The impact of litigation on nursing home quality

Does litigation increase or decrease health care quality?: a national study of negligence claims against nursing homes

BACKGROUND

The tort system is supposed to help improve the quality and safety of health care, but whether it actually does so is controversial. Most previous studies modeling the effect of negligence litigation on quality of care are ecologic.

OBJECTIVE

To assess whether the experience of being sued and incurring litigation costs affects the quality of care subsequently delivered in nursing homes.

RESEARCH DESIGN, SUBJECTS, MEASURES

We linked information on 6471 negligence claims brought against 1514 nursing homes between 1998 and 2010 to indicators of nursing home quality drawn from 2 US national datasets (Online Survey, Certification, and Reporting system; Minimum Data Set Quality Measure/Indicator Reports). At the facility level, we tested for associations between 9 quality measures and 3 variables indicating the nursing homes' litigation experience in the preceding 12-18 months (total indemnity payments; total indemnity payments plus administrative costs; ≥ 1 paid claims vs. none). The analyses adjusted for quality at baseline, case-mix, ownership, occupancy, year, and facility and state random effects.

RESULTS

Nearly all combinations of the 3 litigation exposure measures and 9 quality measures--27 models in all--showed an inverse relationship between litigation costs and quality. However, only a few of these associations were statistically significant, and the effect sizes were very small. For example, a doubling of indemnity payments was associated with a 1.1% increase in the number of deficiencies and a 2.2% increase in pressure ulcer rates.

CONCLUSIONS

Tort litigation does not increase the quality performance of nursing homes, and may decrease it slightly.

Malpractice litigation and nursing home quality of care

OBJECTIVE

To assess the potential deterrent effect of nursing home litigation threat on nursing home quality.

DATA SOURCES/STUDY SETTING

We use a panel dataset of litigation claims and Nursing Home Online Survey Certification and Reporting (OSCAR) data from 1995 to 2005 in six states: Florida, Illinois, Wisconsin, New Jersey, Missouri, and Delaware, for a total of 2,245 facilities. Claims data are from Westlaw's Adverse Filings database, a proprietary legal database, on all malpractice, negligence, and personal injury/wrongful death claims filed against nursing facilities.

STUDY DESIGN

A lagged 2-year moving average of the county-level number of malpractice claims is used to represent the threat of litigation. We use facility fixed-effects models to examine the relationship between the threat of litigation and nursing home quality.

PRINCIPAL FINDINGS

We find significant increases in registered nurse-to-total staffing ratios in response to rising malpractice threat, and a reduction in pressure sores among highly staffed facilities. However, the magnitude of the deterrence effect is small.

CONCLUSIONS

Deterrence in response to the threat of malpractice litigation is unlikely to lead to widespread improvements in nursing home quality. This should be weighed against other benefits and costs of litigation to assess the net benefit of tort reform.

Nursing home deficiency citations for physical restraints and restrictive side rails

This article examines whether nursing home facility-level characteristics are associated with the likelihood of receiving deficiency citations for physical restraints, including restrictive side rails. Data from the on-line survey certification of automated records were used to calculate odds ratios for facility-level characteristics associated with these deficiency citations. Repeat records from 2000 to 2007 were combined to produce longitudinal data. The results of this study show that restraint/side rail deficiency citations were negatively associated with higher staffing levels of registered nurses and licensed practical nurses (p ≤ .001) and higher Medicaid reimbursement rates (p ≤ .01). Citations were positively associated with greater nurse aide staffing (p ≤ .01) and higher quality-of-care deficiency citation percentiles (p ≤ .001). The extent of physical restraint and restrictive side rail misuse within nursing homes appears to vary according to various facility characteristics. It is less clear how internal processes within a facility bring about these observed patterns of variation.

Relationship between quality of care and negligence litigation in nursing homes

BACKGROUND

It is unclear whether high-quality health care institutions are less likely to be sued for negligence than their low-performing counterparts.

METHODS

We linked information on tort claims brought against 1465 nursing homes between 1998 and 2006 to 10 indicators of nursing home quality drawn from two U.S. national data sets: the Online Survey, Certification, and Reporting system and the Minimum Data Set Quality Measure/Indicator Report. We tested for associations between the incidence of claims and the quality measures at the facility calendar-quarter level, correcting for facility clustering and adjusting for case mix, ownership, occupancy, year, and state. Odds ratios were calculated for the effect of a change of 1 SD in each quality measure on the odds of one or more claims in each facility calendar-quarter.

RESULTS

Nursing homes with more deficiencies (odds ratio, 1.09; 95% confidence interval [CI], 1.05 to 1.13) and those with more serious deficiencies (odds ratio, 1.04; 95% CI, 1.00 to 1.08) had higher odds of being sued; this was also true for nursing homes that had more residents with weight loss (odds ratio, 1.05; 95% CI, 1.01 to 1.10) and with pressure ulcers (odds ratio, 1.09; 95% CI, 1.05 to 1.14). The odds of being sued were lower in nursing homes with more nurse's aide-hours per resident-day (odds ratio, 0.95; 95% CI, 0.91 to 0.99). However, all these effects were relatively small. For example, nursing homes with the best deficiency records (10th percentile) had a 40% annual risk of being sued, as compared with a 47% risk among nursing homes with the worst deficiency records (90th percentile).

CONCLUSIONS

The best-performing nursing homes are sued only marginally less than the worst-performing ones. Such weak discrimination may subvert the capacity of litigation to provide incentives to deliver safer care.

Nursing Home Litigation and Tort Reform: A Case for Exceptionalism

The medical malpractice crisis that is currently spreading across the United States bears many similarities to earlier crises. One novel aspect of the current crisis is the explicit inclusion of litigation against nursing homes as a target of reform. Encouraged by the nursing home industry, policymakers are considering the extension of conventional medical malpractice tort reforms to the nursing home sector. In this article, we caution against such an approach. Nursing home litigation has a number of distinctive features that raise serious questions about the wisdom of implementing reforms generically across the care continuum. Drawing on findings from our previous study of nursing home litigation, we outline these features and argue for careful attention to them as policymakers evaluate options for reform.