Facility effects on racial differences in nursing home quality of care

Identifying Nursing Homes With Diverse Racial and Ethnic Resident Compositions: The Importance of Group Heterogeneity and Geographic Context

Racial/ethnic composition of nursing home (NH) plays a particularly important role in NH quality. A key methodological issue is defining when an NH serves a low versus high proportion of racially/ethnically diverse residents. Using the Minimum Data Set from 2015 merged with Certification and Survey Provider Enhanced Reports, we calculated the racial/ethnic composition of U.S.-based NHs for Black or Hispanic residents specifically, and a general Black, Indigenous, and People of Color (BIPOC) grouping for long-stay residents. We examined different definitions of having a high racial/ethnic composition by varying percentile thresholds of composition, state-specific and national thresholds, and restricting composition to BIPOC residents as well as only Black and Hispanic residents. NHs with a high racial/ethnic composition have different facility characteristics than the average NH. Based on this, we make suggestions for how to identify NHs with diverse racial/ethnic resident compositions.

Resident racial and ethnic composition, neighborhood-level socioeconomic status, and COVID-19 infections in California SNFs

BACKGROUND

In California, >29,000 residents in skilled nursing facility (SNFs) were diagnosed with novel coronavirus disease 2019 (COVID-19) between March 2020 and November 2020. Prior research suggests that SNFs serving racially and ethnically minoritized residents often have fewer resources and lower quality of care. We performed a cross-sectional analysis of COVID-19 incidence among residents in California SNFs, assessing the association of SNF-level racial and ethnic compositions and facility- and neighborhood-level (census tract- and county-level) indicators of socioeconomic status (SES).

METHODS

SNFs were grouped based on racial and ethnic composition using data from the Centers for Medicare and Medicaid Services; categories included SNFs with ≥88% White residents, SNFs with ≥32% Black or Latinx residents, SNFs with ≥32% Asian residents, or SNFs not serving a high proportion of any racial and ethnic composition (mixed). SNF resident-level COVID-19 infection data were obtained from the National Healthcare Safety Network from May 25, 2020 to August 16, 2020. Multilevel mixed-effects negative binomial regressions were used to estimate incidence rate ratios (IRR) for confirmed COVID-19 infections among residents.

RESULTS

Among 971 SNFs included in our sample, 119 (12.3%) had ≥88% White residents; 215 (22.1%) had ≥32% Black or Latinx residents; 78 (8.0%) had ≥32% Asian residents; and 559 (57.6%) were racially and ethnically mixed. After adjusting for confounders, SNFs with ≥32% Black or Latinx residents (IRR = 2.40 [95% CI = 1.56, 3.68]) and SNFs with mixed racial and ethnic composition (IRR = 2.12 [95% CI = 1.49, 3.03]) both had higher COVID-19 incidence rates than SNFs with ≥88% White residents. COVID-19 incidence rates were also found to be higher in SNFs with low SES neighborhoods compared to those in high SES neighborhoods.

CONCLUSION

Public health personnel should consider SNF- and neighborhood-level factors when identifying facilities to prioritize for COVID-19 outbreak prevention and control.

Structural Racism In Historical And Modern US Health Care Policy

The COVID-19 pandemic has illuminated and amplified the harsh reality of health inequities experienced by racial and ethnic minority groups in the United States. Members of these groups have disproportionately been infected and died from COVID-19, yet they still lack equitable access to treatment and vaccines. Lack of equitable access to high-quality health care is in large part a result of structural racism in US health care policy, which structures the health care system to advantage the White population and disadvantage racial and ethnic minority populations. This article provides historical context and a detailed account of modern structural racism in health care policy, highlighting its role in health care coverage, financing, and quality.

Decomposing Racial and Ethnic Disparities in Nursing Home Quality of Life

This study examines the racial/ethnic disparity among nursing home (NH) residents using a self-reported, validated measure of quality of life (QoL) among long-stay residents in Minnesota. Blinder-Oaxaca decomposition techniques determine which resident and facility factors are the potential sources of the racial/ethnic disparities in QoL. Black, Indigenous, and other People of Color (BIPOC) report lower QoL than White residents. Facility structural characteristics and being a NH with a high proportion of residents who are BIPOC are the factors that have the largest explanatory share of the disparity. Modifiable characteristics like staffing levels explain a small share of the disparity. To improve the QoL of BIPOC NH residents, efforts need to focus on addressing systemic disparities for NHs with a high proportion of residents who are BIPOC.

