Public Healnh Briefs ant) and integrated general practice unit. Br J Obstet GynaecoL 1983;90:118-128. 12. Levine MG, Holroyde J, Woods JR, Siddiqi TA, Scott M, Miodovnik M. Birth trauma: incidence and predisposing factors. Obstet GynecoL 1984;63:792-795. 13. Banta HD, Thacker SB. Assessing the costs and benefits of electoi fetal monitoring. Obstet GynecolSuv. 1979;35:627-642. 14. Haverkamp AD, Orleans M, Langendoer-

M.,

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fer S, McFee J, Murphy J, Thompson HE. A controlled trial of the differential effects of intrapartum fetal monitoring. Am J Obskt GynecoL 1979;134:399-412. 15. Brinsden PR, Clark AD. Postpartum hemorrhage after induced and spontaneous labour. Br Med J. 1978;2:855-856. 16. Hack M, Fanaroff AA, Klaus MH, Mendelawitz BD, Merkatz IR. Neonatal respiratory distress following elective delivery:

a preventable disease? AmJObstet GynecoL 1976;126:43-47. 17. Baumgarten K Advantages and disadvantages of low amniotomy. J Pennat Med 1976;89:963-967. 18. Kennell J, Klaus M, McGrath S, Robertson S, Hinkley C. Continuous emotional support during labor in a US hospital: a randomized, controlled trial. JAMA4. 1991;265(17):2197-2201.

Skilled Nursing Facility Care for Persons with AIDS: Comparison with Other Patients James H. Swan, PhD, A. E. Benjamin, PhD, and Andrew Brown, MD

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Intrdudion Skilled nursing facility (SNF) care for persons with acquired immunodeficiency syndrome (AIDS) (PWAs) is limited but will likely grow.' As the postdiagnosis life expectancy of PWAs increases2 and greater numbers of PWAs find no other locus of care,3-5 SNFs should become accepted parts of an AIDS continuum of care.6-8 AIDS poses major challenges to providers that are inexperienced with PWAs9.10 and the populations from which they derive," and that are not equipped to deal with special care needs9 or special precautions and infection controls.10 PWAs are generally thought to be costlier than traditional nursing home patients12,13 because they need different, more complex, and higher volumes of care.10 Kerschner reports that PWAs in the final months of life require, on the average, 7 hours of nursing home care daily.'4 Adams15 reports that PWAs require an average of over 5 hours' direct intermediate care facility-level nursing care daily. Swan and Benjamin report an average daily total nursing time of 6.5 hours (5.4 hours direct time) for PWAs in a freestanding AIDS-dedicated SNF'; this time approaches the 6.5 to 7.5 hours of care required daily for functionally dependent nursing home patients with complex needs.16 Some industry observers have argued that PWAs' need for heavy care has been overstated,17 but no research has directly examined the relative costs of SNF care for PWAs versus "traditional" nursing home populations. This study begins

to fill the gap, using comparative data on AIDS and non-AIDS care in a single hospital-based SNF in Calffornia.

Mehods In our study of care for PWAs in two Northern California SNFs with dedicated AIDS beds, a random sample of 29 nonAIDS patients was drawn from a hospitalbased SNF between August 18 and December 31, 1987. (The other SNF served PWAs only.) The sample was drawn from two wards that also cared for AIDS patients-an oncology ward and a general ward. These 29 patients averaged 51 days of care per patient, compared with 41 days per patient for the 20 PWAs receiving care in the SNF in the same period. A major issue was whether nursing hours were greater for PWAs than for others. Nursing hours were measured in two ways: (1) monthly nursing personnel time divided by days of care provided that month, and (2) daily direct plus indirect nursing time per patient attributed to nursing procedures recorded using GRASP,18 At the time of this study, all authors were with

the Institute for Health Policy Studies, University of California, San Francisco. James H. Swan is now with the Health Care Administration Program, California State University, Long Beach, Calif. Requests for reprints should be sent to James H. Swan, PhD, Health Care Administration Program, California State University, Long Beach, CA 90840. This paper was submitted to the journal December 11, 1990, and accepted with revisions June 10, 1991.

American Journal of Public Health 453

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adapted to the SNF. (GRASP is proprietary to FCG Enterprises, Inc, Morgantown, NC.) A comparison showed close agreement between the two methods.1 Because patients differ in numbers of days of care and because of a general concern for daily resource use, daily nursing hours are reported. Analysis of variance was employed to test differences in nursing hours.

