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Frank2002 PDF
Frank2002 PDF
Objective: Chronic constipation is a common disorder ical chart review for each subject. Nurse wage rate
among residents in long-term care; yet the cost to the data was obtained from the Nursing Home Salary and
nursing home of constipation-related care is not Benefits Report, a US-based national source. Resident
known. The objective of this study was to quantify the and nursing home descriptive information was also
nursing staff and supply-related cost of constipation collected.
care to nursing homes from the perspective of the
nursing home. Results: The average cost per task occurrence ranged
from $0.72 for enema administration to $1.74 for oral
Design: Prospective, observational time-and-motion medication administration. Average nursing staff
design. costs per subject per year were $1577 for oral medica-
tion administration, $215 for dietary supplement ad-
Setting: Two United States nursing homes. ministration, $39 for constipation assessment, $17 for
suppository administration, and $6 for enema admin-
Participants: A total of 59 nursing home residents with istration. Based on estimates of frequency of occur-
chronic constipation and nursing staff providing con- rence, the total annual labor and supply cost per long-
stipation care to them. term care resident with constipation was $2253.
Measurements: Actual time to complete constipation Conclusion: Nursing staff performance of constipation
care-related tasks was measured via stopwatch by care-related tasks is time consuming and costly in the
trained observers, and the number and professional long-term care setting. (J Am Med Dir Assoc 2002; 3: 215–
level (eg, staff nurse, CNA) of staff performing each 223)
task was recorded. Frequency of constipation care task
data was obtained through 60-day retrospective med- Keywords: Constipation; costs; staff burden
Constipation is a widespread disorder, and prevalence in- research estimates vary largely due to differences in definitions
creases with age. Between 30% and 40% of people aged 65 or of constipation, limiting estimation of the true magnitude of
over report constipation problems,1,2 and up to half of all the problem.
nursing home residents suffer from the condition.3,4 Available There are multiple causes of constipation, some of which
are particularly relevant to institutionalized older adults.
Among these are immobility, medications, endocrine or met-
Research scientist (L.F., L.K.) and project manager (J.S.), MEDTAP Interna- abolic problems, neurological disorders, clinical depression,
tional, Inc., Bethesda, Maryland; assistant director, Janssen Pharmaceutica,
Titusville, New Jersey (R.S.); professor, Department of Geriatrics, College of eating disorders, structural anomalies of the colon or rectum,
Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas inadequate fiber intake, and repressed or ignored urge to
(C.B.); professor, Anna and Harry Borun Center for Gerontological Research,
University of California, Los Angeles, California (J.S.); executive director,
defecate due to inconvenience or incapacity.2,3,5,6 Constipa-
Health Economics, Johnson & Johnson, Titusville, New Jersey (M.R.). tion may lead to additional morbidity such as hemorrhoids,
Financial support for this research was provided by the Janssen Research anal fissures, rectal prolapse, fecal impaction, and fecal incon-
Foundation. tinence, each of which may reduce patient and caregiver
Address correspondence to Lori Frank, PhD, MEDTAP International, Inc., 7101 quality of life.3,7,8 The disorder as well as the sequelae carry a
Wisconsin Avenue, Bethesda, MD 20814. E-mail: Frank@MEDTAP.com. cost in terms of staff time to diagnose, treat, and manage.
