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AIDS PATIENT CARE and STDsVolume 15, Number 7, 2001Mary Ann Liebert, Inc.
Nursing Home Residents with HIV and Anemia
ROBERT J. BUCHANAN, Ph.D.,1 SUOJIN WANG, Ph.D.,2 and CHUNFENG HUANG3
ABSTRACT
This research profiles nursing home residents who have human immunodeficiency virus(HIV) and anemia at the time of admission, utilizing the minimum data set (MDS). In addi-tion, this article compares residents with HIV and anemia to other nursing home residentswith HIV. These resident profiles include sociodemographic characteristics, health status mea-sures, and special treatments and procedures received. This study analyzed 1,281 admissionassessments for HIV residents with anemia and 3,832 admission assessments for other resi-dents with HIV in the MDS between June 22, 1998 and January 17, 2000. A significantly greaterpercentage of HIV residents with anemia were female (38.6%) compared to other residentswith HIV (27.9% female). Almost two-thirds of HIV residents with anemia and three-quar-ters of other residents with HIV received Medicaid coverage at the time of their admissionto the nursing home. Approximately 3 of every 4 residents with HIV and anemia and otherresidents with HIV were from racial/ethnic minority groups. Significantly greater percentagesof residents with HIV and anemia also had dementia, depression, pneumonia, hepatitis, re-nal failure, anxiety disorder, and cancer than other residents with HIV. These analyses dem-onstrate that at the time of admission to the nursing home, those residents with HIV and ane-mia were significantly more likely to have other diseases, infections, and health careconditions than other residents with HIV. In addition, HIV residents with anemia were sig-nificantly more likely to receive special treatments and procedures in the nursing home thanother residents with HIV.
373
INTRODUCTION
ANEMIA IS THE MOST COMMON hematologicabnormality among people with human
immunodeficiency virus (HIV) disease.1,2 Ane-mia is defined by a decrease in the number ofred blood cells. Anemic people exhibit fatigue,difficulty breathing, increased heart rate, andpallor.3 HIV-related anemia can be caused byHIV infection itself, opportunistic infections,neoplasms, or drug therapies.4–7 Zidovudine,for example, has been linked with anemia in
people with HIV disease.8 Ganciclovir, used totreat cytomegalovirus (CMV) infections, cancerchemotherapy drugs, and hydroxyurea canalso induce anemia in people with HIV.1 In ad-dition to affecting the quality of life for peoplewith HIV disease, anemia has been associatedwith early death.9 Studies indicate that peoplewith HIV disease who recovered from anemiahad increased median length of survival and areduced risk of death.4,10
The objectives of this study were to presentprofiles of residents with HIV who also had
1Department of Health Policy and Management, School of Rural Public Health, The Texas A&M University Sys-tem Health Science Center, College Station, Texas.
2Department of Health Statistics, Texas A&M University, College Station, Texas.3Doctoral candidate, Department of Health Statistics, Texas A&M University, College Station, Texas.
anemia at the time of their admission to the nurs-ing home and to compare these profiles to nurs-ing home residents with HIV who did not haveanemia. This research analyzes the “minimumdata set (MDS) for nursing home resident as-sessment and care screening” to create these twosets of profiles, describing and comparing theirsociodemographic characteristics, their healthstatus, and the care and services these residentsreceive. Analyses identified statistically signifi-cant differences in the profiles of these two setsof nursing home residents with HIV.
THE MINIMUM DATA SET
To improve the quality of nursing home care,in 1986 the Institute of Medicine (IOM) recom-mended the comprehensive functional assess-ment of nursing home residents.11 The IOMconcluded that these assessments would gen-erate data essential to the development of in-dividualized care plans for nursing home resi-dents as well as assist with the development ofresident-level quality of care measures. Thefederal Omnibus Budget Reconciliation Act of1987 (OBRA ‘87) codified the IOM recommen-dations, requiring all Medicare and Medicaid-certified nursing homes to implement a stan-dardized assessment tracking form for allresidents, regardless of payment source.
The Health Care Financing Administrationof the U.S. Department of Health and HumanServices developed The Basic Assessment Track-ing Form to perform these comprehensive as-sessments of nursing home residents, creatingthe Minimum Data Set (MDS) for NursingHome Resident Assessment and Care Screen-ing.12 Full MDS assessments are required foreach resident at admission, with significantchanges in status, and at least annually afteradmission. In addition, residents are assessedquarterly on a subset of items in the MDS track-ing form. Effective June 22, 1998 the federalgovernment required that the states and nurs-ing homes encode and transmit the MDS.13
The MDS tracking form
The MDS tracking form contains compre-hensive assessments and care screening of all
nursing home residents in the United States, in-cluding sociodemographic variables such asgender, birth date, marital status, residenceprior to admission to the nursing home,race/ethnicity, and payment source. The MDSalso includes data on cognitive skills, painsymptoms, oral/dental status, and variablesthat assess physical functioning. In addition,the MDS records disease diagnoses, infections,the number of medications that residents mayhave, as well as any special treatments, pro-grams, and procedures they may receive.