Does Living in a Higher Proportion Minority Facility Improve Quality of Life for Racial/Ethnic Minority Residents in Nursing Homes?

Background and Objectives

The proportion of racial/ethnic minority older adults in nursing homes (NHs) has increased dramatically and will surpass the proportion of white adults by 2030.Yet, little is known about minority groups’ experiences related to the quality of life (QOL). QOL is a person-centered measure, capturing multiple aspects of well-being. NH quality has been commonly measured using clinical care indicators, but there is growing recognition for the need to include QOL. This study examines the role of individual race/ethnicity, facility racial/ethnic composition, and the interaction of both for NH resident QOL.

Research Design and Methods

We used a unique state-level data set that includes self-reported QOL surveys with a random sample of long-stay Minnesota NH residents, using a multidimensional measure of QOL. These surveys were linked to resident clinical data from the Minimum Dataset 3.0 and facility-level characteristics. Minnesota is one of the two states in the nation that collects validated QOL measures, linked to data on resident and detailed facility characteristics. We used mixed-effects models, with random intercepts to model summary QOL score and individual domains.

Results

We identified significant racial disparities in NH resident QOL. Minority residents report significantly lower QOL scores than white residents, and NHs with higher proportion minority residents have significantly lower QOL scores. Minority residents have significantly lower adjusted QOL than white residents, whether they are in low- or high-minority facilities, indicating a remaining gap in individual care needs.

Discussion and Implications

The findings highlight system-level racial disparities in NH residents QOL, with residents who live in high-proportion minority NHs facing the greatest threats to their QOL. Efforts need to focus on reducing racial/ethnic disparities in QOL, including potential public reporting (similar to quality of care) and resources and attention to provision of culturally sensitive care in NHs to address residents’ unique needs.

Association of Race and Poverty With Mortality Among Nursing Home Residents on Maintenance Dialysis

OBJECTIVES

The association of race, ethnicity, and socioeconomic factors with survival rates of nursing home (NH) residents with treated end-stage renal disease (ESRD) is unclear. We examined whether race/ethnicity, ZIP code-level, and individual-level indicators of poverty relate to mortality of NH residents on dialysis.

DESIGN

Retrospective cohort study.

PARTICIPANTS/SETTING

Using the United States Renal Data System database, we identified 56,194 nursing home residents initiated on maintenance dialysis from January 1, 2007 through December 31, 2013, followed until May 31, 2014.

MEASUREMENTS

We evaluated baseline characteristics of the NH cohort on dialysis, including race and ethnicity. We assessed the Medicare-Medicaid dual eligibility status as an indicator of individual-level poverty and ZIP code-level median household income (MHI) data. We conducted Cox regression analyses with all-cause mortality as the outcome variable, adjusted for clinical and sociodemographic factors including end-of-life preferences.

RESULTS

Adjusted Cox analysis showed a significantly lower risk of death among black vs nonblack NH residents [adjusted hazard ratio (AHR) 0.91, 95% confidence interval (CI) 0.89, 0.94]. Dual-eligibility status was significantly associated with lower risk of death compared to those with Medicare alone (AHR 0.80, 95% CI 0.78, 0.82). Compared to those in higher MHI quintile levels, NH ESRD patients in the lowest quintile were significantly associated with higher risk of death (AHR 1.09, 95% CI 1.06, 1.13).

CONCLUSIONS/IMPLICATIONS

Black and Hispanic NH residents on dialysis had an apparent survival advantage. This "survival paradox" occurs despite well-documented racial/ethnic disparities in ESRD and NH care and warrants further exploration that could generate new insights into means of improving survival of all NH residents on dialysis. Area-level indicator of poverty was independently associated with mortality, whereas dual-eligibility status for Medicare and Medicaid was associated with lower risk of death, which could be partly explained by improved access to care.

Racial/Ethnic Differences in Receipt of Influenza and Pneumococcal Vaccination among Long-Stay Nursing Home Residents

OBJECTIVE/STUDY QUESTION

To examine racial/ethnic differences in influenza and pneumococcal vaccination receipt and nonreceipt among nursing home (NH) residents post implementation of federal vaccination policy. DATA SOURCES/STUDY SETTING/STUDY DESIGN/DATA COLLECTION/EXTRACTION METHODS: An analysis of a merged national cross-sectional dataset containing resident assessment, facility, and community data for years 2010-2013 was conducted. Logistic regressions omitting and including facility fixed effects were used to examine the influence of race and ethnicity (black, Hispanic, white) and black concentration on vaccination status across and within NHs.

