Heather Ladd

Is There Evidence of Cream Skimming among Nursing Homes following the Publication of the Nursing Home Compare Report Card

PURPOSE A national quality report card for nursing homes, Nursing Home Compare, has been published since 2002. It has been shown to have some, albeit limited, positive impact on quality of care. The objective of this study was to test empirically the hypothesis that nursing homes have responded to the publication of the report by adopting cream skimming admission policies. DESIGN AND METHODS The study included all non-Medicare newly admitted patients to all Medicare- and Medicaid-certified nursing homes nationally during the 2001-2005 period. Using the Minimum Data Set data, we calculated for each quarter several admission cohort characteristics: average number of activity of daily living limitations and percent of residents admitted with pain, with pressure ulcers, with urinary incontinence, with diabetes, and with memory limitations. We tested whether residents admitted in the postpublication period were less frail and sick compared with residents admitted in the prepublication period by estimating fixed facility effects longitudinal regression models. Analyses were stratified by nursing home ownership, occupancy, reported quality ranking, chain affiliation, and region. RESULTS Evidence for cream skimming was found with respect to pain and, to a lesser degree, with respect to memory limitation but not with respect to the 4 other admission cohort characteristics. IMPLICATIONS Despite the theoretical expectation, empirical evidence suggests only a limited degree of cream skimming. Further studies are required to investigate this phenomenon with respect to other admission cohort characteristics and with respect to post-acute patients.

Stability of cardiopulmonary resuscitation and do-not-resuscitate orders among long-term nursing home residents.

Background:High-quality care for long-term nursing home residents should include discussions and follow-up on patients’ end-of-life care wishes. Yet, recent changes to the Minimum Data Set data collection exclude this information from routine assessment of patients mandated by the Centers for Medicare & Medicaid Services, making the provision of high-quality end-of-life care less likely. We examined the stability of cardiopulmonary resuscitation (CPR) and do-not-resuscitate (DNR) orders to offer guidance to policy and care practice developments. Methods:We examined changes in DNR status of a national long-term care nursing home cohort, following them for 5 years after admission. A competing risk model was estimated to identify covariates predicting changes from CPR to DNR status and vice versa. Results:About half the cohort chose DNR at admission and did not change its status. Of those who entered with CPR status, 40% changed to DNR. The most important factors influencing change were hospitalizations and nursing home transfers, followed by race and ethnicity with black race (relative to white) in particular having the largest effect on change. Other individual and nursing home characteristics influenced the likelihood of changing from CPR to DNR as well. Conclusions:Long-term nursing home patients who enter with full-code CPR have a high probability of changing their status to DNR during their stay. High-quality care should offer them the opportunity to revisit their choice periodically, documenting changes in end-of-life choices when they occur, thus ensuring that care will match patients’ wishes. As the Minimum Data Set plays a prominent role in patients’ care, Centers for Medicare & Medicaid Services should consider reinstating information about advance directive in it.

Have Racial Disparities in Ambulatory Care Sensitive Admissions Abated Over Time

Background:Racial disparities in access to care and access to high-quality care have been persistent over many decades. They have been documented in all areas of health care, including ambulatory care. Policy initiatives have been implemented to address disparities and close the gaps in care that minorities face. Less is known about the effectiveness of these polices. Objectives:To evaluate whether disparities in quality of ambulatory care have abated during the decade of 2000 by answering 2 questions: (1) were there differences in ambulatory care sensitive hospital admissions rates by race?; (2) have these differences been declining over time? Research Design:Multivariable linear regressions with fixed county effects and robust SEs of longitudinal panel data. Subjects:A total of 4,032,322 discharges in 172 counties in 6 states during 2003–2009. Measures:Prevention Quality Indicators (PQIs) developed by the Agency for Healthcare Research and Quality, by county, and race calculated from the Healthcare Cost and Utilization Project dataset. Results:In 2003 the overall PQI admission rates were higher for African Americans (around 16.5/1000) than for whites (around 15/1000). By 2009, the overall and the chronic PQI admission rates declined significantly (P<0.01) for whites. They either did not decline or increased for African Americans. Acute PQI rates declined significantly for whites and remained stable for African Americans. Conclusions:Policies addressing persisting racial disparities in quality of ambulatory care for African Americans should focus on the chronic PQIs. In addition, efforts should be made to improve data quality for race and ethnicity information on hospital discharge data to enable informed policy evaluation and planning.

Prototype End-of-Life Quality Measures Based on MDS 3 Data.

Background:The Nursing Home Compare (NHC) report card does not include end-of-life (EOL) quality measures (QMs). Objectives:To develop and examine the properties of EOL QMs. Subjects:A total of 39,590 nursing home decedents in 626 facilities in New York State in fiscal year 2012. Design:Statistical analyses of Minimum Data Set 3 data, including multivariable regression analyses and descriptive statistics. Measures:Death in the hospital, number of hospitalizations, pain, and depression during the last 90 days before death. Results:Overall, 32% of residents died in the hospital. They averaged 0.49 hospitalizations in the last 90 days before death, 10% reported moderate to severe pain, and 17% had depressive symptoms. The EOL QMs exhibited variation across facilities similar to that observed for other QMs. They showed low or moderate correlations. The pain and depression QMs were significantly better among nursing homes ranked by NHC as 4 and 5 stars compared with those ranked as 1 and 2 stars for most dimensions. The hospitalizations QMs were significantly better among nursing homes ranked by NHC as 4 and 5 stars compared with those ranked as 1 and 2 stars only when compared on the staffing dimension. Conclusions:The Minimum Data Set 3 includes much information that can be used to assess quality of EOL care in nursing homes. The prototype measures we developed could be improved if information about advance directives and the nonclinical aspects of care, such as comfort and emotional support for both the resident and the family and respect for resident and family preferences, were collected.