Reliability of the MDS
The initial testing of the MDS involved twowaves of testing interassessor reliability. MDSitems in key areas such as activities-of-daily-living (ADL) performance, cognitive perfor-mance, and diagnoses achieved a Spearman-Brown intraclass correlation of 0.7 or higher.14
Phillips and Morris analyzed two scales devel-oped using the MDS: an ADL scale and a cog-nitive performance scale.17 They comparedthese scales (derived from staff ratings at thenursing home) with the same scales completedduring a study that used registered nurses withgeriatric nursing experience. Cronbach a forthe two scales in each of these groups wasnearly identical and the correlations among theindividual terms were very similar between thetwo groups. These studies indicate excellent re-liability of the MDS, confirming its use inanalyses of nursing home residents.
METHODS
This research utilized the MDS to create pro-files of people with HIV disease who also hadanemia at admission to the nursing home, aswell as profiles of residents with HIV at ad-mission who did not have anemia. (Residentswith HIV who did not have anemia will be re-ferred to as other residents with HIV in the re-mainder of this article.) The MDS tracking formincludes “HIV infection” in the subsection on“Infections” (Section I, 2.d.) and “anemia” inthe subsection “Diseases” (Section I, 1.oo) in the“Disease Diagnoses” section. The MDS definesanemia to include anemia of any etiology.16
To create profiles of residents at a compara-
BUCHANAN ET AL.374
ble stage of their nursing home stay, this studyanalyzes admission assessments. From June 22,1998 through January 17, 2000 there were 1,281admission assessments for nursing home resi-dents with HIV who also had anemia in theMDS.* There were 3,832 admission assessmentsfor other residents with HIV in the MDS duringthis same time period. These data demonstratethat 25.1% of all nursing home residents withHIV also had anemia at admission to the nurs-ing home. Data from these admission assess-ments were analyzed using the statistical soft-ware package SAS. The MDS data displayed inthis research are consistent with HCFA’s datarelease and privacy guidelines.
These groups of HIV residents with anemiaand other residents with HIV are not samplesbut entire populations. We computed for theseanalyses population characteristics such as per-centages, means, medians, standard deviations,etc. These characteristics were obtained from thewhole populations, and thus, these characteris-tics were not estimated from random samples.Because we have population characteristics forHIV residents with anemia and for other resi-dents with HIV at admission to the nursinghome, these two groups can be compared with-out any concern for sampling error. It is not nec-essary to construct confidence intervals aroundpoint estimates for the overall population (i.e.,25.1% of nursing home residents who were di-agnosed with anemia at admission).
However, it is important to ascertainwhether the variability across subgroups ex-ceeds the variability within each subgroup(thus statistical testing). This is especially rele-vant for linear variables such as the many scalesincluded in this study. It is also relevant whenthe scales or data are divided to create di-chotomous variables or categories. To test fordifferences of statistical significance betweenHIV residents with anemia and other residentswith HIV, we used two sample tests for com-parisons of proportion (e.g., gender) and forcontinuous variables (e.g., age, ADL LongScale). We used the two-way contingency table
x2 test for categorical data (e.g., marital status).In the tables that summarize comparisons ofMDS characteristics between these two sub-groups of nursing home residents with HIV,we denote statistically significant differences atthe 0.05, 0.01, 0.001, and 0.0001 levels.
RESULTS: RESIDENT PROFILES
Sociodemographic characteristics
Table 1 provides sociodemographic compar-isons of HIV residents with anemia at admissionto the nursing home to other residents with HIVat admission. HIV residents with anemia weresignificantly more likely to be female (38.6%)than other residents with HIV (27.9% were fe-male). HIV residents with anemia were signifi-cantly older (mean age was 45.99 years) thanother residents with HIV (mean age was 43.93years). Looking at age from another perspective,76.9% of other residents with HIV were 50 yearsor younger in contrast to only 71.0% of HIV res-idents with anemia who were 50 years oryounger. Differences in age distributions be-tween the two sets of nursing home residentswith HIV were statistically significant.
Racial/ethnic differences between HIV resi-dents with anemia compared to other residentswith HIV were statistically significant. AsTable 1 illustrates, 61.9% of HIV residents withanemia were black compared to 58.4% of otherresidents with HIV who were black. In contrast,only 13.9% of HIV residents with anemia wereHispanic compared to 16.9% of other residentswith HIV who were Hispanic. There is virtu-ally no difference in the percentages of whitepeople in each of these two groups of HIV res-idents (23.4% of HIV residents with anemia and23.5% of HIV residents without anemia).
Table 1 presents the various payment sourcesfor the care provided to both groups of nurs-ing homes residents with HIV. Residents withHIV and anemia were significantly less depen-dent on the state Medicaid programs (65.3%)than other residents with HIV (72.3%). A sig-nificantly higher percentage of residents withHIV and anemia had private health insurancecoverage (14.4%) than other residents with HIV(11.8%).
NURSING HOME RESIDENTS WITH AIDS AND ANEMIA 375
*Any MDS data from New York State included in thisstudy are from January 1, 1998 through January 17, 2000.All other MDS data from other states are from the periodJune 22, 1998 through January 17, 2000.
TABLE1.