Findlings PWAs in the hospital-based SNF were more severely ill and functionally debilitated than were PWAs in the community. Two thirds scored 30 or lower on the Karnofsky Performance Status Scale; three fourths had diagnoses of dementia; half were dependent in all activities of daily living; three fourths were discharged by reason of death. Three fourths listed their sexual orientation as homosexual; one third reported intravenous drug use; half were aged 40 or older. Except in age, these PWAs were relatively similar to PWAs nationwide.19%l An analysis of variance was conducted to compare average daily direct nursing time for PWAs and non-AIDS patients (Table 1). PWAs averaged over an hour more direct nursing time (6.5 hours) than did non-AIDS patients (5.4 hours). The latter group still represents high resource use, far greater than the 3.0 total nursing hours defining SNF care in California. This difference is attributable to the SNF's being hospital-based and thus associated with heavy care. Although the small sample size restricted analytic power, limiting the ability to control for covariates, an analysis of variance was used to compare differences

454 American Journal of Public Health

between PWAs and non-AIDS patients on the oncology ward and the general ward (Table 2). On the oncology ward, PWAs averaged over 1.5 nursing hours per day more than did other patients (6.7 vs 5.1 hours). On the general ward, the difference was about 0.7 hours, which, because of small numbers and wide variation among patients, was not significant. PWAs averaged less nursing time on the general ward than on the oncology ward, whereas non-AIDS patients received more nursing care on the general ward; these differences were not significant.

Discussion It is generally thought that PWAs in nursing homes require more and costlier care than do non-AIDS patients. Judging by the data presented here on average nursing time per patient day, this argument appears tobe true at a hospital-based SNF in California. Our major finding is that PWAs received about 20% more nursing time than did other SNF patients. We found a difference of 1 hour per day (1½2 hour on the oncology ward) in a hospital-based SNF, where all care is likely to be far heavier than that at freestanding SNFs, which constitute the majority of such facilities.21

Because not much is known about SNF care for PWAs, we cannot say whether our sample is similar to other groups of PWAs in nursing homes. The level of direct nursing time per patient day for non-AIDS patients at this SNF is double the level defining SNF care in California. Both PWAs and non-AIDS patients appear to approximate the designation of functionally dependent nursing home patients with complex needs.16 Despite expectations that hospitalbased SNFs, which are paid by Medicaid at higher rates, deliver heavier care than do freestanding SNFs, data from a freestanding AIDS-dedicated SNF1 suggest nursing times per patient day nearly as high as those we found at a hospital-based SNF. The difference between AIDS and non-AIDS care should be larger in freestanding SNFs, where the average patient is a chronicalBy ill older woman receiving minimal nursing care, primarily from allied health personnel.22 Thus, our comparison of care for PWAs and care for nonAIDS patients in the hospital-based SNF is a conservative test of the differences in nursing care for these two groups. Our small sample size limits the power of the analysis, however, and a more refined analysis of which patients and diagnoses account for care differences will require a study of a larger number of patients from a representative sample of facilities. Future research should focus on subsamples of PWAs in nursing homes, particularly intravenous drug users and ethnic minorities. El

Acknowledgments The research reported herein was supported by the California Department of Health Services, Office of AIDS (contract no. 98-91877). The interpretations and conclusions are those of the authors and should not be attributed to the funding agency. A version of this paper was presented at the 116th annual meeting of the American Public Health Association, Boston, Mass, November 1988. We acknowledge the efforts of Robyn East, Thomas McKenzie, and Elaine Weston. We thank Dr Philip R. Lee for his guidance and support.

References 1. Swan JH, Benjamin AE. Nursing costs of skilled nursing facility care for AIDS.AIDS

Public PolicyJ. 1990;5:64-67. 2. Rango N. Nursing home care for people with AIDS. In: Rogers DE, Ginzberg E, eds. TheAlDSPatient:AnActionAgenda.

Boulder, Colo: Westview; 1988:35-41. 3. Edwards KS. Where will all the patients go? a statewide lcok at facilities for AIDS patients. Ohio Med~1988;84:373-380.

March 1992, Vol. 82, No. 3

Public Health Briefs 4. Perry S, Maretta RF. AIDS dementia: a review of the literature.Alzheimer Dis Assoc Disord. 1987;1:221-235. 5. Wyatt A. Caring for persons with AIDS in geriatric nursing homes: geriatric nursing home care can work for persons with AIDS. Health Soc Work 1988;13:156-157. 6. Benjamin AE. Long term care and AIDS: perspectives from experience with the elderly. Milbank Q. 1988;66:415-443. 7. Beresford L. Alternative outpatient settings of care for people with AIDS. QRB. 1989;15:9-16. 8. McNally L, Beck LM. A chronic care approach to health and social services for people with AIDS. J Palliat Care.

