Reducing the Use of Physical Restraints in Nursing Homes - NCBI

Reducing the Use of Physical Restraints in Nursing Homes: Will It Increase Costs?

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Charles D. Phil4ps, PhD, MPH, Catherine Hawes, PhD, and Brant E. Fries, PhD

Intmducton For decades, physical restraints have been an integral part of the care provided to hundreds of thousands of nursing home residents in the United States. Restraint use continues despite increasing evidence that it is a hazardous intervention, with known negative effects on residents' physical and mental health. Moreover, there has been considerable resistance to federal law mandating restraint reduction. Much of this resistance comes from providers and some state policymakers who argue that, whatever the clinical rationale for reducing restraint use, this reform will be prohibitively costly to implement. Indeed, the argument over the restraint reduction provisions ofthe Omnibus Budget Reconciliation Act of 1987 is so heated that it has contributed to lawsuits.1"2 This conflict over implementing the restraint reduction provisions of the 1987 budget act occurs against a backdrop of widespread current and historical use of physical restraints. The 1977 National Nursing Home Survey found that 380 000 nursing home residents (25% of the population) were physically restrained through the use of trunk restraints, limb restraints, or chairs that prevent residents from rising and moving about.3 Numerous other studies have also found use of physical restraints to be common.41' More recent data from specific states have suggested that the rate of use may have risen since the mid-1970s. Data from 1989 indicate that physical restraints were applied to as many as 45% of Medicaid recipients in Texas nursing homes.12 Health industry officials in Oregon reported that 50%o of residents were physically restrained; however, even this estimate is low because it excludes residents who were placed in geriatric chairs that prevent them from rising

(information derived from a letter dated May 18, 1990, from S. Goodwin, executive director of the Oregon Association of Homes for the Aged, and E. N. Sage, executive director of the Oregon Health Care Association, to Albert J. Benz, administrator, Medicaid Division, Health Care Financing Administration, Region X). A 1991 report from an independent state commission in California indicates that more than two thirds of the residents in California nursing homes were physically restrained at some time during their

stay.13 Operators and staff of nursing facilities often argue that such restraints are protective devices designed to prevent falls and manage behaviors that endanger or distress residents.14-16 Similar arguments for restraint use in hospital settings have been raised.17,18 In addition, some nursing home operators use restraints because they fear litigation if unrestrained residents injure themselves or others.19 Other observers have argued that physical restraints have been used as a substitute for good clinical care and appropriate staffing.10'20 Whatever the reason, reCharles D. Phillips is with the Center for Social Research and Policy Analysis, and Catherine Hawes is with the Center for Policy Studies, at Research Triangle Institute, Research Triangle Park, NC. Brant E. Fries is with the Institute of Gerontology and School of Public Health at the University of Michigan and Ann Arbor Veterans Administration Medical Center. Requests for reprints should be sent to Charles D. Phillips, Research Triangle Institute, PO Box 12194, Research Triangle Park, NC 27709. This paper was submitted to the Journal January 30, 1992, and accepted with revisions November 9, 1992. The views expressed herein are solely the responsibility of the authors.

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Restraints and Costs in Nursing Homes straint use has become common practice in this nation's nursing homes. This widespread use of physical restraints in nursing facilities has been a source of continuing concern to both clinicians and advocates for residents. The lack of autonomy, limits on freedom of movement, and restriction in activity such restraints entail have daily consequences for the quality of residents' lives. Signs of these negative effects can be seen in the depression and withdrawal, as well as in the increased agitation and combativeness, of many physically restrained residents.1014,2122 Both nursing home residents and hospital patients have described the experience of being in restraints as emotionally devastating, frightening, and