PRINCIPLE FINDINGS

Vaccination receipt of 107,874 residents in 742 NHs was examined. Blacks were less likely than whites to receive influenza and pneumococcal vaccinations (OR = 0.75; OR = 0.81, respectively, p-values <.001). The likelihood of not being offered the influenza vaccination was greater for blacks (OR=1.25, p = .004) and the likelihood of not being offered the pneumococcal vaccination was greater for Hispanics (OR = 1.65, p = .04) compared to whites. Fixed effects showed that within the same NH, Hispanics were more likely to receive both vaccinations compared to whites (OR=1.22, p = .004 (influenza); OR=1.34, p < .001 (pneumococcal)). Facilities highly concentrated with blacks accounted for large proportions of differences seen in vaccination receipt.

CONCLUSIONS

Racial/ethnic differences remain despite policy changes. Focused strategies aimed at NH personnel and racially segregated NHs are critical to improving vaccination delivery and eliminating disparities in care.

Personal Care Aide Turnover in Residential Care Settings: An Assessment of Ownership, Economic, and Environmental Factors

Turnover among personal care aides is a chronic problem facing long-term-care industries. High turnover leads to high recruitment and training costs and to the potential for substandard care. Studies in nursing homes have found environmental factors to be more important than economic factors in predicting turnover rates, but no studies have been done in an assisted living setting or have considered the effects of the physical environment and location of the facility. This study assesses the importance of a variety of factors on turnover among personal care aides, using a two-part model. The results show that certain ownership and environmental factors (facility type, chain ownership, and attractiveness of the neighborhood)are important predictors of turnover. Although adequate economic compensation is undoubtedly important in attracting and retaining qualified staff, the results identify facility characteristics that may indicate a greater level of turnover as well as greater potential for improvement through interventions to reduce turnover.

Racial Differences in Minnesota Nursing Home Residents' Quality of Life: The Importance of Looking Beyond Individual Predictors

OBJECTIVES

The aim of this study is to investigate racial differences in nursing home (NH) residents' quality of life (QOL) at the resident and facility levels.

METHOD

We used hierarchical linear modeling to identify significant resident- and facility-level predictors for racial differences in six resident-reported QOL domains. Data came from the following: (a) resident-reported QOL (n = 10,929), (b) the Minimum Data Set, and (c) facility-level characteristics from the Minnesota Department of Human Services (n = 376).

RESULTS

White residents reported higher QOL in five of six domains, but in full models, individual-level racial differences remained only for food enjoyment. On the facility level, higher percentage of White residents was associated with better scores in three domains, even after adjusting for all characteristics.

DISCUSSION

Racial differences in QOL exist on individual and aggregate levels. Individual differences are mainly explained by health status. The finding that facility racial composition predicts QOL more than individual race underscores the importance of examining NH structural characteristics and practices.

Contextual determinants of US nursing home racial/ethnic diversity

We hypothesized that for-profit/chain affiliated nursing homes, those in states with higher Medicaid reimbursement, and those in more competitive markets would have greater resident racial/ethnic diversity than nursing homes not meeting these criteria. Using 2004 Online Survey, Certification and Reporting data, Minimum Data Set, Lewis Mumford Center for Comparative Urban and Regional Research data, and the Area Resource File, we included U.S. Medicare/Medicaid certified nursing homes (N = 8950) located in 310 Metropolitan Statistical Areas. The dependent variable quantified facility-level multiracial diversity. Ordinary least squares regression showed support for the hypothesized relationships: for-profit/chain affiliated nursing homes were more diverse than nursing homes in all other ownership/chain member categories, while higher Medicaid per-diem rates, greater residential diversity, and stronger market competition were also positively associated with nursing home racial/ethnic composition. Results suggest there is room for policy changes to achieve equitable access to all levels of nursing home services for minority elders.

Nursing home quality and financial performance: does the racial composition of residents matter?

OBJECTIVE

To examine the effects of the racial composition of residents on nursing homes' financial and quality performance. The study examined Medicare and Medicaid-certified nursing homes across the United States that submitted Medicare cost reports between the years 1999 and 2004 (11,472 average per year).

