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Updated: Nov 3, 2025
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An R-Based Landscape Validation of a Competing Risk Model
Published on: September 16, 2022
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Adjusting Client-Level Risks Impacts on Home Care Organization Ranking
Aylin Wagner1,2, René Schaffert1, Julia Dratva1,3
1Institute of Health Sciences, ZHAW Zurich University of Applied Sciences, Katharina-Sulzer-Platz 9, 8401 Winterthur, Switzerland.
Summary
Risk adjustment is crucial for accurately comparing home care quality. This study developed a model for urinary incontinence (UI) quality indicators, showing that risk adjustment significantly impacts quality rankings of home care organizations (HCOs).
Area of Science:
- Gerontology
- Health Services Research
- Nursing Informatics
Background:
- Quality indicators (QIs) using the Resident Assessment Instrument-Home Care (RAI-HC) enable home care organization (HCO) performance assessment.
- Fair comparison of HCOs necessitates risk adjustment to account for patient case-mix differences.
Purpose of the Study:
- Develop a risk adjustment model for worsening or new-onset urinary incontinence (UI) using RAI-HC data.
- Evaluate the impact of risk adjustment on HCO quality rankings for UI care.
Main Methods:
- Identified UI risk factors from scientific literature.
- Developed a multivariable logistic regression model using the HomeCareData database.
- Calculated observed and risk-adjusted QI rates, assessed uncertainty with bootstrapping, and analyzed tertile ranking shifts.
Main Results:
- Included 12,652 clients from 76 Swiss HCOs (2017-2018).
- Identified eight significant UI risk factors: older age, female sex, obesity, cognitive impairment, hygiene impairment, bathing impairment, unsteady gait, and hospitalization.
- Risk adjustment considerably impacted HCO rankings, with 14 (20%) of 70 HCOs shifting tertiles.
Conclusions:
- Risk adjustment is essential for equitable comparisons of UI care quality among HCOs.
- The developed model demonstrated fair discrimination power for UI risk.
- Findings underscore the importance of accounting for patient complexity in quality assessments.
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