SOCIO
DEMOGRAPHIC
CHARACTERISTIC
SOFN
URSINGH
OM
ERESIDENTS
WIT
HHIV
(MDS A
SSESS
MENTS
ATTIM
EOFA
DM
ISSION)
Characteristic
HIV residents with anemia
HIV residents without anemia
Gen
der
aMale
561
.4%; Fe
male
538.6%
Male
572
.1%; Fe
male
527
.9%
Age
aMea
n 5
45.99 ye
ars; M
edian
543
.15 ye
ars (SD 5
14.95; first
Mea
n 5
43.93 ye
ars; M
edian
542
.78 ye
ars (SD 5
11.10; first
quartile 5
36.62; third quartile 5
51.52)
quartile 5
36.66; third
quartile 5
49.31)
Age
distribution
a30
yea
rs or yo
ung
er 5
7.4%
; 31
to 40
years 5
29.7%; 4
1 to 50
30 years or yo
ung
er 5
6.1%
; 31
to 40
years 5
31.9%; 4
1 to 50 ye
ars
years
533
.9%; 5
1 to 60 ye
ars
515
.6%; 61
to 70
yea
rs 5
5.0%
;5
38.9%; 5
1 to 60 ye
ars
514
.9%; 61
to 70
yea
rs 5
5.5%
; 71 to 80
71 to 80 yea
rs 5
3.2%
; 80 years or olde
r 5
5.2%
years
51.9%
; 80
yea
rs or olde
r 5
0.7%
Racial/ethn
icityb
Black
(no
t Hispa
nic) 5
61.9%; W
hite (no
t Hispa
nic) 5
23.4%;
Black
(no
t Hispa
nic) 5
58.4%; W
hite (no
t Hispa
nic) 5
23.5%;
Hispan
ic 5
13.9%; American
Ind
ian/
Alaskan
Native
,1%
;Hispan
ic 5
16.9%; American
Ind
ian/
Alaskan
Native
,1%
;Asian
/Pacific Islan
der ,
1%Asian
/Pacific Islan
der ,
1%
Marital statusa
Nev
er m
arried
560
.8%; D
ivorced 5
11.6%; M
arried
510
.4%;
Nev
er m
arried
567.4%; D
ivorced 5
11.8%; M
arried
59.8%
;W
idow
ed 5
10.0%; S
eparated
57.2%
Widow
ed 5
5.5%
; Se
parated
55.6%
Paym
ent source
Med
icaid per diem
a5
65.3%; Pr
ivate he
alth ins
uranc
eb5
14.4%;
Med
icaid per diem
a5
72.3%; Pr
ivate he
alth ins
uranc
eb5
11.8%;
(may
hav
e more
Other per diem
e5
7.1%
; Med
icare per diem
e5
5.2%
; Med
icare
Other per diem
e5
8.0%
; Med
icare per diem
e5
5.6%
; Med
icare
than
one
)Part A
e5
4.1%
; Self Pay
e5
3.8%
; Med
icaid Liability/
Med
icare
Part A
e5
4.9%
; Se
lf Pay
e5
3.6%
; Med
icaid Liability/
Med
icare
Co-pa
ye5
3.3%
; Med
icare Part Bd
51.8%
; VA/CHAMPUSe
51.1%
Co-pay
e5
4.1%
; Med
icare Pa
rt B
d5
3.3%
; VA/CHAMPUSe
51.0%
Admitted to nu
rsing
Acu
te care ho
spital 5
82.3%; P
riva
te hom
e/ap
artm
ent witho
ut hom
eAcu
te care ho
spital 5
76.4%; P
riva
te hom
e/ap
artm
ent witho
utho
me from
che
alth 5
6.1%
; Other 5
3.7%
; Nur
sing
hom
e 5
3.2%
; Priva
teho
me he
alth 5
7.0%
; Other 5
6.0%
; Nursing ho
me
54.4%
; ho
me/
apartm
ent with ho
me he
alth 5
1.8%
; Reh
abilitation
Priva
te hom
e/ap
artm
ent with ho
me he
alth 5
2.6%
; Reh
abilitation
hosp
ital 5
1.1%
; Psych
iatric hospital/M
R/DD facility 5
1.0%
; ho
spital 5
1.0%
; Psych
iatric hospital/M
R/DD facility 5
1.3%
; Boa
rd and
care/
assisted
living/
grou
p hom
e 5
0.9%
Boa
rd and
care/
assisted
living/
grou
p hom
e 5
1.4%
Lived
alone
prior
No
563.9%; Y
es 5
27.9%; O
ther facility 5
8.1%
No
559
.6%; Y
es 5
29.3%; O
ther facility 5
11.0%
to admission
d
a ,0.0001
; b,0.05; c
,0.00
1; d
,0.01; e, n
ot significant.
NURSING HOME RESIDENTS WITH AIDS AND ANEMIA 377
Table 1 also provides information on mari-tal status, where residents were admitted to thenursing home from, and whether these resi-dents lived alone prior to their admission tothe nursing home. A smaller percentage of HIVresidents with anemia never married (60.8%)compared to other residents with HIV whonever married (67.4%). A higher percentage ofHIV residents with anemia were widowed(10.0%) compared to other residents with HIV(5.5%). These differences in marital status be-tween the two sets of residents with HIV werestatistically significant. A significantly higherpercentage of HIV residents with anemia wereadmitted to the nursing home from an acutecare hospital (82.3%) compared to other resi-dents with HIV (76.4%) who were admittedfrom an acute care hospital. Only 1.8% of res-idents with HIV and anemia and 2.6% of otherresidents with HIV were admitted to a nursinghome from a private home or apartment wherethey received home health services.
