Original Study| Volume 21, ISSUE 10, P1490-1496, October 2020

Download started.


Long-Term Care Facility Ownership and Acute Hospital Service Use in British Columbia, Canada: A Retrospective Cohort Study



      Previous studies report higher hospitalization rates in for-profit compared with nonprofit long-term care facilities (LTCFs), but have not included staffing data, a major potential confounder. Our objective was to examine the effect of ownership on hospital admission rates, after adjusting for facility staffing levels and other facility and resident characteristics, in a large Canadian province (British Columbia).


      Retrospective cohort study.

      Setting and Participants

      Our cohort included individuals resident in a publicly funded LTCF in British Columbia at any time between April 1, 2012 and March 31, 2016.


      Health administrative data were extracted from multiple databases, including continuing care, hospital discharge, and Minimum Data Set (MDS 2.0) assessment records. Cox extended hazards regression was used to estimate hospitalization risk associated with facility- and resident-level factors.


      The cohort included 49,799 residents in 304 LTCF facilities (116 publicly owned and operated, 99 for-profit, and 89 nonprofit) over the study period. Hospitalization risk was higher for residents in for-profit (adjusted hazard ratio [adjHR] 1.34; 95% confidence interval [CI] 1.29–1.38) and nonprofit (adjHR 1.37; 95% CI 1.32–1.41) facilities compared with publicly owned and operated facilities, after adjustment for staffing, facility size, urban location, resident demographics, and case mix. Within subtypes, risk was highest in single-site facilities: for-profit (adjHR 1.42; 95% CI 1.36–1.48) and nonprofit (adjHR 1.38, 95% CI 1.33–1.44).

