this article was submitted, Ms. Toth was a geriatric nurse practitioner student at the University of Minnesota School of Nursing, Minneapolis, Minnesota. Dr. Bliss is Professor in Long-Term Care of Elders and Interim Associate Dean for Research, Ms. Savik is Senior Statistician, and Dr. Wyman is Professor and Cora Miedl Siehl Endowed Chair in Nursing Research, University of Minnesota School of Nursing, Minneapolis, Minnesota. Dr. Wyman is also Professor of Community Health and Family Practice, School of Medicine, University of Minnesota.

The authors thank the staff and administration of the nursing homes for their cooperation with this study. They acknowledge data collection by Lisa Rice and Jill Scholz, who were graduate research assistants at the University of Minnesota School of Nursing.

This study was funded in part by a grant from the Gerontological Nursing Interventions Research Center NIH #P30 NR03970 [PI: Toni Tripp-Reimer, The University of Iowa College of Nursing] and an unrestricted faculty development grant by 3M Medical Division, both to Dr. Donna Z. Bliss.

Address correspondence to Anna M. Toth, RN, BAN, MSN, 517 Deer Trail, Montgomery, MN 56069; e-mail: atoth@frontiernet.net.

Perineal dermatitis (PD) is an inflammation of the skin in the genital, buttock, and thigh areas that can result in decreased well-being and increased health care costs. In mild cases, PD manifests as redness and discomfort. In more severe cases, there is loss of superficial skin layers, a rash or oozing vesicles, and pain. Secondary fungal infection may also occur (Brown & Sears, 1993). It is estimated that 35% of older adults who are incontinent have a rash or redness requiring treatment; the estimated annual cost of such skin irritations in nursing home residents with urinary incontinence is $6.6 billion (Wilson, Brown, Shin, Luc, & Subak, 2001). Yet, few studies about PD or its associated factors in older adults in any setting have been conducted.

Bliss, Savik, Harms, Fan, and Wyman (2006) investigated the prevalence and correlates of PD in nursing home residents, guided by a conceptual model of PD (Brown & Sears, 1993). Minimum Data Set (MDS) items were used to represent the factors in the model. Because numerous items from the MDS could be used to define each PD factor, composite variables of MDS items needed to be developed (Savik, Fan, Bliss, & Harms, 2005). This study reports the preliminary analysis of the validity of the MDS items used to operationally define those PD factors. Determining the validity of sources of data or measures of variables is important to show the degree to which they measure what they intend to measure. Criterion validity is determined by comparing the relationship between a data source and an external criterion (Polit & Beck, 2004). When the data obtained within the instruments agree or correlate highly with those of the external criterion, the instrument is validated.

The purpose of this study was to ascertain the validity of items on the MDS that are postulated to be associated with PD. This was done by determining the agreement between data on the MDS and in the medical and nursing records of nursing home residents. Determining the validity of the MDS items was an important step before the PD factors they defined could be used in any subsequent analysis (Bliss et al., 2006).

Literature Review

The MDS is a standardized instrument used for the comprehensive assessment and care planning of nursing home residents; it provides a rich source of information that is useful for researching the health problems of nursing home residents. Federal law mandates that all residents in nursing facilities certified by Medicare or Medicaid be assessed using the MDS at admission, with any significant change in health condition, and at set intervals (Centers for Medicare & Medicaid Services, 2006).

Several studies have reported the validity of the MDS overall (Casten, Lawton, Parmelee, & Kleban, 1998; Lawton, Casten, Parmelee, Van Haitsma, & Kleban, 1998; Morris, Jones, Fries, & Hirdes, 2004). Previous studies have also validated selected items on the MDS by comparing them with other validated scales and nursing home chart records. For example, the validity of MDS items related to mood (Meeks, 2004), pain (Cohen-Mansfield, 2004), and cognition (Cohen-Mansfield, Taylor, McConnell, & Horton, 1998; Gruber-Baldini, Zimmerman, Mortimore, & Magaziner, 2000) showed fair to good correlations that were statistically significant; MDS items were also found to be predictive of protein calorie malnutrition (Crogan & Corbett, 2002).

The validity of some MDS items can differ depending on the sample. Therefore, validating MDS data is important when using it for research.