Health status/medical condition characteristics
Physical dependency. ADLs are used to as-sess the physical dependency of nursing homeresidents, with levels of ADL dependency de-ciding nursing and rehabilitation care for mostresidents. Based on MDS data, Morris et al.17
developed ADL scales: an ADL Long Scale(possible scores of 0–28) and an ADL ShortScale (possible scores of 0–16). The higher the score on each ADL scale, the more physi-cally dependent the nursing home resident.Using approximately 175,000 MDS assess-ments recorded in 1994 from seven states, Mor-ris et al.17 calculated a mean of 15.24 for allnursing home residents for the ADL Long Scale(median 5 16; SD 5 9.25) and a mean of 8.73for the ADL Short Scale (median 5 9; SD 55.36). Buchanan et al.18 applied the ADL LongScale methodology to MDS admission assess-ments of nursing home residents with multi-ple sclerosis, observing a mean of 18.55 (me-dian 5 19; SD 5 7.77).
Compared to this seven-state cohort of allnursing home residents and recently admittedresidents with MS, residents with HIV aremuch less physically dependent at the time oftheir admission to the nursing home. HIV res-
idents with anemia averaged only 9.08 on theADL Long Scale and 5.34 on the ADL ShortScale at their admission to the nursing home.Other recently admitted residents with HIVwere even less physically dependent, averag-ing 8.10 on the ADL Long Scale and 4.75 on theADL Short Scale. Differences in the ADL Scalesbetween the two sets of nursing home residentswith HIV were statistically significant. To pro-vide another perspective on physical depen-dency, 75% of HIV residents with anemia re-ceived a score of 16 or less on the ADL LongScale and 10 or less on the ADL Short Scale;75% of other residents with HIV received ascore of 15 or less on the ADL Long Scale and9 or less on the ADL Short Scale.
In addition, 30.76% of HIV residents withanemia were completely physically indepen-dent (score 5 0), as measured by the ADL LongScale compared to 35.11% of other residentswith HIV who were completely physically in-dependent as measured by this scale. Similarly,32.40% of HIV residents with anemia werecompletely physically independent (score 50), as measured by the ADL Short Scale com-pared to 36.96% of other residents with HIVwho were completely physically independentas measured by this scale. These ADL scalesdocument that recently admitted residentswith HIV tend to be substantially much lessphysically dependent than other nursing homeresidents. However, residents with HIV andanemia were significantly more physically de-pendent than other residents with HIV, as mea-sured by these ADL scales.
Cognitive skills. The MDS measures eachnursing home resident’s cognitive skills fordaily decision making. Table 2 demonstratesno statistical difference in measures of cogni-tive skills between HIV residents with anemiaand other residents with HIV at admission tothe nursing home. Almost identical percent-ages of residents with HIV and anemia andother residents with HIV were independent incognitive skills for daily decision making. HIVresidents with anemia were slightly morelikely to be severely impaired in these cogni-tive skills (6.9%) compared to other residentswith HIV (5.6%).
TABLE2.
HEALTHST
ATUS
ANDM
EDIC
ALC
ONDIT
IONC
HARACTERISTIC
SOFN
URSINGH
OM
ER
ESIDENTS
WIT
HHIV
(MDS A
SSESS
MENTS
ATTI
ME
OFA
DM
ISSION)
Characteristic
HIV residents with anemia
HIV residents without anemia
ADL Lo
ng Scale
aMean
59.08
; med
ian
56 (SD 5
9.37
; first qua
rtile
50; third
Mean
58.10
; Med
ian
54 (SD 5
9.34; first qu
artile 5
0; third
qua
rtile
515
)qu
artile 5
16)
ADL Sh
ort Scaleb
Mean
55.34
; med
ian
54 (SD 5
5.51
; first qua
rtile
50; third
Mean
54.75
; med
ian
52 (SD 5
5.44
; first qua
rtile
50; third
qua
rtile
59)
quartile 5
10)
Cog
nitive
Skills
for
Indep
ende
nt 5
53.3%; m
odified ind
epen
denc
e 5
20.2%; m
oderately
Indep
ende
nt 5
53.1%; M
odified inde
pend
ence 5
21.1%; M
oderately
Daily D
ecision
impa
ired
519
.6%; s
everely im
paired
56.9%
impa
ired
520.2%; s
everely im
paired
55.6%
Mak
ingc
Con
tine
nce, bladde
