Background: Screening and intervention for alcohol problems can reduce drinking and its consequences but are often not implemented. Objective: To test whether providing physicians with patients' alcohol screening results and simple individualized recommendations would affect the likelihood of a physician's having a discussion with patients about alcohol during a primary care visit and would affect subsequent alcohol use. Design: Cluster randomized, controlled trial. Setting: Urban academic primary care practice. Participants: 41 faculty and resident primary care physicians and 312 patients with hazardous drinking. Interventions: Providing physicians with alcohol screening results (CAGE questionnaire responses, alcohol consumption, and readiness to change) and recommendations for their patients at a visit. Measurements: Patient self-report of discussions about alcohol use immediately after the physician visit and alcohol use 6 months later. Results: Of 312 patients, 240 visited faculty physicians, 301 (97%) completed the outcome assessment after the office visit, and 236 (76%) were followed for 6 months. Faculty physicians in the intervention group tended to be more likely than faculty physicians in the control group to give patients advice about drinking (adjusted proportion, 64% [95% CI, 47% to 79%] vs. 42% [CI, 33% to 53%]) and to discuss problems associated with alcohol use (74% [CI, 59% to 85%] vs. 51% [CI, 39% to 62%]). Resident physicians' advice and discussions did not differ between groups. Six months later, patients who saw resident physicians in the intervention group had fewer drinks per drinking day (adjusted mean number of drinks, 3.8 [CI, 1.9 to 5.7] versus 11.6 [CI, 5.4 to 17.7]). Conclusions: Although effects seem to differ by physician level of training, prompting physicians with alcohol screening results and recommendations for action can modestly increase discussions about alcohol use and advice to patients and may decrease alcohol consumption.

OBJECTIVE:To examine quality improvement (QI) implementation in nursing homes, its association with organizational culture, and its effects on pressure ulcer care.DATA SOURCES/STUDY SETTING:Primary data were collected from staff at 35 nursing homes maintained by the Department of Veterans Affairs (VA) on measures related to QI implementation and organizational culture. These data were combined with information obtained from abstractions of medical records and analyses of an existing database.STUDY DESIGN:A cross-sectional analysis of the association among the different measures was performed.DATA COLLECTION/EXTRACTION METHODS:Completed surveys containing information on QI implementation, organizational culture, employee satisfaction, and perceived adoption of guidelines were obtained from 1,065 nursing home staff. Adherence to best practices related to pressure ulcer prevention was abstracted from medical records. Risk-adjusted rates of pressure ulcer development were calculated from an administrative database.PRINCIPAL FINDINGS:Nursing homes differed significantly (p<.001) in their extent of QI implementation with scores on this 1 to 5 scale ranging from 2.98 to 4.08. Quality improvement implementation was greater in those nursing homes with an organizational culture that emphasizes innovation and teamwork. Employees of nursing homes with a greater degree of QI implementation were more satisfied with their jobs (a 1-point increase in QI score was associated with a 0.83 increase on the 5-point satisfaction scale, p<.001) and were more likely to report adoption of pressure ulcer clinical guidelines (a 1-point increase in QI score was associated with a 28 percent increase in number of staff reporting adoption, p<.001). No significant association was found, though, between QI implementation and either adherence to guideline recommendations as abstracted from records or the rate of pressure ulcer development.CONCLUSIONS:Quality improvement implementation is most likely to be successful in those VA nursing homes with an underlying culture that promotes innovation. While QI implementation may result in staff who are more satisfied with their jobs and who believe they are providing better care, associations with improved care are uncertain.

OBJECTIVES: New methods developed to improve the statistical basis of provider profiling may be particularly applicable to nursing homes. We examine the use of Bayesian hierarchical modeling in profiling nursing homes on their rate of pressure ulcer development.DESIGN: Observational study using Minimum Data Set data from 1997 and 1998.SETTING: A for-profit nursing home chain.PARTICIPANTS: Residents of 108 nursing homes who were without a pressure ulcer on an index assessment.MEASUREMENTS: Nursing homes were compared on their performance on risk-adjusted rates of pressure ulcer development calculated using standard statistical techniques and Bayesian hierarchical modeling.RESULTS: Bayesian estimates of nursing home performance differed considerably from rates calculated using standard statistical techniques. The range of risk-adjusted rates among nursing homes was 0% to 14.3% using standard methods and 1.0% to 4.8% using Bayesian analysis. Fifteen nursing homes were designated as outliers based on their z scores, and two were outliers using Bayesian modeling. Only one nursing home had greater than a 50% probability of having a true rate of ulcer development exceeding 4%.CONCLUSIONS: Bayesian hierarchical modeling can be successfully applied to the problem of profiling nursing homes. Results obtained from Bayesian modeling are different from those obtained using standard statistical techniques. The continued evaluation and application of this new methodology, in nursing homes may ensure that consumers and providers have the most accurate information regarding performance.