Copyright ©2002 American Medical Directors Association Constipation care tasks are largely the responsibility of
DOI: 10.1097/01.JAM.0000019536.75245.86 nursing staff in long-term care; yet there is limited informa-
erage cost for that task to obtain a “frequency adjusted” task half the staffing of Site 2. Median staff nurse wages were
cost. The adjusted task costs were summed to obtain a total $17.07 for licensed practical nurses (LPNs) and $23.03 for
estimated cost per constipated resident per year. registered nurses (RNs) based on the Nursing Home Salary
Average labor cost per task (dollars) ⫽ average labor time per and Benefits Report. Both sites had staff nurse wages above
task ⫻ wage rate per staff level. national median values. Pay for CNAs was comparable to
Average per task cost ⫽ average labor cost per task ⫹ medica- national values at Site 1 ($10.40 vs. $9.67 national) but was
tion costs ⫹ supply costs. nearly 70% above at Site 2 ($16.41). This difference is due in
Data from the observations were entered into a computer- part to differences in regional wage rates. Subjects were older
ized Oracle clinical database and were double-keyed to ensure on average at Site 2 (89.1 ⫾ 6.7 vs. 78.9 ⫾ 14.7, t ⫽ 3.70,
accuracy. Data were converted to SAS and Microsoft Excel P⬍0.05) but there were no site differences on gender, race,
spreadsheet formats. The unit of analysis was the individual BMI, average number of bowel movements per week, or
constipation care task. Discrepancies were resolved by con- MMSE score.
sultation with source documents. There were no missing data Subject demographic information is presented in Table 2.
from the observational component. Data are assumed to be Mean subject age for the sample of 59 residents was 86 (⫾11)
complete because it is not possible to determine what, if any, years; all subjects were over 65 with the exception of one. The
care was not recorded in the medical record. majority of the sample was white (97%) and female (69%).
Sensitivity analyses were conducted on cost calculations, These characteristics are comparable to those of national
first using the highest and lowest observed task time values by nursing home data:24 88.7% white, 71.6% female. Available
task for calculation of annual cost per resident with constipa- MMSE scores spanned the range from lowest (0) to highest
tion. Task frequency estimates were varied separately, to test (30). The median MDS score was closer to intact than im-
the effect on base case results with a frequency increase and paired. Forty-six percent of subjects showed a high level of
decrease of 50% of the mean frequency obtained from medical dependence on ADLs, and the majority of subjects were on a
chart review. formal constipation preventive program. This may explain
the mean bowel movement frequency per week of nearly 7
RESULTS (⫾3). The observers reported that subjects generally qualified
Site and Subject Characteristics for enrollment based on the medication criteria, and only one
resident had ⬍2 bowel movements per week at enrollment.
Descriptive information by site is presented in Table 1.
Both sites had an occupancy rate of 98% in the 12 months
before data collection. One third of residents at Site 1 and Task Observation
over two thirds of the residents at Site 2 were Medicaid Of the original nine constipation care tasks listed on the
funded. Site 1 had nearly half the bed capacity but less than data collection form, only five were observed. Constipation
evaluation was never observed, and we therefore combined medications provided for constipation care during the 60-day
medical record review mentions of this task with the consti- medical record review for each subject are presented in Table
pation assessment task. Some tasks were observed in combi- 5. Based on non-PRN orders, Peri-Colace™, Colace™, sor-
nation, precluding separate observational time estimates for bitol, and Senokot™ were the most frequently administered
each; some of these combination tasks were assigned to a medications.
single category. Oral medication administration observed The average labor cost based on staff time for oral medica-
times may include administration of non-constipation medi- tion administration was $1577 per resident with constipation
cations as well. No additional constipation care tasks (beyond per year. Average labor cost for administration of dietary
those captured by observation) were identified through the supplements was more than $215 per resident with constipa-
medical record review. A detailed explanation of specific tion per year. The labor and supply costs for all constipation
assumptions regarding task categorization may be obtained care tasks were summed to obtain the total nursing labor and
from the authors. supply cost per resident with constipation per year: $2253.