Rationale and study protocol for the Nursing Home Compare Plus (NHCPlus) randomized controlled trial: A personalized decision aid for patients transitioning from the hospital to a skilled-nursing facility

BACKGROUND Annually more than 3 million people are admitted to one of the 15,965 skilled nursing facilities (SNFs) in the United States, with 90% of admissions occurring from a hospital. Although the Centers for Medicare and Medicaid Services (CMS) publishes several internet-based report cards, including one for nursing homes (Nursing Home Compare, NHC), they are not widely used. This is due, in part, to the complexity of the information available and the fact that the choice of nursing homes is typically made while in the hospital without access to the web-based NHC. We developed Nursing Home Compare Plus (NHCPlus) to address these limitations and to improve the decision-making process. METHODS/DESIGN This paper describes the design and rationale of a two-arm randomized controlled trial designed to test the effectiveness of NHCPlus compared to usual care only, in a sample of patients being discharged from the hospital to an SNF (N=229). Assessments were conducted within 24h prior to patient discharge and 30-days post discharge. Primary outcomes to be examined included the use of NHC, increased choice of nursing homes with better reported outcomes, and increased distance between patient/family residence and nursing home. Secondary outcomes included satisfaction with the decision to go to a nursing home, confidence in the choice of nursing home, and reduced hospital length of stay. DISCUSSION NHCPlus is an innovative mobile application designed to allow patients to personalize their choice of nursing homes to meet their medical needs and preferences. The application to other quality report cards is discussed.

Incremental cost of postacute care in nursing homes.

OBJECTIVES To determine whether the case mix index (CMI) based on the 53-Resource Utilization Groups (RUGs) captures all the cross-sectional variation in nursing home (NH) costs or whether NHs that have a higher percent of Medicare skilled care days (%SKILLED) have additional costs. DATA AND SAMPLE: Nine hundred and eighty-eight NHs in California in 2005. Data are from Medicaid cost reports, the Minimum Data Set, and the Economic Census. RESEARCH DESIGN We estimate hybrid cost functions, which include in addition to outputs, case mix, ownership, wages, and %SKILLED. Two-stage least-square (2SLS) analysis was used to deal with the potential endogeneity of %SKILLED and CMI. RESULTS On average 11 percent of NHs days were due to skilled care. Based on the 2SLS model, %SKILLED is associated with costs even when controlling for CMI. The marginal cost of a one percentage point increase in %SKILLED is estimated at U.S.

Impact of Nursing Home Palliative Care Teams on End-of-Life Outcomes: A Randomized Controlled Trial

70,474 or about 1.2 percent of annual costs for the average cost facility. Subanalyses show that the increase in costs is mainly due to additional expenses for nontherapy ancillaries and rehabilitation. CONCLUSION The 53-RUGs case mix does not account completely for all the variation in actual costs of care for postacute patients in NHs.

Alternatives to Care in Physician Offices: Patients’ Expectations and Satisfaction

Background: Deficits in end-of-life care in nursing homes (NHs) are reported, but the impact of palliative care teams (PCTeams) on resident outcomes remains largely untested. Objective: Test the impact of PCTeams on end-of-life outcomes. Research Design: Multicomponent strategy employing a randomized, 2-arm controlled trial with a difference-in-difference analysis, and a nonrandomized second control group to assess the intervention’s placebo effect. Subjects: In all, 25 New York State NHs completed the trial (5830 decedent residents) and 609 NHs were in the nonrandomized group (119,486 decedents). Measures: Four risk-adjusted outcome measures: place of death, number of hospitalizations, self-reported moderate-to-severe pain, and depressive symptoms. The Minimum Data Set, vital status files, staff surveys, and in-depth interviews were employed. For each outcome, a difference-in-difference model compared the pre-post intervention periods using logistic and Poisson regressions. Results: Overall, we found no statistically significant effect of the intervention. However, independent analysis of the interview data found that only 6 of the 14 treatment facilities had continuously working PCTeams throughout the study period. Decedents in homes with working teams had significant reductions in the odds of in-hospital death compared to the other treatment [odds ratio (OR), 0.400; P<0.001), control (OR, 0.482; P<0.05), and nonrandomized control NHs (0.581; P<0.01). Decedents in these NHs had reduced rates of depressive symptoms (OR, 0.191; P⩽0.01), but not pain or hospitalizations. Conclusions: The intervention was not equally effective for all outcomes and facilities. As homes vary in their ability to adopt new care practices, and in their capacity to sustain them, reforms to create the environment in which effective palliative care can become broadly implemented are needed.

Publication of Quality Report Cards and Trends in Reported Quality Measures in Nursing Homes

Patients have several choices besides physicians’ offices or emergency rooms (ERs) when seeking care for minor illnesses, including urgent care, retail clinics, and virtual physicians. The limited literature assessing costs and quality offered in these settings has mixed findings, concluding that they are attractive to patients when costs are lower while quality may not be comparable. 1–3 Our goal is to provide the patient’s perspective, missing from the extant literature.