rcCon
tine
nt 5
67.7%; us
ually
con
tine
nt 5
4.4%
; occasion
ally
Con
tine
nt 5
71.1%; us
ually
con
tine
nt 5
3.9%
; oc
casion
ally inc
ontine
ntincontinen
t 5
4.2%
; frequ
ently incontinen
t 5
7.0%
;5
4.4%
; frequ
ently inco
ntinen
t 5
5.3%
; inc
ontine
nt 5
15.3%
incontinen
t 5
16.7%
Con
tine
nce, bow
eld
Con
tine
nt 5
64.5%; us
ually
con
tine
nt 5
3.8%
; occasion
ally
Con
tine
nt 5
69.3%; us
ually
con
tine
nt 5
3.6%
; oc
casion
ally inc
ontine
ntincontinen
t 5
4.2%
; frequ
ently incontinen
t 5
5.3%
; 5
3.6%
; frequ
ently inco
ntinen
t 5
4.2%
; inc
ontine
nt 5
19.4%
incontinen
t 5
22.2%
Oral pr
oblems
Che
wing prob
lem
e5
13.9%; sw
allowing problem
a5
11.6%;
Che
wing prob
lem 5
9.5%
; swallowing prob
lem 5
9.1%
; Mou
th pain
Mou
th paine
56.6%
52.2%
Oral status
Daily m
outh cared
596.6%; S
ome/
all na
tural teeth loss
e5
46.4%
Daily m
outh care
595.0%; S
ome/
all na
tural teeth loss 5
40.0%
Broke
n, loo
se, o
r cariou
s teethe
519
.6%; D
entures/
bridge
e5
16.6%;
Broke
n, loo
se, o
r cariou
s teeth
511
.5%; D
entures/
bridge
510.5%;
Inflam
ed gum
se5
13.4%; D
ebris/
mou
the
58.0%
Inflam
ed gum
s 5
4.4%
; Deb
ris/
mou
th 5
1.4%
Pain sym
ptom
scNo pa
in 5
49.8%; p
ain
,daily 5
18.7%; P
ain da
ily 5
31.5%
No pa
in 5
52.5%; p
ain
,daily 5
18.6%; P
ain da
ily 5
28.9%
Pain inten
sity
dMild
pain
522
.8%; m
oderate pa
in 5
60.7%; tim
es w
hen pa
in is
Mild
pain
525
.6%; m
oderate pa
in 5
56.6%; tim
es w
hen pa
in is ho
rrible/
(for tho
se w
ith
horrible/excruc
iating
516
.6%
excruciating
517.8%
pain)
Abn
ormal lab
oratory
Yes 5
84.0%
Yes 5
78.0%
values
e
Disease diagn
oses
Dem
entia (other tha
n Alzhe
imer’s)e
526
.1%; d
epressione
525
.7%;
Dem
entia (other tha
n Alzhe
imer’s)
519
.3%; d
epression
519
.0%;
(% of ne
w
pne
umon
iae
521.6%; rena
l failu
ree
518.1%; h
epatitis
e5
14.4%;
pne
umon
ia 5
10.9%; r
enal failure 5
5.6%
; hep
atitis 5
5.2%
; ST
Ds
admission
s)ST
Dse
513.7%; u
rina
ry tract infection
e5
13.2%; a
nxiety disorde
re5
7.3%
; urina
ry tract infection
54.2%
; anx
iety disorde
r 5
4.2%
;5
13.0%
; can
cere
511
.6%; r
espiratory infection
e5
11.5%; a
ntibiotic
canc
er 5
5.8%
; resp
iratory infection
52.6%
; antibiotic resistan
t resistan
t infectione
511
.3%; s
eptic
emia
e5
11.3%; tub
ercu
losise
infection
52.7%
; sep
ticemia 5
2.6%
; tube
rculos
is 5
2.0%
; wou
nd5
10.4%; w
ound
infection
e5
10.0%; s
chizop
hren
iae
59.9%
; clostridium
infection
52.3%
; sch
izop
hren
ia 5
3.9%
; Clostridium
dificile
51.3%
;dificile
e5
9.6%
; bipolar disease
e5
9.1%
; co
njunc
tivitise
57.9%
bipo
lar disease 5
2.0%
; con
junc
tivitis
50.4%
a ,0.01
; b,0.00
1; cno
significanc
e; d
,0.05
; e,0.00
01
Continence. The MDS admission assess-ment indicates whether the resident is bladderand bowel continent in the 14 days prior to theassessment. As Table 2 presents, 71.1% of otherresidents with HIV were bladder continentcompared to 67.7% of HIV residents with ane-mia. A slightly higher percentage of HIV resi-dents with anemia were bladder incontinent(16.7%) compared to other residents with HIV(15.3%) who were bladder incontinent. Anydifferences in bladder continence between thetwo sets of nursing homes residents with HIVwere not statistically significant.
A smaller percentage of HIV residents withanemia were bowel continent (64.5%) com-pared to other residents with HIV (69.3%) whowere bowel continent. Table 2 also shows that22.2% of HIV residents with anemia werebowel incontinent compared to 19.4% of otherresidents with HIV who were bowel inconti-nent. Differences in bowel continence betweenthe two sets of nursing homes residents withHIV were statistically significant.
Oral/dental status. Residents with HIV andanemia were significantly more likely to havechewing problems, swallowing problems, andmouth pain at admission to the nursing homethan other residents with HIV as shown inTable 2. Similarly, residents with HIV and ane-mia were significantly more likely to have toothloss, broken teeth, dentures or a bridge, in-flamed gums, or debris (soft, easily moveablesubstances) present in their mouths prior tobed than other residents with HIV.