When compared with nursing home chart data, MDS data related to falls collected over a longer period (180 days) showed good agreement (kappa = 0.50, p < 0.001); shorter term (collected in 30 days) MDS data related to falls had fair agreement with chart data (kappa = 0.29, p < 0.001) (Hill-Westmoreland & Gruber-Baldini, 2005). Chart documentation of incontinence care processes was consistent with MDS reporting; for example, MDS data about residents’ requiring toileting assistance agreed with chart documentation about residents’ reports of needing and having received toileting assistance. However, some differences were found when MDS items were compared with residents’ recall of care instead of the nursing home chart data (Schnelle et al., 2003). The validity of some MDS items can differ depending on the sample. Therefore, validating MDS data is important when using it for research. Using nursing home residents’ charts as a criterion against which to compare MDS data is a standard approach for validating the MDS.

© 2008/DigitalVision/Getty Images

© 2008/DigitalVision/Getty Images

Method

Records of residents in two nonprofit nursing homes in the Twin Cities area of Minnesota were analyzed. Each nursing home housed residents on three floors; a total of 106 residents lived in one home and 184 lived in the other. Residents were eligible for the study if they had a full MDS assessment within the previous 12 months, were age 65 or older, and experienced urinary or fecal incontinence. A nursing home staff member used MDS data to screen all residents for meeting the inclusion criteria, and other nursing home staff confirmed eligibility.

Sample

Given the intensity of the chart review process, time involved in contacting some of the residents’ legal representatives for informed consent, and amount of funds available for the study, a sample size of approximately 40 residents (approximately 20 from each nursing home) was planned. Eligible residents were stratified by kind of incontinence, location in the nursing home, and whether they had perineal skin damage. Because it is not possible to determine using the MDS whether skin damage is in the perineal area, this information was obtained from residents’ chart records.

Using a list of computer-generated random numbers, residents were selected for recruitment from each stratum on the basis of their proportion in the nursing home. Random recruitment from strata was done to avoid inclusion of residents with only one kind of incontinence or skin status or from one floor. The number to be recruited from each stratum was determined by the proportion of residents in that stratum to the entire nursing home population. Residents who met the inclusion criteria were asked by nursing home staff whether they were interested in discussing the study with the investigators. If residents were unable to give consent, their legal representative was contacted in person or by letter by the nursing home staff. Research assistants (RAs) (graduate nursing students) assigned to each nursing home obtained informed consent from residents or their legal representatives. This study was approved by the participating university’s committee for the protection of human subjects in research.

Variables

The conceptual model of PD (Brown & Sears, 1993) guided the selection of variables to be compared between the MDS and medical and nursing home records. In the model, factors associated with PD are grouped into three main categories:

  • Tissue tolerance.
  • Perineal environment.
  • Toileting ability.

Indicators of tissue tolerance include factors such as age, health problems, problems with nutrition, perfusion, oxygenation, and fever. Factors in the perineal environment include frequency and kind of incontinence, mechanical chafing, skin irritants, problems of skin hydration, and fecal enzymes. Factors of toileting ability include problems of mobility, neurosensory deficits, and cognitive awareness.

The model was originally developed for a study of PD in hospital patients, but Bliss et al. (2006) saw a potential use for guiding analysis of PD in nursing home residents. They added the use of restraints as an indicator of toileting ability because of its high relevance to nursing home residents and operationalized its components using the MDS after the analysis described in this study was completed. Items found both on the model and in the chart were identified.

Data Collection

A data collection form based on Brown and Sears’ (1993) model was developed by the investigators to collect the needed information from the medical or nursing home records. The RA recorded data from more than 20 medical and nursing home forms reported during the time that coincided with completion of corresponding variables on the full MDS; examples included the nursing care plan, medical orders, treatment plans, medication administration records, nutrition assessment forms, special skin/wound assessment forms, bedside forms such as intake and output and dietary records, and progress notes. The RA entered data collected from the medical and nursing home records and the MDS into SPSS, version 13, which was also used for analysis.

To ensure reliability of the RAs’ data collection, the principal investigator (D.Z.B.) randomly selected one resident from each nursing home and independently recorded the same kind of data from the resident’s medical and nursing records as did the data collectors.

Data Analysis

A percentage agreement was calculated between data from individual items on the MDS and nursing home records. A kappa statistic was used to determine overall agreement beyond chance between data obtained from all of the items on the MDS and all of the items collected from the nursing home records of the study participants and between the data collected by the principal investigator and each RA. Interpretations of kappa statistics show that values greater than 0.7 are considered very good and those 0.9 and greater are considered excellent (Feinstein & Cicchetti, 1990).