DATA SOURCE

Data were obtained from the Minimum Data Set, the On-Line Survey Certification and Reporting, Medicare Cost Reports, and the Area Resource File.

STUDY DESIGN

Panel data regression with random intercepts and negative binomial regression were conducted with state and year fixed effects.

PRINCIPAL FINDINGS

Financial and quality performance differed between nursing homes with high proportions of black residents and nursing homes with no or medium proportions of black residents. Nursing homes with no black residents had higher revenues and higher operating margins and total profit margins and they exhibited better processes and outcomes than nursing homes with high proportions of black residents.

CONCLUSION

Nursing homes' financial viability and quality of care are influenced by the racial composition of residents. Policy makers should consider initiatives to improve both the financial and quality performance of nursing homes serving predominantly black residents.

Racial disparities in job strain among American and immigrant long-term care workers

BACKGROUND

Nursing homes are occupational settings, with an increasing minority and immigrant workforce where several psychosocial stressors intersect.

AIM

This study aimed to examine racial/ethnic differences in job strain between Black (n = 127) and White (n = 110) immigrant and American direct-care workers at nursing homes (total n = 237).

METHODS

Cross-sectional study with data collected at four nursing homes in Massachusetts during 2006-2007. We contrasted Black and White workers within higher-skilled occupations such as registered nurses or licensed practical nurses (n = 82) and lower-skilled staff such as certified nursing assistants (CNAs, n = 155).

RESULTS

Almost all Black workers (96%) were immigrants. After adjusting for demographic and occupational characteristics, Black employees were more likely to report job strain, compared with Whites [relative risk (RR): 2.9, 95% confidence interval (CI) 1.3 to 6.6]. Analyses stratified by occupation showed that Black CNAs were more likely to report job strain, compared with White CNAs (RR: 3.1, 95% CI: 1.0 to 9.4). Black workers were also more likely to report low control (RR: 2.1, 95% CI: 1.1 to 4.0). Additionally, Black workers earned $2.58 less per hour and worked 7.1 more hours per week on average, controlling for potential confounders.

CONCLUSION

Black immigrant workers were 2.9 times more likely to report job strain than White workers, with greater differences among CNAs. These findings may reflect differential organizational or individual characteristics but also interpersonal or institutional racial/ethnic discrimination. Further research should consider the role of race/ethnicity in shaping patterns of occupational stress.

Racial differences in dementia care among nursing home residents

OBJECTIVES

This article aims to describe potential racial differences in dementia care among nursing home residents with dementia.

METHODS

Using data from the 2004 National Nursing Home Survey (NNHS) in regression models, the authors examine whether non-Whites are less likely than Whites to receive special dementia care--defined as receiving special dementia care services or being in a dementia special care unit (SCU)--and whether this difference derives from differences in resident or facility characteristics.

RESULTS

The authors find that non-Whites are 4.3 percentage points less likely than Whites to receive special dementia care.

DISCUSSION

The fact that non-Whites are more likely to rely on Medicaid and less likely to pay out of pocket for nursing home care explains part but not all of the difference. Most of the difference is due to the fact that non-Whites reside in facilities that are less likely to have special dementia care services or dementia care units, particularly for-profit facilities and those in the South.

Are patients with serious mental illness more likely to be admitted to nursing homes with more deficiencies in care?

BACKGROUND

Patients diagnosed with serious mental illness (SMI) who qualify for nursing home placement tend to require high levels of both psychiatric and nursing care. However, it is unknown whether they are equally likely to be admitted to nursing homes with adequate quality of care compared with other patients.

METHODS

We analyzed a national cohort of more than 1.3 million new nursing home admissions in 2007 using the minimum data set. The total and healthcare-related deficiency citations for each facility were obtained from the Online Survey, Certification, and Reporting file. Bivariate and multivariate regression analyses determined the association of schizophrenia or bipolar disorder with admissions to facilities with higher deficiencies.

RESULTS

Compared with other patients, patients with schizophrenia (n=23,767) tended to enter nursing homes with more total (13.3 vs. 11.2, P<0.001) and healthcare-related deficiencies (8.6 vs. 7.2, P<0.001); and patients with bipolar disorder (n=19,741) were more likely to enter facilities with more problematic care too (12.5 vs. 11.2, P<0.001 for total deficiencies; and 8.2 vs. 7.2, P<0.001 for healthcare-related deficiencies). After sequentially controlling for the within-county choice of facilities, patient characteristics, and facility covariates, the association of SMI with admitting to higher-deficiency nursing homes persisted.