Pain. The literature demonstrates that painis common in people with HIV disease.19–21
Table 2 illustrates that residents with HIV andanemia were slightly more likely to experiencedaily pain (31.5%) at admission to the nursinghome than other residents with HIV (28.9%).Looking at the prevalence of pain from anotherperspective, 52.5% of other residents with HIVexperienced no pain at the time of admissioncompared to 49.8% of HIV residents with ane-mia who experienced no pain. However, anydifferences in pain symptoms between the twosets of nursing home residents with HIV werenot statistically significant.
For residents with HIV who were experienc-
ing pain, residents with HIV and anemia weremore likely to experience moderate pain(60.7%) than other residents with HIV (56.6%).Table 2 also shows that other residents withHIV were slightly more likely to experiencemild pain (25.6%) than HIV residents with ane-mia (22.8%). Differences in the intensity of painbetween the two sets of residents with HIVwho experienced pain were statistically signif-icant.
Other diseases. The MDS records disease di-agnoses that have a relationship to currentADL status, cognitive status, mood and be-havior status, medical treatments, nursingmonitoring, or risk of death (not including in-active diagnoses). Table 2 illustrates that nurs-ing home residents from both of these HIVgroups were typically clinically complex at ad-mission to the nursing home. However, resi-dents with HIV and anemia were much morelikely to have other disease diagnoses thanother residents with HIV. For example, 26.1%of recently admitted residents with HIV andanemia also had dementia (other than Alzhei-mer’s) compared to only 19.3% of other resi-dents with HIV. Similarly, 25.7% of residentswith HIV and anemia were depressed, 21.6%had pneumonia, and 18.1% had renal failurecompared to only 19.0%, 10.9%, and 5.6%, re-spectively for other residents with HIV. Differ-ences in the prevalence of other diseases be-tween the two sets of nursing home residentswith HIV were statistically significant.
Table 2 also documents that HIV residentswith anemia were often much more likely tohave a range of other diseases at admission tothe nursing home than other residents withHIV. For examples, 14.4% of residents withHIV and anemia also had hepatitis comparedto only 5.2% of other residents with HIV; 11.6%of residents with HIV and anemia also had can-cer compared to only 5.8% of other residentswith HIV; and 10.4% of residents with HIV andanemia also had tuberculosis compared to only2.0% of other residents with HIV. In additionto depression, residents with HIV and anemiawere considerably more likely to have anxietydisorder, schizophrenia, and bipolar diseasethan other residents with HIV. Again, these dif-ferences are statistically significant.
NURSING HOME RESIDENTS WITH AIDS AND ANEMIA 379
Treatments, procedures, and services
Discharge potential. The MDS projects eachresident’s discharge potential at the time of ad-mission to the nursing home, assessing if dis-charge is projected within 90 days of the as-sessment (not including discharge due todeath). Table 3 demonstrates that the projectednursing home stay for residents with HIV andanemia is similar to the projected stay for otherresidents with HIV. Approximately 4 of 10 HIVresidents with anemia and 4 of 10 other resi-dents with HIV were not expected to be dis-charged from the nursing home within 90 days.However, residents with HIV and anemia wereslightly more likely to be discharged within 30days (12.6%) than other residents with HIV(10.9%). Any differences in discharge potentialbetween the two sets of nursing home residentswith HIV are not statistically significant.
Special treatments and procedures. Table 3shows that residents with HIV and anemia av-eraged a significantly higher number of med-ications received (11.54 medications) than otherresidents with HIV (10.46 medications). TheMDS documents special treatments and proce-dures that each nursing home resident receives.Table 3 also presents the most utilized specialtreatments and procedures that these recentlyadmitted residents with HIV disease received.Significantly higher percentages of HIV resi-dents with anemia consistently received thesetreatments and procedures than other residentswith HIV. For example, 32.6% of HIV residentswith anemia received monitoring for acutemedical conditions compared to only 24.1% ofother residents with HIV. Similarly, 26.9% ofHIV residents with anemia received intra-venous medications compared to 21.3% ofother residents with HIV.
Analyses of the MDS reveal that 7.0% of HIVresidents with anemia received transfusionscompared to only 1.1% of other residents withHIV. Traditionally, transfusions have beenused to improve the health of people with ane-mia.4 However, the literature suggests thattransfusions carry the risk of transfusion reac-tion and the transmission of additional infec-tions, as well as the transfusions may be im-munosuppressive.1,4,22,23 Recent studies indicate
that recombinant human erythropoietin is avalid treatment for anemia in people with HIVdisease.1,4,22,24 However, the MDS data ana-lyzed for this research does not record whetherresidents received recombinant human eryth-ropoietin in the nursing home.
Special care programs. The MDS records eachresident’s utilization of special care programsin the nursing home. Compared to other resi-dents with HIV, significantly greater percent-ages of residents with HIV and anemia re-ceived care in alcohol or drug treatmentprograms in the nursing home, hospice care,care in an Alzheimer’s/dementia special careunit, care in a pediatric unit, and respite care.In addition, residents with HIV and anemiawere significantly more likely to receive train-ing in skills required to return to the commu-nity (for example, taking medications, housework, shopping, transportation, ADLs) thanother residents with HIV.