Purpose To examine associations between fellowship training and career outcomes among primary care physician—faculty. Method A total of 821 full-time primary care physician—faculty from 24 representative U.S. medical schools were surveyed using a self-administered questionnaire. Primary outcomes were recent grant submissions and funding, career referred publications, rank, and salary. Findings were adjusted for demographic and professional characteristics. Results Of the 500 respondents, 234 of the physician—faculty had completed a fellowship and 266 had not. Fellowship-trained physician—faculty were more than four times as likely to have submitted a grant proposal and to have had a grant funded (both p < 0.0001) than were physician—faculty without fellowship training. They were also more likely to have had any refereed publications (OR 3.8, p < 0.0001) and to have achieved senior academic rank (OR = 1.9, p = 0.02). Among those with fellowship experience, the amount of research training was important. Those with at least one year of research experience in their fellowship program had more grant proposal submissions (OR = 1.9, p = 0.02), more grants funded (OR = 2.9, p = 0.0003), more publications (OR = 2.4, p = 0.02), and higher academic ranks (OR 2.3, p = 0.03) than did those with less research training. Salaries were similar in every comparison. Conclusion Fellowship-trained primary care physician—faculty were more productive researchers and were more likely to have achieved senior academic rank than were their no—fellowship-trained peers. Even among physician—faculty with fellowship experience, more research training was associated with higher productivity and rank. Salaries were not affected by training experience.

Clinical practice guidelines are an important tool for improving quality of care. This study determined whether and how guidelines are being used in nursing homes. We surveyed staff at 36 Department of Veterans Affairs (VA) nursing homes. Employees were asked whether they were familiar with guidelines as well as whether 5 specific guidelines had been read, were available, and had been adopted. Among 1065 respondents (60% of those surveyed), 79% reported familiarity with guidelines. The proportion of staff at a facility reporting adoption was generally less than 50%. Those nursing homes in which a high percentage of the staff reported adoption of one guideline were more likely to have adopted other guidelines. However, staff were not more likely to report adoption of a specific guideline when the nurse manager stated that it was adopted. We conclude that staff at VA nursing homes are familiar with guidelines. Guideline adoption at individual nursing homes, however, is not a systematic process involving the entire staff.

OBJECTIVE: To validate a previously derived risk-adjustment model for pressure ulcer development in a separate sample of nursing home residents and to determine the extent to which use of this model affects judgments of nursing home performance.DESIGN: Retrospective observational study using Minimum Data Set (MDS) data from 1998.SETTING: A large, for-profit, nursing home chain.PARTICIPANTS: Twenty-nine thousand and forty observations were made on 13,457 nursing home residents who were without a pressure ulcer on an index assessment.MEASUREMENTS: We used logistic regression in our validation sample to calculate new coefficients for the 17 previously identified predictors of pressure ulcer development. Coefficients from this new sample were compared with those previously derived. Expected rates of pressure ulcer development were determined for 108 nursing homes. Unadjusted and risk-adjusted rates of pressure ulcer development from these homes were also calculated and outlier identification using these two approaches was compared.RESULTS: Predictors of pressure ulcer development in the derivation sample generally showed similar effects in the validation sample. The model c-statistic was also unchanged at 0.73, but it was not calibrated as well in the validation sample. On applying the model to the nursing homes, expected rates of ulcer development ranged from 1.1% to 3.2% (P < .001). The observed rates ranged from 0% to 12.1% (P < .001). There were 12 outliers using unadjusted rates and 15 using adjusted performance. Ten nursing homes were identified as outliers using both approaches.CONCLUSIONS: Our MDS risk-adjustment model for pressure ulcer development performed well in this new sample. Nursing homes differ significantly in their expected rates of pressure ulcer development. Outlier identification also differs depending on whether unadjusted or risk-adjusted performance is evaluated.