humiliating.18,23 There are also adverse effects on residents' physical health. Use of physical restraints is associated with increased mortality and morbidity. Among the reported consequences attributed to restraints are skin breakdown, incontinence, constipation, fecal impaction, manifestations of sad and anxious moods, behavioral problems, and declines in mobility and other aspects of physical functioning, as well as death.'0,11,18,2A Moreover, recent studies have found that restraint use does not reduce serious falls and their associated complications.18,25 Because of these negative consequences, federal regulations, as early as 1974, required that restraints must be ordered by a physician and that those restrained must be released every 2 hours for 10 minutes of exercise. Recently, demands for reducing restraints or eliminating their use have increased and become part of a national movement to "untie the elderly." This movement has gained strength from the positive experience among nursing facilities that have moved toward "restraint-free" environments,26 as well as from the reforms mandated in the 1987 budget act and in the new guidelines and proposed federal regulations issued by the Health Care Financing Administration (HCFA).27 These proposed federal regulations and HCFA's interpretive guidelines require nursing facility staff to review all restraint use to reduce inappropriate application and prohibit use solely to control residents' behaviors. The response of nursing home owners and operators to this movement has been mixed. Many early skeptics have been won over by the positive results of changes in their clinical practice, but others remain concerned about the feasibility of significantly reducing or eliminating the March 1993, Vol. 83, No. 3

use of physical restraints.28 And cutting across all the responses is concern about the cost of implementing restraint reduction.29 While some operators have reported decreased costs with reduced restraint use,26 most industry representatives have raised the specter of increased costs,24 and the American Health Care Association has sued the federal govemment for failing to ensure that states adequately reimburse nursing facilities for new costs associated with nursing home reform.25 26,30 Many state Medicaid plan amendments that address the costs of implementing the nursing home reforms stipulated in the 1987 budget act have reflected the operators' contention that reducing restraint use increases costs. One such state plan amendment, for example, estimated that cost to be as much as $5.00 per resident day. Even costs of only $2.00 per resident daywould mean an increase in total national nursing home expenditures of approximately $1 billion per year. The basis for the industry's and states' estimates of increased costs appears to be the belief that reducing the use of physical restraints will require increased staffing. Yet these estimates have not been informed by empirical data. This paper directly addresses this issue by comparing the staff time devoted to caring for restrained residents with that devoted to caring for residents free from physical

restraints.

Mehods Data The data used in this analysis derive from the nursing home time studies performed in seven different states over a period of 7 years. These data were collected in nursing homes in New York in 1983; in Texas in 1986; and in Kansas, Maine, Mississippi, Nebraska, South Dakota, and Texas in 1990. The 1983 and 1986 data were collected as part of the development of nursing home case-mix reimbursement systems by New York and Texas. The 1990 data were collected as part of casemix demonstrations or development activities, largely HCFA's Nursing Home Case-Mix and Quality Demonstration (NHCMQD). In all these data collection efforts, facilities were chosen only from those meeting at least minimum standards of quality. For example, in the NHCMQD, facilities had to meet project-determined staffing levels as well as be deemed free from serious fiscal and quality-of-are

problems by each state's licensing and certification and Medicaid agencies. These data collection efforts are described briefly below and are further described in considerable detail elsewhere.31-33 In each data collection, entire nursing home units were selected for study. In each study unit, all residents received a comprehensive multidimensional assessment that recorded their cognitive, functional, and health status. In the NHCMQD, these assessments used a slightly modified version of the nationally mandated Minimum Data Set for Nursing Home Resident Assessment and Care Screening.34 In addition to comprehensive assessments for all residents on these units, all facility care providers recorded the amount of time spent caring for each resident in one 24-hour period. The assessment data for each resident were then merged with the data on the staff resources used by that resident. Across these data sets, assessment and resource provision data were gathered on a total of 11 932 residents receiving care in 276 nursing homes in seven states. More than 4800 of these residents (40%) were physically restrained, in most cases by either trunk restraints or chairs that prevented

rising. Resource Use Indicators In this analysis, three measures of staff resource provision were used as dependent variables. The first two were the total amount of time devoted to caring for each resident by licensed nursing staff (i.e., registered nurse, licensed practical, or vocational nurse) and by nursing aides and assistants. The third measure was the sum of all nursing time weighted by the relative wage rates of the various types of staff. This third measure allowed us to capture the relative cost of the nursing services provided to each resident. Staffing costs commonly comprise more than 60% of the resident care-related expenses incurred by nursing homes.35