Incontinence appliances and programs. TheMDS records the use of a number of inconti-nence appliances and programs by residents.As illustrated in Table 3, significantly greaterpercentages of residents with HIV and anemiautilized these appliances and programs thanother residents with HIV. For example, 1 of 3of residents with HIV and anemia used padsor briefs compared to only 1 of 4 other residentswith HIV who used pads or briefs. HIV resi-dents with anemia were more than twice aslikely to use an indwelling catheter and ascheduled toileting plan as other residents withHIV. In addition, approximately 1 of 7 resi-dents with HIV and anemia, compared to only1 of 17 other residents with HIV, did not usethe toilet, commode, or urinal during the last14 days prior to the MDS assessment. For an-other perspective, 66.0% of other residents withHIV did not use any of the incontinence appli-ances and programs listed in the MDS trackingform compared to 59.8% of HIV residents withanemia who did not use any of these appliancesor programs. Differences in the use of inconti-nence appliances and programs between thesetwo sets of nursing home residents with HIVwere statistically significant.
BUCHANAN ET AL.380
TABLE3.
NURSINGH
OM
ERESIDENTS
WIT
HHIV
: TREATM
ENTS , P
ROCEDURES , A
NDSE
RVIC
ES(M
DSA
SSESS
MENTS
ATTIM
EOFA
DM
ISSION)
Characteristic
HIV residents with anemia
HIV residents without anemia
Projected stay of
No
539
.8%; within 30
day
s 5
12.6%; 3
1–90
day
s 5
8.3%
: discha
rge
No
538
.7%; w
ithin 30 day
s 5
10.9%; 3
1–90
day
s 5
8.5%
; disch
arge
sh
ort dur
ationa
status
unc
ertain 5
39.2%
status
unc
ertain 5
41.9%
Numbe
r of
Mean
511.54 med
ications
; med
ian
511
med
ications (SD
55.03
; Mean
510
.46 med
ications
; med
ian
510 m
edications
(SD
54.44
; med
ications
bfirst qu
artile 5
8; third quartile
515)
first qu
artile 5
7; third quartile 5
13)
Special treatm
ents
Mon
itoring acute med
ical con
dition
b5
32.6%; IV m
edicationb
526.9%;
Mon
itoring acute m
edical con
ditio
nb5
24.1%; IV m
edicationb
521.3%;
and pr
oced
ures
intake
/output
c5
22.9%; ox
ygen
the
rapyb
510
.7%; d
ialysisb
58.0%
;intake
/output
c5
19.0%; ox
ygen
the
rapyb
56.7%
; dialysisb
53.4%
;(%
of ne
wtran
sfus
ionb
57.0%
; ostom
y care
b5
5.7%
; su
ctioning
b5
4.6%
;tran
sfusion
b5
1.1%
; ostom
y care
b5
2.6%
; suctioning
b5
1.8%
;ad
mission
s)trache
ostomy care
b5
4.4%
; ch
emothe
rapyb
53.4%
; radiation
b5
3.4%
trache
ostomy care
b5
1.4%
; ch
emothe
rapy
b5
1.1%
; rad
iation
b5
,1%
Special treatm
ent
Alcoh
ol/d
rug treatm
entd
515.5%; training in com
mun
ity skillsb
512
.1%;
Alcoh
ol/d
rug treatm
entd
511.5%; training
in commun
ity skills
b5
8.2%
;program
sho
spice care
c5
6.7%
; Alzhe
imer’s/de
men
tia SC
Ub
53.0%
;ho
spice care
c5
4.5%
; Alzhe
imer’s/de
men
tia SC
Ub
50.4%
; ped
iatric
(% of ne
wpe
diatric unitb
52.5%
; respite careb
52.5%
unitb
50.3%
; respite careb
50.2%
admission
s)
Incontinen
ce,
Pads
/briefs
b5
34.9%; d
id not use toiletb
514.1%; ind
wellin
g Pad
s/briefs
b5
25.9%; d
id not use toiletb
56.0%
; ind
wellin
g catheter
b
applia
nces
catheter
b5
13.7%; s
ched
uled
toileting
planb
513
.3%;
56.1%
; sch
eduled
toileting
planb
56.1%
; ex
tern
al cathe
terb
52.1%
;& program
sexternal cathe
terb
59.1%
; ostom
y presen
tb5
8.8%
;ostomy present
b5
1.3%
; bladd
er retraining probram
b5
1.0%
blad
der retraining probram
b5
8.3%
; en
emas
b5
8.0%
; en
emas
b5
0.7%
; interm
ittent cathe
terb
50.5%
; non
e of the
se
interm
itten
t catheter
b5
7.7%
; non
e of the
se applianc
es or
applianc
es or prog
ramsb
566.0%
prog
ramsb
559
.8%
Interven
tion pr
ograms
Evaluation by
a licen
sed m
ental he
alth spe
cialistb
529
.8%; p
articipa
ted
Eva
luation by
a licen
sed m
ental he
alth spe
cialist
524
.3%; p
articipa
ted
for moo
d, beh
avior,
in group therap
y (last 7 day
s)b
516
.8%
in group therap
y (last 7 day
s) 5
8.3%
cogn
itive loss
(% of ne
wad
mission
s)
Health services
Hospital adm
ission
s with ov
ernigh
t stay
a5
0.67
adm
ission
sHospita
l ad
mission
s with ov
ernigh
t stay
a5
0.59
adm
ission
ssinc
e ad
mission
*(M
edian
51; SD 5
0.85; first qua
rtile
50; third
qua
rtile
51)
(Med
ian
50; SD 5
2.06
; first qua
rtile
50; third
qua
rtile
51)
(ave
rage
numbe
r)ER
visits
a5
0.20
visits (M
edian
50; SD 5
0.52
; first qua
rtile
50;
ER visits
50.18
visits (M
edian
50; SD 5
0.51
; first qu
artile
50;
third quartile 5
0)third qua
rtile
50)
Physician visits
b5
2.35 visits** (M
edian
52; SD 5
2.33
; first
Phy
sician
visits
51.92
visits** (M
edian
51; SD 5
1.81; first quartile
quartile 5
1; third quartile
53)
51; third
qua
rtile
52)
*The
se admission
assessm
ents of ne
w nursing
hom
e residen
ts m
ust be
don
e within 14 day
s of admission
.**The
se phy
sician
visits may
also includ
e au
thorized
assistant or practitio
ner visits.