Results

The sample included 43 residents (23 from one nursing home and 20 from the other), was 93% Caucasian and 88% female, and consisted of residents from all three floors of the nursing homes. Table 1 provides the main characteristics of the sample according to the three factors in the conceptual model of PD (Brown & Sears, 1993). In the tissue tolerance category, the sample included age (mean age = 86, SD = 8 years), the presence of comorbid health problems (e.g., Alzheimer’s disease, stroke), and nutrition problems. In the perineal environment category, both urinary and fecal incontinence was most common and present in approximately two thirds of the residents. A high percentage of residents wore absorbent products. In the toileting ability category, few residents (2%) were bedfast, and nearly half of the sample was totally dependent in toileting and hygiene care. Restraints were used with 9% of the residents.

Characteristics of Nursing Home Residents According to MDS Factors Associated with Perineal Dermatitis (N = 43)Characteristics of Nursing Home Residents According to MDS Factors Associated with Perineal Dermatitis (N = 43)

Table 1: Characteristics of Nursing Home Residents According to MDS Factors Associated with Perineal Dermatitis (N = 43)

Accurate documentation in residents’ charts and on the MDS are important for planning resident care and supporting nursing research.

Table 2 shows the percentage of agreement between the individual items on the MDS and the medical and nursing home records of both nursing homes’ residents. Variables are arranged according to the three main categories in the conceptual model of factors associated with PD (Brown & Sears, 1993). Two items had 100% agreement, and all items except two (hypertension [54%] and eating <25% of food at most meals [61%]) showed an agreement of at least 70%. The highest percentage of agreement between the MDS and the charts (≥95%) was found for the items of age, fever, weight gain or loss, parenteral feedings, oxygenation (oxygen therapy), fecal incontinence, and paraplegia or quadriplegia.

Agreement Between Data in MDS and Medical/nursing Home Records on Factors Related to Perineal DermatitisAgreement Between Data in MDS and Medical/nursing Home Records on Factors Related to Perineal Dermatitis

Table 2: Agreement Between Data in MDS and Medical/nursing Home Records on Factors Related to Perineal Dermatitis

The kappa statistic (standard error) for overall agreement beyond chance of all of the items compared was 0.72 (0.03) (p < 0.001, 95% confidence intervals = 0.66 to 0.78). These results indicate very good agreement. The kappa statistic for the agreement between the principal investigator and the RA was 1 (p = 0.000007) in one nursing home and 0.72 (p = 0.00006) in the other nursing home. These results show excellent agreement.

Discussion

Previous studies have demonstrated the importance of validating MDS items for use in research by comparing the MDS items with nursing home records. The findings of this study show a very good agreement between documentation in the nursing home charts and the MDS items selected and, therefore, support collecting data related to PD using the MDS. These findings are in agreement with comparisons of nursing home chart and MDS data reported by others (Hill-Westmoreland & Gruber-Baldini, 2005; Schnelle et al., 2003). Resident survey data or observer-collected data may yield different results. The conceptual model of PD was useful in guiding data collection. Not unlike other studies that focused on a small number of nursing homes, the generalizability of this study was limited by the small sample.

Nursing Implications

Clinical implications of the findings indicate that accurate documentation in residents’ charts and on the MDS are important for planning resident care and supporting nursing research. Nurse documentation on the MDS may be used for research studies and thus to improve resident outcomes and care processes. The numerous and interdisciplinary forms on which resident data are documented support the need for an organized approach and quality check when completing the MDS.

Summary

PD is one of the main complications of incontinence and increases the cost of health care. The MDS contains data about factors associated with PD identified in a published conceptual model of PD. The purpose of this study was to determine the validity of MDS data related to PD risk factors by comparing them with data in nursing home chart records. Findings indicated that MDS items defining factors associated with PD were valid and supported use of the MDS in further investigation of a significant, costly, and understudied health problem of nursing home residents.