Indicators of Care Needs A multivariate model was used to es-

timate the unique effects of restraint use on resource provision and the cost of care. To adjust for care needs other than those resulting from restraint use, we included in each multivariate model a series of binary indicators that represent characteristics identified in previous research as affecting care provision. Several of these variables represent the 16 resident categories developed in the Resource Utilization Groups-Version II (RUG-II) model

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of nursing home staff resource provision.32 These groups identify nursing home residents receiving rehabilitative services, presenting specific special care needs or complex clinical problems, or manifesting severe behavioral problems. They also differentiate among residents based on their need for assistance in activities of daily living. Previous research indicates that resource provision to residents is driven by two types of needs: those for assistance in performing activities of daily living and those deriving from relatively low-prevalence special conditions, treatments, or diagnoses.36-40 The RUG-IT system is built around a recognition of these two fundamental determinants of care provision in nursing homes. Some residents may need more care than others because they cannot dress themselves or use a toilet while unattended. Other residents may receive more staff assistance because they have a tracheostomy, are receiving physical therapy, or have a diagnosis of multiple sclerosis. Far and away, however, the major determinant of staff effort (especially that of nursing assistants) is a resident's need for assistance with activities of daily living, which the RUG-TI model emphasizes. In addition, the RUG-TI categories constitute the most widely used and tested model for predicting variations in nursing home resource provision that are associated with resident impairment and care needs. RUG-IT was developed on the New York database used in this study, and it has been shown to apply well to the Texas data used in this analysis. Moreover, its utility has also been demonstrated in estimating resource provision in the data from the four states involved in the NHCMQD.32,41 Because the RUG-II model does not explicitly include a measure of cognitive functioning, we have included in the models another series of binary variables representing residents' levels of cognitive functioning. Previous research has shown that such variables do not have a very large impact on wage-weighted measures of resource use.40 Nonetheless, they have been included in the models for two reasons. First, a resident's cognitive functioning is an important factor in the facility's and physician's decision to use restraints.4,10,18,20,42,43 Second, more recent research has indicated that cognitive function, though it may not affect total wage-weighted time, has a significant effect on resource provision by nursing aides and among specific subpopulations of residents.40 344 American Journal of Public Health

Reliability ofthe Indicators All the data sets used in this study have been extensively tested for interrater reliability, and these data were collected under strict protocols designed to ensure high data quality. At least 5% of the resident assessments in each data set were reassessed. High agreement between assessors was achieved, and reliability rates were almost always in excess of .7.44,45 The NHCMQD instrument was subjected to yet more stringent testing in that dual assessments were done in the initial development process for the Minimum Data Set and in the NHCMQD data collection.34,46 Studies in all the states used the same method of measuring staff time. These protocols included a variety of techniques to ensure the collection of accurate data, including pilot testing in each facility, routinized staff oversight, detection and correction of abnormal values, and on-site review of forms.

Sampling and StatisticalAnalysis The units included in each time study were from those facilities in each state that were identified as providing at least adequate care. The units were also stratified to present variability in ownership, size, and certification. Moreover, they were chosen to include greater than average proportions of residents who exhibited higher levels of need. Thus, these data do not constitute samples that can be used to make inferences about resource use in the states from which the data derive. These data simply report on the relative differences in resource provision and restraint use among the approximately 12 000 residents on whom data were available. However, for illustrative purposes, the characteristics of these residents are compared with those of residents chosen in a representative national sample. The specifics of the sampling strategies in each study are discussed in greater detail elsewhere.44,45 The multivariate models presented in this effort are ordinary least squares models. An alternative two-stage modeling strategy might have been used. Such models are sometimes useful when a major determinant of the condition of interest (i.e., being restrained), which is also correlated with the dependent variable (i.e., resource use), cannot be included in one's model. Previous research, however, indicates that those major determinants of being restrained that are correlated with resource use (i.e., cognitive status, behav-

ioral problems, performance of activities of daily living) are included in our singlestage ordinary least squares model.47 All the independent variables in these ordinary least squares models are binary. The statistical significance of model parameters is reported because these data are subject to various sources of random error (e.g., measurement process error). To enhance the clarity ofthe presentation, we report only the coefficients of determination for the full models and the individual parameters for the restraint variables. (Tables displaying the full models are available from the primary author of this paper.)