a no sign
ifican
ce; b
,0.00
01; c
,0.01
; d,0.00
1.
Mental health services. The MDS documentswhether each resident received interventionprograms for mood, behavior, and cognitiveloss, regardless of where these programs wereprovided to the residents. Table 3 shows that asignificantly higher percentage of residents withHIV and anemia (29.8%) were evaluated by a li-censed mental health specialist in the last 90days than other residents with HIV (24.3%).Given the higher percentages of HIV residentswith anemia who also had depression, anxietydisorder, and schizophrenia compared to otherresidents with HIV (see Table 2), this higher useof evaluation services from mental health spe-cialists is not surprising. Also, residents withHIV and anemia were twice as likely to haveparticipated in group therapy in the 7 days priorto the assessment than other residents with HIV,with these differences statistically significant.
Acute care services. The MDS records the useof acute care hospital stays, emergency depart-ment visits, and physician visits by each nurs-ing home resident. The admission assessmentsanalyzed for this study were required for theresidents within 14 days of their admission tothe nursing home. Therefore, the utilization ofacute care services by these residents with HIVoccurred in a period of 14 days or less. Residentswith HIV and anemia consistently averagedhigher rates of utilization for these acute careservices than other residents with HIV, althoughonly the differences in physician visits were sta-tistically significant. Given the higher rates ofother disease and infections among residentswith HIV and anemia compared to other resi-dents with HIV (see Table 2), this higher uti-lization of acute care services after admission tothe nursing home is not surprising. However,these utilization statistics indicate many resi-dents with HIV, including residents with andwithout anemia, had intensive utilization ofacute care services in the short period of timesince their nursing home admission.
SUMMARY
Anemia is the most common hematologic ab-normality among people with HIV.1 Anemia
has been associated with early death and re-covery from anemia has been linked to in-creased length of survival and reduced risk ofdeath in people with HIV disease.4,9,10 To learnmore about anemia and HIV, this study pro-files HIV residents with anemia at the time oftheir admission to the nursing home and com-pared these profiles to other residents with HIVat the time of their admission. Differences inthese profiles were statistically significant formost resident characteristics.
Both HIV residents with anemia and otherresidents with HIV are mostly younger adults,overwhelmingly male, and predominantlyfrom racial or ethnic minorities. Significantlyhigher percentages of HIV residents with ane-mia, however, were female, older, and blackthan other residents with HIV. Almost two-thirds of HIV residents with anemia and three-quarters of other residents with HIV receivedMedicaid coverage at the time of their admis-sion to the nursing home.
HIV residents with anemia were signifi-cantly more physically dependent than otherresidents with HIV, based on ADL scales cal-culated for this study. These analyses also in-dicate that residents with HIV and anemiawere significantly more likely to have other dis-eases, infections, and health care conditionsthan other residents with HIV. For example,significantly greater percentages of HIV resi-dents with anemia also had dementia, depres-sion, pneumonia, viral hepatitis, renal failure,anxiety disorder, schizophrenia, cancer, and tu-berculosis than other residents with HIV. In ad-dition, residents with HIV and anemia weresignificantly more likely to receive a range ofspecial treatments, procedures, programs, andservices in the nursing home than other resi-dents with HIV.
ACKNOWLEDGMENTS
Dr. Suojin Wang’s research was supported inpart by the National Cancer Institute (CA-57030) and the TAMU Center for Environmen-tal and Rural Health to do statistical method-ology research and its application to the healthsciences. The authors thank Juan Carlo Olivo,
BUCHANAN ET AL.382
a graduate student in the School of PublicHealth for his assistance with this research.
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Address reprint requests to:Robert J. Buchanan, Ph.D.
Department of Health Policy and ManagementSchool of Rural Public Health
The Texas A&M University System HealthScience CenterTamu 1266
College Station, TX 77843-1266
E-mail: [email protected]
NURSING HOME RESIDENTS WITH AIDS AND ANEMIA 383
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