References

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Characteristics of Nursing Home Residents According to MDS Factors Associated with Perineal Dermatitis (N = 43)

CharacteristicNumber of Residents (%)MDS Code
I. Tissue tolerance factors
Age (mean age = 86, SD = 8 years)AA3
Health status
  Alzheimer’s disease19 (44)I1q
  Arthritis10 (23)I1l
  Stroke17 (40)I1t
  Diabetes3 (7)I1a
  Hypertension22 (51)I1h
  Macular degeneration4 (9)I1mm
  Osteoporosis15 (35)I1o
  Parkinson’s disease3 (7)I1y
  Cancer4 (9)I1pp
  Peripheral vascular disease2 (5)I1j
Medication use
  Antibiotic medications43 (100)O4
  Antipsychotic/hypnotic agents8 (19)O4a
  Diuretic agents13 (30)O4e
  Antidepressant agents23 (53)O4c
Temperature
  Fever0 (0)J1h
Perfusion
  Weight gain or loss >3 pounds in 7 days or 10% in past 180 days0 (0)J1a
  Edema6 (14)J1g
Nutrition
  5% weight gain or loss in past 30 days10 (23)K3b
  Eats <25% of food at most meals19 (44)K4c
  Dietary supplement7 (16)K5f
  Planned weight change program8 (19)K5h
  Mechanically altered diet12 (28)K5c
Nutrition support
  Parenteral/enteral feedings7 (16)K6a, b
Oxygenation
  Oxygen therapy1 (2)P1ag
II. Perineal environment factors
Incontinence
  Urinary only12 (28)H1b
  Fecal only2 (5)H1a
  Pads or briefs used41 (95)H3g
III. Toileting ability factors
Bedfast1 (2)G6a
Sliding board use6 (14)G6e
Manually lifted9 (21)G6c
No locomotion on unit1 (2)G1e
Cane, walker, or crutch use13 (30)G5a
Inability to walk in room23 (53)H1
Wheelchair use28 (65)G5b, c, d
Total dependence with eating9 (21)G1h
Total dependence with bathing23 (53)G2
Total dependence with toileting18 (42)G1i
Total dependence with hygiene care21 (49)G1j
Restraints used4 (9)P4
Neurosensory deficits
  Paraplegia1(2)I1x
  Hemiplegia5 (12)I1v
  Quadriplegia0 (0)I1z
Cognition
  Level of consciousness (alert)39 (91)B1, B4
  Ability to make self understood31 (72)C4
  Memory intact10 (23)B2

Agreement Between Data in MDS and Medical/nursing Home Records on Factors Related to Perineal Dermatitis

Factor% Agreement
I. Tissue Tolerance Factors
Age96
Health status
  Alzheimer’s disease70
  Arthritis86
  Stroke72
  Diabetes90
  Hypertension54
  Macular degeneration79
  Osteoporosis74
  Parkinson’s disease91
  Cancer84
  Peripheral vascular disease93
Medication Use
  Antibiotic medications93
  Antipsychotic/hypnotic agents74
  Diuretic agents93
  Antidepressant agents88
Temperature
  Fever98
Perfusion
  Weight gain or loss >3 lbs in 7 days or 10% in past 180 days98
  Edema88
Nutrition
  5% weight gain or loss in past 30 days83
  Eats <25% of food at most meals61
  Dietary supplement72
  Planned weight change program81
  Mechanically altered diet86
Nutritional support
  Parenteral feedings98
  Enteral feedings91
Oxygenation
  Oxygen therapy98
II. Perineal environment factors
Incontinence
  Urinary only86
  Fecal only98
  Pads or briefs used93
III. Toileting ability factors
Bedfast86
Sliding board use84
Manually lifted72
No locomotion93
Cane, walker, or crutch use77
Inability to walk in room93
Wheelchair use74
Total dependence with eating74
Total dependence with bathing91
Total dependence with toileting86
Total dependence with hygiene care91
Restraints used77
Neurosensory deficits
  Paraplegia100
  Hemiplegia91
  Quadriplegia100
Cognition
  Level of consciousness (alert)86
  Ability to make self understood77
  Memory intact76
Authors

At the time this article was submitted, Ms. Toth was a geriatric nurse practitioner student at the University of Minnesota School of Nursing, Minneapolis, Minnesota. Dr. Bliss is Professor in Long-Term Care of Elders and Interim Associate Dean for Research, Ms. Savik is Senior Statistician, and Dr. Wyman is Professor and Cora Miedl Siehl Endowed Chair in Nursing Research, University of Minnesota School of Nursing, Minneapolis, Minnesota. Dr. Wyman is also Professor of Community Health and Family Practice, School of Medicine, University of Minnesota.

Address correspondence to Anna M. Toth, RN, BAN, MSN, 517 Deer Trail, Montgomery, MN 56069; e-mail: .atoth@frontiernet.net

10.3928/00989134-20080501-10

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