Study finds improvements in response to Nursing Home Compare publication

Newswise, April 30, 2011 — A five-year study co-authored by a Temple University Fox School of Business professor has found that a national report card on nursing homes, which allows consumers to compare the quality of care provided by one facility to another, appears to motivate nursing homes to genuinely improve care.

Jacqueline S. Zinn, a professor of Risk, Insurance and Healthcare Management, served as co-principal investigator on the $1.5 million research project, funded by the National Institute of Aging.

She and her colleagues examined the response to the Centers for Medicare & Medicaid Services’ Nursing Home Compare website, a database intended to inform consumers, provide direction for state regulators and encourage quality improvement among nursing homes.

Published annually since 2002, Nursing Home Compare reports scores on 19 clinical quality measures for nursing homes across the country. It is accessible at www.medicare.gov/nhcompare.

“Fairly major investments in staffing and equipment were reported as being made solely in response to the publication of Nursing Home Compare,” Zinn said. “We found that, indeed, nursing homes appear to be incentivized to invest in clinical quality.”

The researchers concluded that “a substantial portion” of nursing homes now see the report card as influencing decision-making and that the facilities’ responses to the data reflected the extent to which they felt publication made a difference in the choices made by consumers, hospital discharge planners, case managers and others.

For example, nursing homes with low scores were three times more likely to invest in staff and equipment than high-quality facilities in competitive markets, offering further support that quality-measure data publication is perceived to have a competitive impact.

Zinn and her colleagues also examined the potential for dysfunctional responses to score publication, including evidence of “cream skimming,” or avoidance of high-risk admissions that could contribute to poorer scores. While there was some evidence of cream skimming with respect to patients admitted with pain or cognitive limitations, there was none with respect to other high-risk conditions.

To determine whether facilities responded to publication by “teaching to the test,” the researchers examined whether some nursing homes – such as those operated for profit or those with lower reported quality or occupancy – shifted more resources toward clinical services reflected in the reported quality measures and away from investments in hotel-type amenities.

This would be a reaction to increased consumer attention to clinical services as inferred from the published clinical quality measures, as consumers were more focused on hotel services, such as dietary or social programs, in the pre-report card era. The researchers found that while additional resources were invested in clinical services, investments in hotel-type services were not diminished.

Zinn emphasized that improvements in risk adjustment of the quality measures is key to increasing accuracy of the data for comparison purposes. When researchers made more rigorous adjustments to the report card’s risk-adjustment methodology, Zinn said “the ranking of some individual facility scores shifted substantially.”

Despite the methodological limitations, she said there are many positives in releasing quality measures for one of the most heavily regulated industries in the country.

“There’s a strong suggestion that this policy was successful, in terms of changing nursing home behavior,” she said.

Zinn conducted the study with principal investigator Dana B. Mukamel of the University of California, Irvine, as well as David L. Weimer of the University of Wisconsin-Madison and William Spector of the federal Agency for Healthcare Research and Quality.