      Conclusions and Implications

      This is the first Canadian study using linked health data from hospital discharge records, MDS 2.0, facility staffing, and ownership records to examine the adjusted effect of facility ownership characteristics on hospital use of LTCF residents. We found significantly lower adjHRs for hospital admission in publicly owned facilities compared with both for-profit and nonprofit facilities. Our finding that publicly owned facilities have lower hospital admission rates compared with for-profit and nonprofit facilities can help inform decision-makers faced with the challenge of optimizing care models in both nursing homes and hospitals as they build capacity to care for aging populations.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of the American Medical Directors Association
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • MacDonald M.
        Regulating individual charges for long-term residential care in Canada.
        Stud Polit Econ. 2015; 95: 1-32
        • Sivananthan S.N.
        • Doupe M.
        • McGregor M.J.
        Exploring the ecology of Canada's publicly funded residential long-term care bed supply.
        Can J Aging. 2015; 34: 60-74
        • Castle N.G.
        • Ferguson J.C.
        What is nursing home quality and how is it measured?.
        Gerontologist. 2010; 50: 426-442
        • Anderson R.A.
        • Issel L.M.
        • McDaniel Jr., R.R.
        Nursing homes as complex adaptive systems: Relationship between management practice and resident outcomes.
        Nurs Res. 2003; 52: 12-21
        • McGregor M.J.
        • McGrail K.M.
        • Abu-Laban R.B.
        • et al.
        Emergency department visit rates and patterns in Canada's Vancouver coastal health region.
        Can J Aging. 2014; 33: 154-162
        • McGregor M.J.
        • Cox M.B.
        • Slater J.M.
        • et al.
        A before-after study of hospital use in two frail populations receiving different home-based services over the same time in Vancouver, Canada.
        BMC Health Serv Res. 2018; 18: 248
        • Grabowski D.C.
        • Stewart K.A.
        • Broderick S.M.
        • Coots L.A.
        Predictors of nursing home hospitalization: A review of the literature.
        Med Care Res Rev. 2008; 65: 3-39
        • Graverholt B.
        • Forsetlund L.
        • Jamtvedt G.
        Reducing hospital admissions from nursing homes: A systematic review.
        BMC Health Serv Res. 2014; 14: 36
        • Kane R.L.
        • Huckfeldt P.
        • Tappen R.
        • et al.
        Effects of an intervention to reduce hospitalizations from nursing homes: A randomized implementation trial of the INTERACT program.
        JAMA Intern Med. 2017; 177: 1257-1264
        • Rantz M.J.
        • Popejoy L.
        • Vogelsmeier A.
        • et al.
        Successfully reducing hospitalizations of nursing home residents: Results of the Missouri Quality Initiative.
        J Am Med Dir Assoc. 2017; 18: 960-966
        • Graverholt B.
        • Riise T.
        • Jamtvedt G.
        • et al.
        Acute hospital admissions from nursing homes: Predictors of unwarranted variation?.
        Scand J Public Health. 2013; 41: 359-365
        • Bagshaw S.M.
        • Stelfox H.T.
        • McDermid R.C.
        • et al.
        Association between frailty and short- and long-term outcomes among critically ill patients: A multicentre prospective cohort study.
        CMAJ. 2014; 186: E95-E102
        • Boyd C.M.
        • Xue Q.L.
        • Simpson C.F.
        • et al.
        Frailty, hospitalization, and progression of disability in a cohort of disabled older women.
        Am J Med. 2005; 118: 1225-1231
        • Evans S.J.
        • Sayers M.
        • Mitnitski A.
        • Rockwood K.
        The risk of adverse outcomes in hospitalized older patients in relation to a frailty index based on a comprehensive geriatric assessment.
        Age Ageing. 2014; 43: 127-132
        • Mehta K.M.
        • Pierluissi E.
        • Boscardin W.J.
        • et al.
        A clinical index to stratify hospitalized older adults according to risk for new-onset disability.
        J Am Geriatr Soc. 2011; 59: 1206-1216
        • Grabowski D.C.
        • Feng Z.
        • Hirth R.
        • et al.
        Effect of nursing home ownership on the quality of post-acute care: An instrumental variables approach.
        J Health Econ. 2013; 32: 12-21
        • Hirth R.A.
        • Grabowski D.C.
        • Feng Z.
        • et al.
        Effect of nursing home ownership on hospitalization of long-stay residents: An instrumental variables approach.
        Int J Health Care Finance Econ. 2014; 14: 1-18
        • McGregor M.J.
        • Tate R.B.
        • McGrail K.M.
        • et al.
        Care outcomes in long-term care facilities in British Columbia, Canada. Does ownership matter?.
        Med Care. 2006; 44: 929-935
        • Tanuseputro P.
        • Chalifoux M.
        • Bennett C.
        • et al.
        Hospitalization and mortality rates in long-term care facilities: Does for-profit status matter?.
        J Am Med Dir Assoc. 2015; 16: 874-883
        • Comondore V.R.
        • Devereaux P.J.
        • Zhou Q.
        • et al.
        Quality of care in for-profit and not-for-profit nursing homes: Systematic review and meta-analysis.
        BMJ. 2009; 339: b2732
        • Harrington C.
        • Olney B.
        • Carrillo H.
        • Kang T.
        Nurse staffing and deficiencies in the largest for-profit nursing home chains and chains owned by private equity companies.
        Health Serv Res. 2012; 47: 106-128
        • McGregor M.J.
        • Tate R.B.
        • Ronald L.A.
        • et al.
        Trends in long-term care staffing by facility ownership in British Columbia, 1996 to 2006.
        Health Rep. 2010; 21: 27-33
        • Hirdes J.P.
        • Frijters D.H.
        • Teare G.F.
        The MDS-CHESS scale: A new measure to predict mortality in institutionalized older people.
