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Research Questions

  1. What is the feasibility, reliability, and validity of these candidate SPADEs?
  2. What subset of candidate SPADEs can be standardized across PAC settings?
  3. What are the strengths and weaknesses of collecting these data elements in practice, based on the perspectives of research nurses and facility and staff assessors?

The Centers for Medicare & Medicaid Services (CMS) contracted with the RAND Corporation to evaluate candidate standardized patient assessment data elements (SPADEs) in a national field test titled the National Beta Test. The National Beta Test was conducted to evaluate the performance of candidate SPADEs in the clinical categories of (1) cognitive function and mental status; (2) special services, treatments, and interventions; (3) medical conditions and comorbidities; (4) impairments; and (5) other categories, for use in four post-acute care (PAC) settings: home health agencies, inpatient rehabilitation facilities, long-term care hospitals, and skilled nursing facilities.

This is Volume 4 of the final report on the National Beta Test, which includes the identification and testing of candidate SPADEs in the cognitive status clinical category. This volume provides results and significance tests on the feasibility, reliability, validity, stability and change over time, and sensitivity to national representativeness of the candidate SPADEs. The data elements tested include the Brief Interview for Mental Status (BIMS), the Confusion Assessment Method (CAM), Expression and Understanding, and Behavioral Signs and Symptoms. All four cognitive status data elements performed reasonably well, showing feasibility, acceptable reliability, and substantial support from assessors.

Key Findings

All four data elements performed well, with some key differences

  • In terms of feasibility, missing data were very low for all four tested data elements, but there was some variability in time to complete. The BIMS, which consists of seven questions, took the longest to complete.
  • Interrater reliability was acceptable for all data elements, although some performed better than others. Overall kappas for the BIMS were excellent. Kappas were good to moderate for Expression and Understanding. Kappas, where calculated, were also good to moderate for the CAM. However, several kappas could not be calculated for the CAM, and no kappas were calculable for Behavioral Signs and Symptom, because of low prevalence rates.
  • Results for repeat assessment (performed three, five, and seven days after admission and at discharge) generally showed very little variability in data element scores, reinforcing the overall stability of the data elements.
  • As with the quantitative results, assessor feedback was generally supportive of all the cognitive status data elements. That is, the data elements were all deemed at least moderately clinically useful and to have reasonably low burden by the clinical assessors in this study.

Table of Contents

  • Chapter One

    Introduction

  • Chapter Two

    Standardized Assessment of Cognitive Function in Post-Acute Care

  • Chapter Three

    Brief Interview for Mental Status

  • Chapter Four

    Confusion Assessment Method (CAM)

  • Chapter Five

    Expression and Understanding

  • Chapter Six

    Behavioral Signs and Symptoms

  • Chapter Seven

    Conclusion

  • Appendix

    Supplementary Tables

Research conducted by

The research described in this report was sponsored by the Centers for Medicare & Medicaid Services (CMS) and conducted by the Quality Measurement and Improvement Program within RAND Health Care.

This report is part of the RAND Corporation research report series. RAND reports present research findings and objective analysis that address the challenges facing the public and private sectors. All RAND reports undergo rigorous peer review to ensure high standards for research quality and objectivity.

The RAND Corporation is a nonprofit institution that helps improve policy and decisionmaking through research and analysis. RAND's publications do not necessarily reflect the opinions of its research clients and sponsors.