Background. Diagnosis-based case-mix measures are increasingly used for provider profiling, resource allocation, and capitation rate setting. Measures developed in one setting may not adequately capture the disease burden in other settings. Objectives. To examine the feasibility of adapting two such measures, Adjusted Clinical Groups (ACGs) and Diagnostic Cost Groups (DCGs), to the Department of Veterans Affairs (VA) population. Research Design. A 60% random sample of veterans who used health care services during FY 1997 was obtained from VA inpatient and outpatient administrative databases. A split-sample technique was used to obtain a 40% sample (n = 1,046,803) for development and a 20% sample (n = 524,461) for validation. Methods. Concurrent ACG and DCG risk adjustment models, using 1997 diagnoses and demographics to predict FY 1997 utilization (ambulatory provider encounters, and service days–the sum of a patient’s inpatient and outpatient visit days), were fitted and cross-validated. Results. Patients were classified into groupings that indicated a population with multiple psychiatric and medical diseases. Model R-squares explained between 6% and 32% of the variation in service utilization. Although reparameterized models did better in predicting utilization than models with external weights, none of the models was adequate in characterizing the entire population. For predicting service days, DCGs were superior to ACGs in most categories, whereas ACGs did better at discriminating among veterans who had the lowest utilization. Conclusions. Although “off-the-shelf” case-mix measures perform moderately well when applied to another setting, modifications may be required to accurately characterize a population’s disease burden with respect to the resource needs of all patients.

OBJECTIVE: previous studies have shown that women receive fewer invasive procedures for the treatment of coronary artery disease than men, but gender differences in cerebrovascular disease have not been well studied. Our objective was to explore differences in the treatment of stroke between men and women.DESIGN: Secondary database analyses.STUDY PARTICIPANTS: Me examined the use of carotid endarterectomy in a nationally representative sample of Medicare enrollees aged 65 to 84, hospitalized for a principal diagnosis of stroke in 1992, the "all strokes group". We also studied a subgroup of patients, the "carotid disease subgroup", admitted with a principal diagnosis of precerebral arterial occlusion and stenosis or transient cerebral ischemia.MEASUREMENTS: We determined rates of carotid endarterectomy for the all strokes group within gender and age groups and calculated corresponding female-to-male relative risks (RR) and 95% confidence intervals (CI). We also performed similar analyses for the carotid disease subgroup. We then used logistic regression to estimate the relative risk of use of carotid endarterectomy for women, controlling for age and comorbidity.RESULTS: The all-strokes group consisted of 3356 women and 2927 men, of whom 1009 women and 990 men were in the carotid disease subgroup. The overall age-adjusted female-to-male relative risk of undergoing carotid endarterectomy for those aged 65 to 84 was 0.69 (95% CI, 0.64-0.74) in the all strokes group and 0.77 (95% CI, 0.72-0.82) in the carotid disease subgroup. In both analyses, the RR became more pronounced with increasing age. In the all strokes group, for example, the RR was 0.80 (0.70-0.92) for those aged 65 to 69 and 0.39 (0.32-0.48) for those aged 80 to 84. The RR for the all strokes group remained similar in magnitude even after controlling for comorbidity (RR, 0.63 and 95% CI, 0.59-0.70).CONCLUSION: We conclude that women hospitalized for strokes undergo fewer carotid endarterectomies than men. Further studies are needed to examine the reasons for and implications of this gender difference.

Purpose. Despite efforts to increase the numbers of underrepresented minorities (URMs), only 3.9% of medical school faculty are URMs, The authors compared the specialty choices, compensation, and career satisfaction of minority faculty with those of their majority counterparts to determine whether there were differences that might affect the recruitment and retention of minority faculty.Method. In 1995, the authors mailed a self-administered survey to a stratified random sample of 3,013 eligible full-time salaried faculty in 24 randomly selected medical schools. Those schools, which had at least 200 faculty, did not include the Puerto Rican or historically black medical schools.Results. Of the eligible faculty surveyed, 1,807 (60%) responded; 1,463 were majority faculty, 195 were URM faculty, and 149 were other-minority faculty. Similar proportions of the three groups were in the primary care specialties. Only 11% of the URM respondents were in basic science departments. There was no significant difference in adjusted mean compensation between majority, URM, and other minority faculty. However, URM faculty were significantly less satisfied with their careers (adjusted scores: 60 versus > 65; P =.001) and more often considered leaving academic medicine within five years (58% versus < 45%).Conclusion. Given the demographic changes of the U.S. population, these issues should be addressed by deans and department heads in order to enhance recruitment and facilitate retention of URM faculty in academic medicine.

