This, the largest study of its type in the U.S., is the first to broadly examine the relationship of NH characteristics to HP adherence. It is of importance because it can help explain rates of adherence ranging from 20-92%,10
and provide guidance for organizational change to promote HP use. The final analytic model that combined significant facility- and resident-level characteristics identified six facility characteristics related to more adherence. One unfortunate finding is that adherence was lower in facilities with a higher Medicaid case-mix. This finding is consistent with reports of fewer resources and more health-related deficiencies in NHs with more Medicaid residents.30
Facilities with higher Medicaid case-mix also are more likely to serve African American residents, which may explain why this resident-level variable became non-significant in the combined model. Thus, it is possible that racial and socioeconomic disparities in adherence are less related to resident-level characteristics than to health system factors, and this is the first study to document the extension of that disparity to the use of HPs.
Not surprisingly, more paraprofessional training related to adherence, and NHs that better prepare staff for their work, in general, are likely to evidence higher adherence. Other studies also have demonstrated the positive effect of training on falls and hip fracture prevention.31,32
This study also found that having more rotating workers is related to more adherence. As such, it is the third study to run counter to prevailing wisdom in suggesting that permanent (non-rotating) staffing is not always beneficial to residents.33,34
In the case of adherence to HPs, it may be that new staff are especially vigilant to resident care plans due to their unfamiliarity with the resident. While the conclusions do not necessarily suggest the use of rotating workers, they do suggest that NHs focus on more frequent review of and attention to care plans. These two findings, related to training and diligence to care plans, may explain in part why adherence was higher in facilities in which administrators were less involved in meetings; that is, it may be that administrators are less involved when other procedures are in place to assure quality care. In support of this conclusion, administrators were less involved in meetings in NHs that had a falls prevention program (Pearsons r = −.39), commitment to HPs (r = −.37 to −.54), and better quality of care (r = −.63), and more involved in settings that evidenced more DON and RN staff turnover (r = .48 and .38). This interpretation provides hypotheses for further study.
The more eligible residents who were wearing HPs, the less the adherence. This finding persisted when resident-level characteristics were added to the model, suggesting it was the sheer number of residents, rather than their dependence, that related to adherence. One interpretation of this finding relates to the time required for staff to dress residents in the HP. Given the amount of care required by NH residents, the workforce shortages,35
and that over-burdened staff relegate optional tasks to a secondary status,36
these findings suggest three avenues of action. The first is to bolster the workforce, such as to involve families in promoting HP use. Indeed, family involvement is related to increased adherence.18
The second is to provide staff education about the risks and consequences of hip fracture. The third is to target the use of HPs to those most in need, and emphasize their use as an integral component of the care plan.
Finally, non-profit ownership and not being affiliated with a chain were related to almost 6% more adherence. There is abundant evidence that for-profit status is related to poorer quality care and outcomes23,37
and that the majority of for-profit NHs are affiliated with a chain while only a minority of non-profit NHs have a chain affiliation.38
Thus, findings from the current study add to what has been written about for-profit NHs by extending it to adherence with care practices.
This study also demonstrated that with careful attention to adherence, rates averaging 75% or more can be sustained for as long as two years. This figure is markedly higher than other studies (e.g., Kurrle obtained 53% adherence).13
Of course, this study used a run-in period which excluded those with poor adherence; also, as an efficacy study, neither this study nor others can assure that the observed adherence rates will be achieved in daily practice. On the other hand, being a research project and not a standard of care may have adversely affected adherence. It is in this context that this study provides guidance as to the types of facilities in which special efforts will be necessary to maximize the use of HPs – NHs that have a higher Medicaid and African American case-mix, less of a culture of staff training, and staff who are more burdened and may not be able to attend as closely as desired to resident care plans. In instances when staff cannot attend closely to all residents who might benefit from HPs, it is suggested that their use be targeted to those residents who are most likely to use them.10,18
Residents who passed the two-week run-in period were significantly more likely to be incontinent and not independently mobile; to have fallen in the preceding six months; and to have a dementia diagnosis or be taking osteoporosis medicines. However, for those who continued in the study, in models adjusted for resident status, having cognitive impairment was related to lower adherence. Other studies have found less39
adherence among those who are cognitively impaired; and less10
adherence among those who are incontinent. One study found a significant relationship between depression and lower adherence,18
although this was not significant in adjusted analyses. However, comparisons across studies are complicated by the fact that not all controlled for similar characteristics or defined variables similarly. There is evidence, however, that residents at risk of fracture are more likely to be adherent.9,10
In light of conflicting resident-level findings and facility characteristics that suggest a need to target HP use, it may be that the best approach is one that is individualized: offer HPs to all residents who are at risk, and encourage their use in residents who are willing to wear them. The success of this effort in reference to adherence should be evident by twelve weeks time.40
This focus on individualized care is consistent with the importance of treating residents respectfully, which was significantly related to adherence until the fully adjusted model was run.
Despite being the only study to examine facility-level predictors of adherence to HPs in U.S. NHs, this project has limitations. The most notable is that the HP was one-sided, raising concerns as to generalizability. Also, the project used a run-in period that results in higher adherence among those who remain in the study; similarly, research staff visited frequently to encourage adherence. Further, while a large number of facility- and resident-level characteristics were studied, not all were sufficiently powered for analyses. Still, findings that adherence is lower in NHs that have more Medicaid case-mix and African American residents and less training for certified nursing assistants, and in which staff are more burdened, can explain differences in adherence across studies and indicate settings in which special efforts are needed to encourage adherence with HPs to decrease fractures.