Cost Calculations Sensitivity Analyses
Table 3 presents the variables that were used for calculation Specific contributors to the basic cost model were varied as
of average cost per task occurrence. Median values were above part of a sensitivity analysis. See Table 6. The lowest and
$1.25 for assessment/evaluation, administration of dietary sup- highest task times observed were input separately. For admin-
plement, and oral medication administration. Administration istration of dietary supplement, the lowest task time decreased
of oral medication was the most expensive task per occur- the base case cost estimate by approximately $6, and the
rence, at $1.74 (low: $1.60, high: $1.89). Low and high highest time increased it by nearly $600. The lower impact of
Nursing Home Salary and Benefits Report wage rates were use of the low time estimate is most likely because most
used in separate calculations to provide a national range for observations (70%) were below the mean value used in the
costs. base estimate. Varying time estimates for oral medication
Total annual labor costs per task were calculated by mul- administration had the largest effect on the total cost esti-
tiplying average task time by the frequency of task occurrence, mate. Using the lowest observed time for oral medication
and multiplying that product by wage rates (See Table 4). administration in the calculation (5 seconds) reduced the cost
Supply costs were added to average labor costs to obtain the estimate by more than $1100. Use of the highest time esti-
total costs per subject per year. Total annual supply cost for mate (more than 11 minutes) increased the estimate by over
residents with constipation is nearly $400 per year, with the $2400. Results were similar when task frequency rather than
majority of those costs accounted for by oral medications. All task time was altered, using ⫹50% and ⫺50% of mean time
1997–1998 Nursing Home Salary and Benefits Report converted to present wages by Consumer Price Index for Medical Care Services (10/20/99) as wage source. Wages calculated by increasing
$1.16
$1.24
$0.66
$0.90
$1.60
Low
was found for oral medication administration: ⫺$1066 and
⫹$1058 for the ⫺50% and ⫹50% frequency estimates, re-
Task Labor Cost per spectively. For all other constipation care tasks, the differ-
Median
ences were within $100.
$1.28
$1.38
$0.72
$0.97
$1.74
DISCUSSION
Occurrence
(Dollars)†
an hourly rate by 30% to include benefits (Hospital and Healthcare Compensation Service & John R. Zabka Associates, Inc, 1997). Effective date of data: February 1997.
This is the first study of its kind to use an empirical
$1.41
$1.51
$0.81
$1.05
$1.89
approach to examine the nursing labor and supply costs asso-
High
3:38
4:29
2:35
4:37
These results are relevant to cost management and care
quality in long-term care. There is a growing literature on
nurse occupational stress. Although certain aspects of nursing
care in long-term care are immutable (eg, regulations requir-
Occurrences
10
2
1
182
$20.53
$20.81
$20.72
$8.82
Low
$22.70
$22.62
$22.65
$9.67
$24.94
$10.81
$24.30
$24.51
High
2
0
0
Nurse
Staff
155
11
0
1
0
0
administration
It was of interest that frequency of bowel movement was which specify close monitoring of bowel movement frequency
not severely limited in this sample, and that subject eligibility and treatment if ⬍1 movement occurs per 3 days, most likely
was below literature-based prevalence estimates. The fluctu- account for the bowel movement frequency findings. These
ating symptom expression of constipation and our limited protocols represent standard care, and therefore, we do not
enrollment window may, in part, account for this finding. The think that they resulted in more or less care than is generally
bowel programs in place for more than 90% of the subjects, given to patients identified with constipation.
Table 5. Medications, Total Number of Administrations, and Average Cost per Dose for Constipation Care
Drug Name Average Number of Administrations Average Cost
per Patient per Year* per Dose ($)*
Peri-Colace姞 256.70 0.42
Colace姞 191.60 0.41
Sorbitol 171.17 0.15
Senokot姞 116.18 0.35
Dulcolax姞 (oral) 39.41 0.68
Phillips Milk of Magnesia 38.69 0.10
Lactulose 37.56 1.71
Metamucil姞 22.91 0.15
Surfak姞 18.57 0.31
Dulcolax姞 (suppository) 10.42 0.68
Cascara 6.19 0.49
Bisacodyl (oral) 5.88 0.01
Bisacodyl (suppository) 0.21 0.09
*Average number of administrations per year ⫽ total number of administrations for 60-day retrospective medical record review (3540
patient days) ⫻ 365.25/3540.