1988;4(4):96-99. 9. Ciystal S. Persons with AIDS and older people: common long-term care concerns. In: Riley MW, Ory MG, Zablotsky D, eds. AIDS in anAging Society: What We Need to Know. New York: Springer; 1989:147166. 10. Intergovernmental Health Policy Program. AIDS: A Public Health Challenge. Washington, DC: George Washington University; 1987.

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11. Bulkin W, Brown L, Fraioli D, Giannattasio E, McGuire G, Tyler P, Friedland G. Hospice care of the intravenous drug user AIDS patient in a skilled nursing facility. J Acquired Immune Defic Syndromes. 1988;1:375-380. 12. Benjamin AE, Swan JH. Nursing home care for persons with HIV illnesses. Generations. 1989;13(4):63-64. 13. May K. AIDS and the nursing home. Nurs Homes. 1987;36(5):8-11. 14. Kerschner P. Caring for persons with AIDS in geriatric nursing homes: weighing the costs of care. Health Soc Wok 1988; 13(2):157-158. 15. Adams HR. Financial problems inherent in the admission of AIDS patients into long term care facilities. The J Leg Med. 1989; 10(1):89-101. 16. Kearns JM. The 1987 Evaluation and Update ofthe Staffing Citena forthe CiteriaBased ModeL Washington, DC: US Dept of Health and Human Services, Division of Nursing, Health Resources and Services Administration; 1987. 17. Gebhardt RB. Should nursing homes take

AIDS patients? Nurs Homes. 1986; 35(2):13-15. 18. Meyer D. Costing nursing care with the GRASP system. In: Shaffer FA, ed. Costing Out Nursing: Pricing Our Product. New York, NY: National League for Nursing; 1985:55-67. 19. Shulman LC, Mantell JE. The AIDS crisis: a United States health care perspective. Soc Sci Med. 1988;26(10):979-988. 20. Centers for Disease Control. HIVIAIDS Suwveillance: U.S. AIDS Cases Reported Through October 1990. Atlanta, Ga: Centers for Disease Control; November 1990. 21. Harrington C, Preston S, Grant LA, Swan JH. Trends in state nursing home bed capacity and occupancy in the 1978-1989 period. Presented at the 118th annual meeting of the American Public Health Association; October 1990; New York City. 22. Institute of Medicine, Committee to Study the Role of Allied Health Personnel.Allied Health Sevices.: Avoiding Crises. Washington, DC: National Academy Press; 1989.

Risk Factors Associated with the Classification of Unspecified and/or Unexplained Causes of Death in an Occupational Cohort

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Donna L. Cragle, PhD, and Amie Fetcher, DVM, MPH

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Results from cohort studies of workers at Department of Energy (DOE) facilities in Oak Ridge, Tenn, indicated unusual increases in the rate of deaths due to unexplained and/or unspecified causes (International Classification of Diseases, 8th version, codes 780 to 796).1,2 The standardized mortality ratio for deaths coded to these disease categories was 3.05 (338 observed vs 110.92 expected). This increase may have reflected actual increases in the incidence of these unexplained causes of death, variations in the quality and accessibility of health care, and/or inaccuracies recorded on death certificates for the underlying cause of death. These inaccuracies most commonly involve problems related to making the distinction between the underlying cause of death, the immediate cause of death, the manner of death, and conditions contnbuting to death.3 The objective of this study was to

determine the association between various factors and a recorded ill-defined cause of death.

Methods Study Population The cases and controls were chosen from the pooled cohort of all White male DOE Oak Ridge facility workers who worked for more than 30 days between 1943 and 1982 and died between 1945 and 1982. The cohort of workers was comDonna L. Cragle is with Oak Ridge Associated Universities, Oak Ridge, Tenn. Amie Fetcher is with the University of Tennessee, Knoxville. Requests for reprints should be sent to Donna L. Cragle, PhD, Director, Center for Epidemiologic Research, Oak Ridge Associated, PO Box 117, Oak Ridge, TN 37831-0117. This paper was submitted to the Journal February 19, 1991, and accepted with revisions June 19, 1991.

American Journal of Public Health 455