BACKGROUND: Women age 65 years and older account for most newly diagnosed breast cancers and deaths from breast cancer. Yet, older women are least likely to undergo mammography, perhaps because mammography's value is less well demonstrated in older women.OBJECTIVE: To investigate the relationship between prior mammography use, cancer stage at diagnosis, and breast cancer mortality among older women with breast cancer.DESIGN: Retrospective cohort study using the Linked Medicare‐Tumor Registry Database.SETTING: Population‐based data from three geographic areas included in the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program.PARTICIPANTS: Women aged 67 and older diagnosed with a first primary breast cancer, from 1987 to 1993, residing in Connecticut, metropolitan Atlanta, Georgia, or Seattle‐Puget Sound, Washington.MEASUREMENTS: Medicare claims were reviewed and women were classified according to their mammography use during the 2 years before diagnosis: nonusers (no prior mammograms), regular users (at least two mammograms at least 10 months apart), or peri‐diagnosis users (only mammogram(s) within 3 months before diagnosis). Mammography utilization was linked with SEER data to determine stage at diagnosis and cause of death. Our main outcome variables were (1) stage at diagnosis, classified as early (in situ/Stage I) or late (Stage II or greater), and (2) breast cancer mortality, measured from diagnosis until death from breast cancer or end of the follow‐up period (December 31, 1994).RESULTS: Older women who were nonusers of mammography were diagnosed with breast cancer at Stage II or greater more often than regular users (adjusted odds ratio (OR), 3.12; 95% confidence interval (CI), 2.74–3.58). This association was present within each age group studied. Nonusers of mammography were at significantly greater risk of dying from their breast cancer than regular users for all women (adjusted hazard ratio (HR), 3.38; 95% CI, 2.65–4.32) and for women within each age group. Even assuming a lead time of 1.25 years, nonusers of mammography continued to be at increased risk of dying from breast cancer. Our findings remained significant for all women and for the two youngest age groups (67–74 years, 75–85 years), although the benefit was no longer statistically significant for the oldest women (85 years and older).CONCLUSIONS: Older women who undergo regular mammography are diagnosed with an earlier stage of disease and are less likely to die from their disease. These data support the use of regular mammography in older women and suggest that mammography can reduce breast cancer mortality in older women, even for women age 85 and older.

BACKGROUND:Many patients with hypertension have inadequate control of their blood pressure. Improving the treatment of hypertension requires an understanding of the ways in which physicians manage this condition and a means of assessing the efficacy of this care.METHODS:We examined the care of 800 hypertensive men at five Department of Veterans Affairs sites in New England over a two-year period. Their mean (+/-SD) age was 65.5+/-9.1 years, and the average duration of hypertension was 12.6+/-5.3 years. We used recursive partitioning to assess the probability that antihypertensive therapy would be increased at a given clinic visit using several variables. We then used these predictions to define the intensity of treatment for each patient during the study period, and we examined the associations between the intensity of treatment and the degree of control of blood pressure.RESULTS:Approximately 40 percent of the patients had a blood pressure of > or =160/90 mm Hg despite an average of more than six hypertension-related visits per year. Increases in therapy occurred during 6.7 percent of visits. Characteristics associated with an increase in antihypertensive therapy included increased levels of both systolic and diastolic blood pressure at that visit (but not previous visits), a previous change in therapy, the presence of coronary artery disease, and a scheduled visit. Patients who had more intensive therapy had significantly (P<0.01) better control of blood pressure. During the two-year period, systolic blood pressure declined by 6.3 mm Hg among patients with the most intensive treatment, but increased by 4.8 mm Hg among the patients with the least intensive treatment.CONCLUSIONS:In a selected population of older men, blood pressure was poorly controlled in many. Those who received more intensive medical therapy had better control. Many physicians are not aggressive enough in their approach to hypertension.