CONCLUSIONS

Patients diagnosed with schizophrenia or bipolar disorder (ie, SMI) were more likely than other patients to be admitted to nursing homes with higher deficiency citations for both overall quality and clinical care quality. Further research is necessary to understand the reasons behind the disparity in quality of nursing home care associated with SMI.

Racial disparities in receipt of influenza and pneumococcus vaccinations among US nursing-home residents

OBJECTIVES

We examined racial disparities in receipt and documentation of influenza and pneumococcus vaccinations among nursing-home residents.

METHODS

We performed secondary analyses of data from a nationally representative survey of White (n = 11 448) and Black (n = 1174) nursing-home residents in 2004. Bivariate and multivariate analyses determined racial disparities in receipt of influenza vaccination in 2003 and 2004, receipt of pneumococcus vaccination ever, and having a documented history for each vaccination.

RESULTS

The overall vaccination rate was 76.2% for influenza and 48.5% for pneumococcus infection. Compared with Whites, Blacks showed a 13% lower vaccination rate and a 5% higher undocumentation rate for influenza, and a 15% lower vaccination rate and a 7% higher undocumentation rate for pneumococcus. For influenza, the odds ratio (OR) for Blacks being unvaccinated was 1.84 (P < or = .001), and the OR for Blacks having undocumented vaccination was 1.85 (P = .001). For pneumococcus infection, the OR for Blacks being unvaccinated was 1.70 (P < or = .001), and the OR for Blacks having undocumented vaccination was 1.95 (P < or = .001). Stratified analyses confirmed persistent racial disparities among subpopulations.

CONCLUSIONS

Racial disparities exist in vaccination coverage among US nursing-home residents. Targeted interventions to improve vaccination coverage for minority nursing-home residents are warranted.

Disparities in long-term care: building equity into market-based reforms

A growing body of evidence documents pervasive racial, ethnic, and class disparities in long-term care in the United States. At the same time, major quality improvement initiatives are being implemented that rely on market-based incentives, many of which may have the unintended consequence of exacerbating disparities. We review existing evidence on disparities in the use and quality of long-term care services, analyze current market-based policy initiatives in terms of their potential to ameliorate or exacerbate these disparities, and suggest policies and policy modifications that may help decrease disparities. We find that racial disparities in the use of formal long-term care have decreased over time. Disparities in quality of care are more consistently documented and appear to be related to racial and socioeconomic segregation of long-term care facilities as opposed to within-provider discrimination. Market-based incentives policies should explicitly incorporate the goal of mitigating the potential unintended consequence of increased disparities.

Black-White Disparities in Care in Nursing Homes

Nursing homes serve many severely ill poor people, including large numbers of racial/ethnic minority residents. Previous research indicates that blacks tend to receive care from lower quality nursing homes (Grabowski, 2004). Using the Institute of Medicine (IOM) definition of racial-ethnic disparities, this study decomposes nursing home disparities into within and across facility components. Using detailed person-level nursing home data, we find meaningful black-white disparities for one of the four risk-adjusted quality measures, with both within and across nursing home components of the disparity. The IOM approach, which recognizes mediation through payer status and education, has a small effect on measured disparities in this setting. Although we did not find disparities across the majority of quality measures and alternate disparity definitions, this approach can be applied to other health care services in an effort to disentangle the role of across and within facility variation and the role of potential mediators on racial/ethnic disparities.

Factors associated with the initiation and discontinuation of secondary stroke prevention agents in nursing homes

BACKGROUND AND PURPOSE

Little is known about factors relating to initiation and discontinuation of antiplatelet and anticoagulant therapies among stroke survivors in nursing homes.

METHODS

In 6 states from 1992 to 1996, we followed up stroke survivors admitted to nursing homes for at least 6 months; 9547 were not receiving any secondary stroke prevention treatment at admission, whereas 6244 were receiving therapy. Factors relating to initiation and discontinuation of drug therapy included resident factors (e.g., sociodemographics, clinical factors) and facility factors (e.g., for profit, part of a chain). Generalized estimating equations provided estimates of residents and facility characteristics adjusting for the clustering effects owing to the correlation of residents living within the same home.

