Resnick N M, Brandeis G H, Baumann M M, Morris J N
Hebrew Rehabilitation Center for Aged, Brigham and Women's Hospital, Boston, MA 02115, USA.
Neurourol Urodyn. 1996;15(6):583-98. doi: 10.1002/(SICI)1520-6777(1996)15:6<583::AID-NAU1>3.0.CO;2-B.
Evaluation of 1 million incontinent American nursing home residents is hampered by both failure to detect incontinence and logistical barriers to diagnostic testing. The nationally mandated Minimum Data Set (MDS) and Resident Assessment Protocol (RAP) were devised to address these deficiencies. Although both instruments are also used in at least 18 other countries, neither has been evaluated. Our goal was to determine the reliability of the MDS and the accuracy of the RAP in predicting the lower urinary tract cause of incontinence. We determined interrater reliability for the 13 MDS items related to urinary incontinence in 123 randomly selected residents of 13 nursing homes in 5 states; forms were completed blindly by 2 nurses from each facility who were trained for a day. The RAP was assessed in 102 representative institutionalized women by blinded evaluation of its diagnostic accuracy compared with the multichannel videourodynamic criterion standard. For the MDS, interrater reliability for incontinence of all grades was excellent (weighted kappa correlation coefficient = 0.90), although reliability was greater at the extremes of measurement than for incontinence of intermediate severity. With the exception of delirium, correlations for the 11 MDS items related to incontinence were 0.65-0.96; for 6 items, correlations were > or = 0.8. The diagnostic accuracy of the RAP, successfully administered to 80% of women, was 70%. The accuracy of the nearly identical algorithm that formed the basis for the RAP was 84%. Importantly, serious misclassifications were not observed for either the RAP or the algorithm. Although its definitions should be modified slightly, the MDS appears to be feasible and reliable when administered by trained staff. In women, the diagnostic accuracy and safety of the RAP are good-particularly when administered as instructed-but the original, sex-specific algorithm is preferable. Together, the MDS and modified RAP provide a useful, stepwise, and non-urodynamically based strategy to guide evaluation and therapy of incontinence in this setting.
对100万美国失能疗养院居民进行评估受到未能发现失禁情况以及诊断测试后勤障碍的阻碍。国家规定的最低数据集（MDS）和居民评估方案（RAP）旨在解决这些缺陷。尽管这两种工具也在至少其他18个国家使用，但均未得到评估。我们的目标是确定MDS的可靠性以及RAP在预测失禁的下尿路病因方面的准确性。我们确定了5个州13家疗养院中123名随机挑选居民的13项与尿失禁相关的MDS项目的评分者间可靠性；每个机构的2名护士经过一天培训后盲目填写表格。通过与多通道视频尿动力学标准对照，对102名具有代表性的机构化女性进行盲法评估，以评估RAP的诊断准确性。对于MDS，所有等级失禁的评分者间可靠性都非常好（加权kappa相关系数 = 0.90），尽管在测量极值时的可靠性高于中度严重程度失禁的可靠性。除谵妄外，与失禁相关的11项MDS项目的相关性为0.65 - 0.96；6项的相关性≥0.8。成功应用于80%女性的RAP的诊断准确性为70%。构成RAP基础的几乎相同算法的准确性为84%。重要的是，未观察到RAP或算法出现严重错误分类。尽管其定义应稍作修改，但由经过培训的工作人员实施时，MDS似乎是可行且可靠的。在女性中，RAP的诊断准确性和安全性良好——尤其是按指示实施时——但原始的、针对性别的算法更可取。总之，MDS和改良后的RAP提供了一种有用的、逐步的且基于非尿动力学的策略，以指导在这种情况下对失禁的评估和治疗。