Results Table 1 displays information on the characteristics of the nursing home residents in the three data sets and in the 1987 National Medical Expenditures SurveyInstitutionalized Population Component.48 As this table indicates, the residents included in the case-mix databases were, on the whole, more impaired than the residents sampled in the representative national survey. For example, eating is the activity of daily living in which independence is usually retained for the longest time. In the national sample, 34% of residents needed assistance in eating; in the case-mix samples, however, the proportion of residents needing such assistance was much higher. The case-mix samples also contain higher proportions of residents suffering from some cognitive impairment. The higher impairment levels in the case-mix samples were not unexpected. The case-mix samples were purposely constructed to include a relatively larger number of more seriously impaired, or heavy-care, residents in each state. However, as these data indicate, there was considerable variation across the states in resident status. The prevalence of restraint use also varied considerably across the three casemix samples. In all instances, however, the prevalence of physical restraint use was higher than that found in the 1977 National Nursing Home Survey.3 The level in the 1986 Texas sample (45%) was, for example, approximately 80% higher than that found in the 1977 national sample. In total, roughly 40% of the approximately 12 000 residents included in these samples were subject to regular use of physical restraints. The care-time estimates for the residents in the time-study samples also apMarch 1993, Vol. 83, No. 3

Restraints and Costs in Nursing Homes pear in Table 1. In these samples, the majority of the care was provided by nursing aides, who spent between 71 and 84 minutes a day caring for the "average" resident. Between 25% and 35% of the total care time was provided by licensed nursing staff. The weighted care time, which varies from 81 to 108 across the three samples, is the wage-weighted sum ofthe care provided by the different types of staff. The weights are relative weights based on the average national wage for each tpe of staff member. Though not calibrated into actual dollars, these measures reflect the relative cost of the staff time provided to different residents. Table 2 displays the bivariate relationships between restraint use and staff care time in the case-mix databases. Residents who were restrained received significantly more care time-and between 40% and 60% more weighted care timethan unrestrained residents. As Table 2 demonstrates, the bulk of this difference comes in the much higher levels of aide time provided to restrained residents. Although restrained residents received slightly more licensed staff time than did other residents, these differenceswere relatively small. In our three data sets, restrained residents received between 67% and 75% more aide time than did restraintfree residents. One potential problem with the results found in Table 2 is that the differences in care time between restrained and unrestrained residents may derive from differences other than the presence or absence of restraints. Table 3 displays some of the differences that one finds among these residents. The restrained and unrestrained residents were relatively similar in gender and age. However, they differed dramatically across factors consistently associated with higher levels of staff time: prevalence of behaviors seen as inappropriate by staff, cognitive impairment, and need for assistance with activities of daily

liVing.32-3-0

To control for differences in stafftime that are unrelated to restraint use, we estimated a series of multivariate ordinary least squares regression models. As indicated above, these models included indicators of residents' self-performance of activities of daily living, cognitive status, behavioral problems, rehabilitative care needs, and other special care needs (e.g., suctioning). These analyses, the results of which are partially presented in Table 4, estimate the effects of restraint use on licensed nurse time, aide time, and total wage-weighted care time, while statistiMarch 1993, Vol. 83, No. 3

cally adjusting for those

other resident characteristics that have been shown to affect staff time. The reported models include these characteristics of residents as they are represented in the RUG-II classification system. The robustness of these results was tested in various ways. Analyses were performed in which the various elements of the RUG-II system were independently included in the model. For example, in

one set of analyses, the RUG-1I categories were not used and direct indicators of activities of daily living and behavioral problems were included in the model. In another analysis, the resource use indicators were logged to determine the sensitivity of our results to the distributions of the dependent variables. None of these efforts produced results inconsistent with those reported here. The time-study results concerning

