Should Racial and Ethnic Disparities in Nursing Home Quality be Reported Publicly?

CFAR | November 20, 2017 | by Steven Syre

New research led by an assistant professor of gerontology at the University of Massachusetts Boston may support calls favoring public reporting, at the individual nursing-home level, of quality measures based on race and ethnicity.

Reports examining racial and ethnic disparities in the quality of nursing home care typically focus on the collective experience of thousands of residents living in many nursing homes.

Jennifer Gaudet Hefele, an assistant professor of gerontology at the University of Massachusetts Boston, believes information about racial and ethnic disparities can and should be publicly reported for individual nursing homes as well.

Hefele, who is a fellow in the LeadingAge LTSS Center @UMass Boston, recently joined 6 co-authors in publishing the results of the first study to examine differences in quality by race and ethnicity within nursing homes, based on a large set of publicly reported national measures.

Their results showed:

  • Small overall differences in quality within nursing homes, based on race and ethnicity. Most of those differences were less than 2 percentage points, and sometimes indicated slightly poorer care of white residents, on average.
  • The range of quality scores at some individual homes, based on race and ethnicity, was substantial. Some nursing homes had quality scores for residents of different races and ethnicities that differed by as much as 30 percentage points.

The authors concluded that their results supported calls favoring public reporting of quality measures based on race and ethnicity at the individual nursing home provider level.

“Although the mean differences were small on average, the range of differences suggests that care for residents of different races and ethnicities can be alarmingly different in the same nursing home,” Hefele and her co-authors wrote in The Joint Commission Journal on Quality and Patient Safety.

In a companion blog post, Hefele suggested that gathering data within nursing homes could help providers “get ahead of the curve and take initiative to understand their own performance patterns across race/ethnicity and identify areas in need of improvement.”

Tracking 8 Quality Measures

The study by Hefele and her colleagues examined data from more than 15,000 nursing homes and 3 million residents. Researchers tracked 8 nursing home quality measures used by the Centers for Medicare and Medicaid Services (CMS) and published in Nursing Home Compare report cards for individual homes. Those measures include:

  • Incontinence,
  • Weight loss,
  • Urinary tract infections,
  • High-risk pressure ulcers,
  • Low-risk pressure ulcers,
  • Worsening depression,
  • Functional decline, and
  • Physical restraints.

The study focused on nursing homes that cared for at least 30 white residents and a minimum of 30 residents who were black or 30 who were Hispanic.

Determining Statistical Feasibility

Beyond showing whether and how quality varied by race and ethnicity within the same nursing home, the study also verified that it was statistically feasible to stratify nursing home-level measures.

Stratifying measures creates smaller sample sizes and can result in statistically unstable quality measures, an often-cited obstacle in discussions about measure stratification.

Hefele and her colleagues compared the stability of the stratified measures and publicly reported measures and found similar levels of stability. They concluded that the stratified measures meet the same levels of acceptability as the CMS-reported measures, and are thus statistically feasible to construct and report.

A Call for More Study

The authors maintain that the results of their research show the value of reporting stratified quality measures publicly. However, they cautioned that further study is needed before such public reporting takes place.

“Our work provides support for the call to explore the possibility of publicly reporting stratified nursing home measures,” the authors wrote. “Although the chances of selecting a nursing home that delivers wildly different care to residents of different racial/ethnic groups is low, it is clearly a chance that many would rather not take.”