Minimum Data Set 3.0: a giant step forward.

Over the last year, the Journal has published a series of articles on the validation of the Minimum Data Set 3.0 (MDS 3.0) and its utility.1e6 We have now had a year using the MDS 3.0 in nursing homes in the United States, and so it is an appropriate time to reflect on its functioning in real life. Historically, the Resident Assessment Instruments (RAIs) were developed out of the 1986 call by the Institute of Medicine for a need for “systematized, standardized assessments of residents’ cognitive, functional and educational needs.”7 The 1987 Office of Budget Reconciliation Act by the US Congress mandated such a resident assessment. The first MDS/RAI was released in 1991, proving to be a real oxymoron, as it was by no means minimum, but rather excessively extensive. This represented a great example of attempting to be kind to residents by being cruel to the nursing home industry. Thus, it predictably led to MDS 2.0, which was released in 1995e1996. Unfortunately, MDS 2.0 did little to improve on the first MDS (Table 1). It remained overlong, creating a collection burden with little interface with day-to-day care. A larger problem was it did little to help understand the residents’ quality of life. However, the death knell of the MDS 2.0 was its questionable validity at the individual person level. Studies have found poor validity for depression, behavioral symptoms, advance directives, pain, incontinence, falls, pressure ulcers, and urinary tract infection.8e21 Thus, although the MDS 2.0 has been widely used for epidemiologic studies, its use at the level of individual clinical care was highly questionable.22,23 This resulted in negative provider attitudes toward the MDS 2.0.24 For these reasons, the MDS 3.0, which was developed as a much more user-friendly tool with clinical utility, has been a breath of fresh air. It has better reliability and validity than the MDS 2.0, and it takes less than half the time to complete. Importantly, it gives a clear voice to the resident and provides highly useful information on cognition, behavior, and mood. The incorporation of the Patient Health Questionnaire (PHQ-9) for the diagnosis of depression and the development of a separate component to be answered by the staff is a major step forward. Depression is common and has classically been poorly diagnosed in the nursing home.25e28 Thus, the PHQ-9 is of major utility to clinicians. It needs to be stressed that a PHQ-9 <15 is either dysphoria or minor depression, and the resident is unlikely to respond to antidepressant treatment.29 Those residents need either behavioral therapy