BACKGROUND:Little is known about regional patterns of intraaortic balloon pump (IABP) use in coronary artery bypass graft (CABG) operations. Our objectives were (1) to identify clinical variables associated with IABP use, and (2) to examine risk-adjusted rates of IABP use for 12 Massachusetts hospitals performing CABG operations.METHODS:We used hospital discharge data to identify 6944 CABG surgical cases. Logistic regression was used to identify clinical variables associated with IABP use, and the resulting multivariate model was then used to risk adjust hospital rates of IABP use.RESULTS:The IABP was used in 13.4% of the CABG surgical cases. The clinical variables independently associated with IABP use were cardiogenic shock, same admission angioplasty, prior CABG operation, cardiac arrest, congestive heart failure, recent myocardial infarction, and urgent admission status. Risk-adjusted rates of IABP use varied widely across hospitals from 7.8% to 20.8% (p < 0.0001).CONCLUSIONS:Hospital rates of IABP use vary considerably in Massachusetts. This practice variation may be related to the persistent uncertainty regarding the precise clinical indications for the IABP in this patient population.

Despite the growth in primary care-based women's health centers, little is known about the characteristics of women's health patients and the quality of care provided in women's health centers versus traditional practices. Our objective was to compare a women's health practice and a general internal medicine practice on issues of care during menopause. A cross-sectional survey was administered simultaneously to patients aged 50-70 and their primary care physicians in a women's health practice and an affiliated general internal medicine practice. The survey asked patients about health behaviors, past and current hormone use, menopausal symptoms, and attitudes about menopause. Physicians were asked to estimate their patients' attitudes. Patients in women's health practices were younger, more likely to be smokers, and more likely to have had a prior hysterectomy. Women's health patients were somewhat more likely to report concerns related to menopausal symptoms. Women's health patients and patients attending the general internal medicine practice reported similar rates of past or current use of hormone therapy, after adjusting for prior hysterectomy and age. Physicians in women's health and general medicine were similar in their ability to estimate their patients' attitudes. In the general internal medicine practice, female physicians tended to better estimate their patients' attitudes than their male colleagues. Patients seeking care in a women's health practice differed in symptoms and concerns about the menopause compared with patients in a traditional primary care setting. Physicians' understanding of patients' menopausal concerns did not differ between the two practices. However, there may be gender differences in physicians' understanding of patients' concerns.

BACKGROUND:Hip fracture is a common problem among older Americans. Two types of procedures are available for repairing hip fractures: hip replacement and open or closed reduction with or without internal fixation. The assumption has been that hip replacement produces better functional outcomes. Although that is the common wisdom, outcome studies evaluating hip replacement for treatment of hip fracture are few and have not clearly documented its superiority. OBJECTIVES:To compare outcomes of hip fracture patients who receive hip replacement versus another stabilizing procedure (open or closed reduction with or without internal fixation). DESIGN:Prospective cohort study. PARTICIPANTS:We studied 332 patients (age, > 65) who were hospitalized for a femoral neck fracture and discharged alive. MEASUREMENTS:We examined 2 treatment groups, hip replacement versus another procedure, on 6 outcomes [Activities of Daily Living (ADLs), walking, living situation (institutionalized or not), perceived health (excellent/good vs. fair/poor), rehospitalization, and mortality] at 3 postdischarge times (6 weeks, 6 months and 1 year). RESULTS:Mean age was 80, 80% were female, 96% White, 28% married, and 71% had a hip replacement. The treatment groups were similar at baseline (3 months before admission as reported at discharge) on ADLs, walking, living situation, and perceived health (all P > 0.24). After adjusting for demographics, clinical characteristics, fracture characteristics, and prior ADLs, walking ability, living situation, and perceived health, patients with a hip replacement did not do better at 6 weeks, 6 months, or 1 year post-discharge on any of the 6 outcome measures (all 18 P > 0.10). A global test of all 6 outcomes finds hip replacement patients doing less well at one year (P = 0.02). CONCLUSIONS:Despite the commonly held belief that hip replacement is a superior treatment for hip fracture, we found no suggestion of better outcomes for hip replacement on any of 6 key outcomes.