RESULTS

In all, 12% initiated drug therapy; 30.3% discontinued. Conditions known to increase the risk of recurrent stroke (e.g., atrial fibrillation) were predictive of initiation. Black residents (odds ratio [OR] 0.62, 95% confidence interval [CI] 0.49-0.78) were less likely than non-Hispanic white residents to initiate therapy. American Indian (OR 1.16, 95% CI 0.80-1.68), black (OR 1.23, 95% CI 1.03-1.47), and Hispanic residents (OR 1.30, 95% CI 0.79-2.13) tended to be more likely than non-Hispanic white residents to discontinue therapy, with facility characteristics completely explaining the observed associations.

CONCLUSIONS

In nursing homes, interventions to improve drug management of recurrent stroke are needed and implementation should occur without regard to a patient's skin color. Intervention studies may have little success in the nursing home setting if the context in which the care is given and financial/structural difficulties are not addressed in the implementation of such interventions.

Facility and county effects on racial differences in nursing home quality indicators

This study's goal was to examine the effects of nursing home (NH) and county racial mix on quality of care in NHs. We examined quality indicator (QI) outcomes for residents in 408 urban New York NHs in July through September, 1995. The QI outcomes studied were restraint and antipsychotic drug use (for low and high-risk residents), and at study commencement, these QIs were being used by the Centers for Medicare and Medicaid Services to monitor the quality of care in USA Medicare and/or Medicaid-certified NHs. A hierarchical modeling approach was used to properly reflect the nesting of both residents within NHs and NHs within counties. Separate regression models were fit to the two strata of interest (Urban Non-Hispanic Whites and Urban African Americans) to test, for each race group, the effect on quality of residing in NHs and counties with higher proportions of African Americans (than state medians). Descriptive analyses found that, compared to Whites, the unadjusted restraint rate was lower for African Americans while the antipsychotic drug rate was higher. For both race groups, multi-level analyses showed residence in for-profit NHs was associated with higher likelihoods of being restrained, and of receiving antipsychotic drugs. Also, for both race groups, residence in NHs with higher proportions of African-Americans was associated with lower likelihoods of being restrained and with higher, statistically nonsignificant, likelihoods of receiving antipsychotic drugs. Higher NH nurse staffing ratios were associated with higher likelihoods of being restrained and with lower likelihoods of antipsychotic drug use (statistically significant for low-risk African-Americans). Findings support the notion that differential care is provided in USA NHs caring for higher proportions of African-American residents and thereby suggest intervention at the organizational level is warranted to improve QI outcomes for both race groups.

Nursing Staff and the Outcomes of Nursing Home Stays

BACKGROUND

Findings on the relationship between nurse staffing and nursing home outcomes (eg, dying vs. discharges to the community) have been inconsistent. Although some studies show outcomes related to staffing ratios, others do not. Subjects in studies showing staffing effects may have been primarily short-stay residents and longer stays in studies showing no staffing effects. Outcomes affected by staffing may vary by short and longer stays.

OBJECTIVE

The effect of staffing by duration of stay has not been studied explicitly. The purpose of this study was to discern whether the effect of nursing staffing on discharge status varies between short and longer stays.

METHOD

Data on discharges came from the 1999 National Nursing Home Survey (n = 6386). Models were constructed for short and longer stays applying multinomial logistic regression.

RESULTS

For stays less than 60 days, but not among longer stays, the probability of leaving the nursing home in recovered or stabilized condition increased, and that of dying decreased, with an increasing staffing ratio for registered nurses. Clinical condition was the major factor differentiating discharge status among short and longer stays.

CONCLUSION

Results indicate a likely reason for past inconsistent findings on staffing. Staffing ratios may affect discharge disposition more among short stays. Some discharge dispositions, such as death, may not be the most relevant outcomes to study to discern how staffing affects the care provided to longer-stay residents. More research is warranted on how the sensitivity of outcomes to staffing ratios varies across short- and longer-stay residents.

Effect of educational level and minority status on nursing home choice after hospital discharge

OBJECTIVES

The movement to publicly report data on provider quality to inform consumer choices is predicated on assumptions of equal access and knowledge. We examine the validity of this assumption by testing whether minority/less educated Medicare patients are at greater risk of being discharged from a hospital to the lowest-quality nursing homes in a geographic area.

METHODS

We used the 2002 national Minimum Data Set to identify 62601 new Medicare admissions to nursing homes in 95 hospital service areas with at least 4 freestanding nursing homes and at least 50 African Americans aged 65 years or older with Medicare admissions to nursing homes.