        J Am Geriatr Soc. 2003; 51: 96-100
        • Hawes C.
        • Morris J.N.
        • Phillips C.D.
        • et al.
        Reliability estimates for the Minimum Data Set for nursing home resident assessment and care screening (MDS).
        Gerontologist. 1995; 35: 172-178
        • Poss J.W.
        • Jutan N.M.
        • Hirdes J.P.
        • et al.
        A review of evidence on the reliability and validity of Minimum Data Set data.
        Healthc Manage Forum. 2008; 21: 33-39
        • Landi F.
        • Tua E.
        • Onder G.
        • et al.
        Minimum data set for home care: A valid instrument to assess frail older people living in the community.
        Med Care. 2000; 38: 1184-1190
        • Morris J.N.
        • Jones R.N.
        • Fries B.E.
        • Hirdes J.P.
        Convergent validity of minimum data set-based performance quality indicators in postacute care settings.
        Am J Med Qual. 2004; 19: 242-247
        • British Columbia Office of the Seniors Advocate
        Quick Facts Directory.
        (Available at:)
        • Korn E.L.
        • Graubard B.I.
        • Midthune D.
        Time-to-event analysis of longitudinal follow-up of a survey: Choice of the time-scale.
        Am J Epidemiol. 1997; 145: 72-80
        • van Geloven N.
        • le Cessie S.
        • Dekker F.W.
        • Putter H.
        Transplant as a competing risk in the analysis of dialysis patients.
        Nephrol Dial Transplant. 2017; 32(Suppl 2): ii53-ii59
        • Mitchell S.L.
        • Kiely D.K.
        • Hamel M.B.
        Dying with advanced dementia in the nursing home.
        Arch Intern Med. 2004; 164: 321-326
        • Trotta R.L.
        Quality of death: A dimensional analysis of palliative care in the nursing home.
        J Palliat Med. 2007; 10: 1116-1127
        • Ouslander J.G.
        • Berenson R.A.
        Reducing unnecessary hospitalizations of nursing home residents.
        N Engl J Med. 2011; 365: 1165-1167
        • Rantz M.J.
        • Flesner M.K.
        • Franklin J.
        • et al.
        Better care, better quality: Reducing avoidable hospitalizations of nursing home residents.
        J Nurs Care Qual. 2015; 30: 290-297
        • O'Malley A.J.
        • Caudry D.J.
        • Grabowski D.C.
        Predictors of nursing home residents' time to hospitalization.
        Health Serv Res. 2011; 46: 82-104
        • Shapiro E.
        • Tate R.B.
        Monitoring the outcomes of quality of care in nursing homes using administrative data.
        Can J Aging. 1995; 14: 755-768
      1. Community Care and Assisted Living Act Residential Care Regulation [Includes Amendments up to B.C. Reg. 10/2010, January 15, 2010], Government of British Columbia: Victoria, Canada. 2009
        • Martin R.S.
        • Hayes B.
        • Gregorevic K.
        • Lim W.K.
        The effects of advance care planning interventions on nursing home residents: A systematic review.
        J Am Med Dir Assoc. 2016; 17: 284-293
        • Allers K.
        • Hoffmann F.
        Mortality and hospitalization at the end of life in newly admitted nursing home residents with and without dementia.
        Soc Psychiatry Psychiatr Epidemiol. 2018; 53: 833-839
        • McGregor M.J.
        • Abu-Laban R.B.
        • Ronald L.A.
        • et al.
        Nursing home characteristics associated with resident transfers to emergency departments.
        Can J Aging. 2014; 33: 38-48
        • Intrator O.
        • Zinn J.
        • Mor V.
        Nursing home characteristics and potentially preventable hospitalizations of long-stay residents.
        J Am Geriatr Soc. 2004; 52: 1730-1736
        • Castle N.G.
        • Engberg J.
        Organizational characteristics associated with staff turnover in nursing homes.
        Gerontologist. 2006; 46: 62-73
        • Zimmerman S.
        • Gruber-Baldini A.L.
        • Hebel J.R.
        • et al.
        Nursing home facility risk factors for infection and hospitalization: Importance of registered nurse turnover, administration, and social factors.
        J Am Geriatr Soc. 2002; 50: 1987-1995
        • Berta W.
        • Laporte A.
        • Kachan N.
        Unpacking the relationship between operational efficiency and quality of care in Ontario long-term care homes.
        Can J Aging. 2010; 29: 543-556
        • Berta W.
        • Laporte A.
        • Valdmanis V.
        Observations on institutional long-term care in Ontario: 1996–2002.
        Can J Aging. 2005; 24: 71-84
        • Arendts G.
        • Reibel T.
        • Codde J.
        • Frankel J.
        Can transfers from residential aged care facilities to the emergency department be avoided through improved primary care services? Data from qualitative interviews.
        Australas J Ageing. 2010; 29: 61-65
        • Lima J.C.
        • Intrator O.
        • Karuza J.
        • et al.
        Nursing home medical staff organization and 30-day rehospitalizations.
        J Am Med Dir Assoc. 2012; 13: 552-557
        • Molloy D.W.
        • Guyatt G.H.
        • Russo R.
        • et al.
        Systematic implementation of an advance directive program in nursing homes: A randomized controlled trial.
        JAMA. 2000; 283: 1437-1444
        • Hanson L.C.
        • Zimmerman S.
        • Song M.K.
        • et al.
        Effect of the goals of care intervention for advanced dementia: A randomized clinical trial.
        JAMA Intern Med. 2016; 177: 24-31
        • McGregor M.
        • Pare D.
        • Wong A.
        • et al.
        Correlates of a “do not hospitalize” designation: In a sample of frail nursing home residents in Vancouver.
        Can Fam Physician. 2010; 56: 1158-1164
        • Canadian Institute for Health Information
        Continuing care reporting system data users guide, 2017–2018.
        (Available at:)
        • Kahlon S.
        • Pederson J.
        • Majumdar S.R.
        • et al.
        Association between frailty and 30-day outcomes after discharge from hospital.
        Can Med Assoc J. 2015; 187: 799-804