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Philips et al. utes less care from licensed nursing staff. In the 1990 case-mix sample, restrained residents received more than 2 minutes less licensed nursing care. Separate analyses were also performed on the data for each ofthe six states included in the 1990 NHCMQD database. The results of these analyses were consistent with the results in Table 4. Across all six states, the analysis indicated that restrained residents required more care from nursing assistants. In all six samples, this difference was statistically significant. In five ofthe six samples, restrained residents received less licensed nursing time, but this result was statistically significant in only one state. In five of the six state samples, restrained residents received more weighted care time. This difference was significant in three of those five samples. In no state did restrained residents receive significantly less weighted care time. Obviously, nurse staffing patterns vary from facility to facility and from state to state. One might be concerned that our results derive from such differences. However, two factors argue against the presence of such a bias. First, the dependent variables in this analysis are direct measures of care time provided to residents; they are not staffing indicators. Second, the results reported here are quite consistent across data sets from three different time periods and from seven different states with widely divergent nursing home reimbursement structures, staffing, profitability levels, and patterns of ownership. Both the nature of our dependent variables and the robustness of our results provide considerable support for our contention that the reported results derive from differences in the presence or absence of restraints and are not simply reflective of differences across facilities.

nursing assistant or aide time were quite consistent in the three databases. The unstandardized regression coefficients for the restraint variables in Table 4 reflect differences in units of care related to the presence of restraint use. In the case-mix samples, the unique effect of restraint use was that restrained residents received larger amounts of aide time each day. The largest difference was found in the data from 1990, with restrained residents receiving almost 13 more minutes of aide time per day, whereas the smallest difference was found in the 1983 data from New York, in which restrained residents received only 2 more minutes of aide time per day. After controlling for other factors that may have affected resource provi346 American Journal of Public Health

sion, the total wage-weighted care time provided to residents who were restrained was higher in all three databases. Both of the statistically significant results related to wage-weighted time imply that it costs more, rather than less, to restrain nursing home residents. The explanation for this is found in the additional aide time that is provided to restrained residents. In these samples, restrained residents received more assistance from aides, even after controlling for differences in self-performance of activities of daily living. In two of the three databases, the presence of restraints was inversely related to licensed nursing care time. These differences ranged from the minimal to the significant. In the 1986 Texas sample, restrained residents received only .04 min-

Concuions The data presented clearly indicate that fears about dramatic cost increases being associated with lowered use of restraints are misplaced. Residentswho are restrained are likely to require more, rather than less, staff time and care. These results respond direcly to concems voiced by some state policymakers and segments of the nursing home industry about the potential cost of implementing the reforms in the 1987 budget act. As the results demonstrate, it should be possible to implement the reforms and improve quality of care and life for residents without imposing crippling new long-term care costs on private and public payors. Indeed, restraint reduction may reduce total March 1993, Vol. 83, No. 3

Restrts and Costs in Nursing Homes

nursing home costs, and this should provide a strong financial incentive for facilities to comply with the reforms. The data show that residents who are restrained receive more time from nursing aides or assistants than do similarly impaired residents who are not restrained. This finding is consistent with many observers' expectations that dealing with residents who are restrained is very timeconsuming for direct-care staff. For example, facility staff are required by law to remove the physical restraints and reposition residents every 2 hours. Even if this requirement were rarely honored by staff, the increased needs with activities of daily living, incontinence, and agitation associated with restraint use may demand considerable staff effort. These results imply that the nursing home reforms in the 1987budget act aimed at reducing restraint use will not place an extraordinary cost burden on the nursing home industry or payors. Instead, these reforms may result in considerable savings, even taking only wage-adjusted staff time into account. The savings may be even more significant if, as previous research suggests, restraint reduction is associated with improvements, or a slower rate of decline, in residents' functioning and psychosocial well-being. However, it is important to note the limitations of this research. Our analyses focus on the differentials in care time related to whether a resident is restrained. Other issues, such as the effects of restraint reduction on the well-being of those residents who are not restrained and any changes in well-being for those freed from restraints, are not considered. Nor are the specific costs associated with rehabilitating currently restrained residents who are released. Finally, any long-term financial effects that result from reduced rates of functional decline among residents or changes in staff stress or turnover attributable to restraint reduction are not estimated. E

Acknowledgments This research was supported by a grant from the National Institute of Mental Health (LCR-2 5R01 MH43406-02). Early analyses ofthe 1983 data from New York were supported with funds from the Nursing Home Community Coalition of New York State. All the data used in this research were originally collected during research supported by the Health Care Financing Administration.

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