RESULTS

The probability of African Americans' being admitted to nursing homes in the lowest-quality quartile in the area was greater (relative risk [RR]=1.26; 95% confidence interval [CI]=1.0, 8.45) in comparison with Whites. Individuals without a high-school degree were also more likely to be admitted to a low-quality nursing home (RR=1.22; 95% CI=1.0, 1.46).

CONCLUSIONS

African American and poorly educated patients enter the worst-quality nursing facilities. This finding raises concerns about the usefulness of the current public reporting model for certain consumers.

Pressure ulcers: more lethal than we thought?

OBJECTIVE

To investigate the burden of pressure ulcer-associated mortality in the United States and to examine racial/ethnic differences and associated comorbidities.

DESIGN

A descriptive study with matched odds ratio comparisons.

SETTING

The United States, 1990-2001.

PARTICIPANTS

Pressure ulcer-associated deaths were identified from national multiple cause-coded death records from 1990 to 2001.

MAIN OUTCOME MEASURES

Age-adjusted mortality rates and matched odds ratio comparisons of pressure ulcer-associated deaths with deaths from other conditions.

MAIN RESULTS

Between 1990 and 2001, pressure ulcers were reported as a cause of death among 114,380 persons (age-adjusted mortality rate, 3.79 per 100,000 population; 95% confidence interval [CI], 3.77-3.81). For 21,365 (18.7%) of these deaths, pressure ulcers were reported as the underlying cause. Nearly 80% of pressure ulcer-associated deaths occurred in persons at least 75 years old. Septicemia was reported in 39.7% of pressure ulcer-associated deaths (matched odds ratio, 11.3; 95% CI, 11.0-11.7). Multiple sclerosis, paralysis, Alzheimer disease, osteoporosis, and Parkinson disease were reported more often in pressure ulcer-associated deaths than in matched controls. Pressure ulcer-associated mortality was higher among blacks than among whites (age-adjusted rate ratio, 4.22; 95% CI, 4.16-4.27).

CONCLUSION

Pressure ulcers are associated with fatal septic infections and are reported as a cause of thousands of deaths each year in the United States. Incapacitating chronic and neurodegenerative conditions are common comorbidities, and mortality rates in blacks are higher than in other racial/ethnic groups.

How good is assisted living? Findings and implications from an outcomes study

OBJECTIVES

The objective of this work was to determine 1-year medical outcomes, nursing home transfer, and functional change of assisted living (AL) residents and their relationship to care.

METHODS

On-site interviews and observations regarding the status and care of 2,078 residents in 193 facilities across four states were conducted; follow-up was by telephone interview with care providers.

RESULTS

Annual mortality and transfer rates were 14.4 and 21.3 per 100 residents. The probability of hospitalization and new/worsening morbidities over a standardized quarter per 100 residents was 12.7 and 22.7. Standardized change in function was notable among those who were transferred or died and small among others. Facility characteristics did not generally relate to medical outcomes and transfer, and those that related to functional change were small and occurred across multiple functions. Facilities that are affiliated with another level of care were more likely to transfer; nurse staffing was favorable for hospitalization but not transfer; and aide turnover was protective for mortality.

DISCUSSION

No single component defines "good" AL care. Predictors and outcomes are inconsistent, and effect sizes are small. Therefore, practice and policy should not focus narrowly on any one area or restrict the type of care-this being welcome news that supports diversity to accommodate individual preferences.

End-of-Life Hospitalization for African American and Non-Latino White Nursing Home Residents: Variation by Race and a Facility's Racial Composition

BACKGROUND

Hospitalization of nursing home residents at the end of life is common, more so among African Americans. Whether a nursing home's racial mix is associated with hospitalization is unknown.

OBJECTIVE

This study examined the association between race, a nursing home's racial mix, and end-of-life hospitalization.

DESIGN

This was a retrospective cohort study.

SETTING/SUBJECTS

Studied were nursing home residents in New York (n = 14,159) and Mississippi (n = 1481) who died in 1995-1996 and had a minimum data set (MDS) assessment within 120 days of death.

MEASUREMENTS

The outcome measure was the odds of hospitalization in the last 90 days of life. A variable reflecting a nursing home's proportion of African American residents (in 1995-1996) represented a nursing home's racial mix.