PURPOSE:Nonwhite dialysis patients survive longer than white patients; however, their clinical characteristics differ. We examined whether case mix differences explain the apparent survival advantage of nonwhite dialysis patients. SUBJECTS AND METHODS:We performed a prospective cohort study using data from the US Renal Data System Case Mix Severity Study that included 4,797 randomly selected dialysis patients 20 years of age and older who were followed up for up to 6 years. Demographic, comorbidity, laboratory, nutritional, and functional status data were obtained. Multivariable proportional hazards models adjusted for case mix differences between nonwhite and white dialysis patients. Additional analyses examined the effects of differences in transplantation rates, withdrawal from dialysis rates, and treatment modality selection. RESULTS:Unadjusted survival rates of black, Native American, and Asian or Pacific Islander dialysis patients were similar, and better than that for white dialysis patients. Relative to whites, the unadjusted relative risk (RR) for mortality among nonwhite patients was 0.64 (95% confidence interval [CI]: 0.58 to 0.70). Adjustment for case mix reduced, but did not eliminate, the survival advantage associated with nonwhite race (RR = 0.78, CI: 0.71 to 0.86). Adjustment for differences in transplantation rates (RR = 0.83, CI: 0.75 to 0.91), withdrawal from dialysis rates (RR = 0.81, CI: 0.73 to 0.90), and initial treatment modality (RR = 0.79, CI: 0.71 to 0.87) did not explain the lower mortality among nonwhites. CONCLUSIONS:A survival advantage for nonwhite dialysis patients persists after case mix adjustment. Future studies should explore additional physiologic and socioeconomic factors that might explain this difference.

OBJECTIVE:To use three approaches to compare dialysis survival prediction based on variables included in the Standardized Mortality Ratio (SMR) with prediction based on a clinically enriched set of variables.DATA SOURCE:The United States Renal Data System Case Mix Severity data set containing demographic, clinical, functional, nutritional, and treatment details about a random sample of 4,797 adult dialysis patients from 291 treatment units, incident to dialysis in 1986 and 1987.STUDY DESIGN:This observational study uses baseline patient characteristics in two proportional hazards survival models: the BASE model incorporates age, race, sex, and cause of end-stage renal disease (ESRD); the FULL model includes these and additional clinical information. We compare each model's performance using (1) the c-index, (2) observed median survival in strata of predicted risk, and (3) predicted survival for patients with different characteristics.PRINCIPAL FINDINGS:The FULL model's c-index (0.709, 0.708-0.711) is significantly higher than that of the BASE model (0.675, 0.675-0.676), indicating better discrimination. Second, the sickest patients identified by the FULL model were in fact sicker than those identified as sickest by the BASE model, with observed median survival of 451 days versus 524. Third, survival predictions for sickest patients using the FULL model are one-third shorter than those based on the BASE model.CONCLUSIONS:The model with more detailed clinical information predicted survival better than the BASE model. Clinical characteristics enable more accurate predictions, particularly for the sickest patients. Thus, clinical characteristics should be considered when making quality assessments for dialysis patients.

OBJECTIVE:Although decline in functional status has been recommended as a quality indicator in long-term care, studies examining its use provide no consensus on which definition of functional status outcome is the most appropriate to use for quality assessment. We examined whether different definitions of decline in functional status affect judgments of quality of care provided in Department of Veterans Affairs (VA) long-term care facilities.METHODS:Six measures of functional status outcome that are prominent in the literature were considered. The sample consisted of 15 409 individuals who resided in VA long-term care facilities at any time from 4/1/95 to 10/1/95. Activities of daily living variables were used to generate measures of functional status. Differences between residents' baseline and semi-annual assessments were considered and facility performance using the various definitions of functional status were described.RESULTS:The percentage of residents seen as declining in functional status ranged from 7.7% to 31.5%, depending upon the definition applied. The definition of functional status also affected rankings, z-scores, and 'outlier' status for facilities.CONCLUSION:Judgments of facility performance are sensitive to how outcome measures are defined. Careful selection of an appropriate definition of functional status outcome is needed when assessing quality in long-term care.

This study identifies structural characteristics of VA nursing homes that are associated with the best patient outcomes. We evaluated risk-adjusted rates of pressure ulcer development in VA nursing homes and related these rates to facility size, staffing patterns, teaching nursing home status, and rural versus urban locale. Higher rates of pressure ulcer development were seen among urban teaching nursing homes and among nursing homes associated with both larger and smaller VA hospitals. Staffing patterns had a complex association with pressure ulcer development, and smaller nursing home staffs were not clearly associated with higher rates. For multivariate modeling, only hospital size and staffing remained significant independent predictors of pressure ulcer development. These results emphasize that while structural characteristics of VA nursing homes can provide insights about care, improving the quality of care in this setting will require a much greater understanding of how nursing homes are organized to meet patient needs.