RESULTS

Forty-six percent of African Americans and 32% of whites were hospitalized in the last 90 days of life. After controlling for demographics, diagnoses, function, patient preferences (do-not-resuscitate [DNR]), and facility resources, nursing home residents in facilities having higher proportions of African American residents had greater odds of hospitalization (adjusted odds ratio [AOR] 1.14; 95% confidence interval [CI] 1.10, 1.18 in New York and AOR 1.35; 95% CI 1.24, 1.46 in Mississippi). Age and frailty interacted with race; older African Americans had a 16% greater likelihood (95% CI 1.08, 1.24) of hospitalization, and African Americans with more functional limitations had a 37% (95% CI 1.24, 1.51) greater likelihood of hospitalization than did comparable whites.

CONCLUSIONS

It appears higher end-of-life hospitalization rates for African American residents are attributable to the facilities where most reside, and to differential hospitalization of older or more functional limited residents.

The admission of blacks to high-deficiency nursing homes

BACKGROUND

Although the presence of racial and ethnic disparities in nursing home care has been established, there is no work to date examining the relationship between race and government-cited nursing home deficiencies. Deficiencies are evaluations of poor quality made by state surveyors under the federal nursing home certification regulations.

OBJECTIVE

The objective of this study was to examine whether blacks and other minority elders are disproportionately admitted to high-deficiency nursing homes.

RESEARCH DESIGN

This observational study used a merged file containing individual-level data from the Nursing Home Component of the 1996 Medical Expenditures Panel Study (MEPS) and facility-level quality information from the Online Survey, Certification, and Reporting System.

SUBJECTS

The subjects were a 1996 nationally representative sample of 2690 nursing home admissions from the MEPS.

MEASURES

The key variables of interest were the race and ethnicity of newly admitted nursing home residents and the facility's count of government-assigned deficiency citations.

RESULTS

Controlling for individual, facility, and market characteristics, blacks were disproportionately admitted to nursing homes with a higher number of deficiencies. In a model that controlled for resident and home characteristics, blacks were admitted to nursing homes that exceeded the mean state deficiency level by 1.32.

CONCLUSIONS

Policymakers might wish to consider initiatives that provide better quality information to black nursing home consumers, and, to the extent that black consumers lack choice, provide greater resources and better oversight of facilities that care for predominantly black residents.

Does quality influence consumer choice of nursing homes? Evidence from nursing home to nursing home transfers

We estimated Cox proportional hazards models using assessment data from the Minimum Data Set to test whether nursing home residents and their proxies respond to quality of care by changing providers. Various indicators of poor quality increased the likelihood of transfer. Residents of for-profit homes or homes with excess capacity also were more likely to transfer. Inability to participate in care decisions and factors indicating frailty limited residents' ability to transfer. The apparent responsiveness to quality is encouraging. Nonetheless, because the absolute transfer rate is low, significant barriers to movement among nursing homes still may exist.

Driven to tiers: socioeconomic and racial disparities in the quality of nursing home care

Nursing home care is currently a two-tiered system. The lower tier consists of facilities housing mainly Medicaid residents and, as a result, has very limited resources. The nearly 15 percent of U.S. nonhospital-based nursing homes that serve predominantly Medicaid residents have fewer nurses, lower occupancy rates, and more health-related deficiencies. They are more likely to be terminated from the Medicaid/Medicare program, are disproportionately located in the poorest counties, and are more likely to serve African-American residents than are other facilities. The public reporting of quality indicators, intended to improve quality through market mechanisms, may result in driving poor homes out of business and will disproportionately affect nonwhite residents living in poor communities. This article recommends a proactive policy stance to mitigate these consequences of quality competition.

Distribution of African Americans in residential care/assisted living and nursing homes: more evidence of racial disparity?

OBJECTIVES

In this study, we examined racial separation in long-term care.

METHODS

We used a survey of a stratified sample of 181 residential care/assisted living (RC/AL) facilities and 39 nursing homes in 4 states.

RESULTS

Most African Americans resided in nursing homes and smaller RC/AL facilities and tended to be concentrated in a few predominantly African American facilities, whereas the vast majority of Whites resided in predominantly White facilities. Facilities housing African Americans tended to be located in rural, nonpoor, African American communities, to admit individuals with mental retardation and difficulty in ambulating, and to have lower ratings of cleanliness/maintenance and lighting.

CONCLUSIONS

These racial disparities may result from economic factors, exclusionary practices, or resident choice. Whether separation relates to inequities in care is undetermined.