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Public Quality Reporting and Nursing Home Admission Decisions

Published:September 29, 2022DOI:https://doi.org/10.1016/j.jamda.2022.08.017
      To the Editor:It’s been 20 years since CMS launched Nursing Home Compare, now Nursing Home Care Compare (NHCC), a web-based consumer resource outlining care quality in nursing homes (NHs). Quality metrics are summarized in scorecards grading each facility using a 5-star rating. When the National Quality Forum developed the long-stay quality-measures, they purposefully incorporated only minimal adjustments for resident risk with few, well-defined exclusions.
      National Quality Forum
      National voluntary consensus standards for nursing home care 2004. Accessed August 22, 2022.
      A disadvantage of using unadjusted quality scores is the tendency to underestimate the care quality provided to less healthy patients. Furthermore, an incentive is created for facilities to artificially improve their scores by selecting healthier patients and avoiding frailer individuals.
      • Werner R.M.
      • Konetzka R.T.
      • Stuart E.A.
      • Polsky D.
      Changes in patient sorting to nursing homes under public reporting: improved patient matching or provider gaming?.
      ,
      • Mukamel D.B.
      • Ladd H.
      • Weimer D.L.
      • Spector W.D.
      • Zinn J.S.
      Is there evidence of cream skimming among nursing homes following the publication of the Nursing Home Compare report card?.
      Numerous metaphors describe this routine consequence of quality initiatives leveraging public reporting, including cherry-picking—selecting for easy, straightforward admissions likely to improve scores—and lemon-dropping—discharging difficult residents (usually to the hospital) who negatively impact quality measures.
      • Omoigui N.A.
      • Miller D.P.
      • Brown K.J.
      • et al.
      Outmigration for coronary bypass surgery in an era of public dissemination of clinical outcomes.
      ,
      • Narins C.R.
      • Dozier A.M.
      • Ling F.S.
      • Zareba W.
      The influence of public reporting of outcome data on medical decision making by physicians.
      Some estimates attribute as much as half of NHCC quality measure variation to unadjusted risk.
      • Werner R.M.
      • Konetzka R.T.
      • Stuart E.A.
      • Polsky D.
      Changes in patient sorting to nursing homes under public reporting: improved patient matching or provider gaming?.
      ,
      • Li Y.
      • Schnelle J.
      • Spector W.D.
      • Glance L.G.
      • Mukamel D.B.
      The "Nursing Home Compare" measure of urinary/fecal incontinence: cross-sectional variation, stability over time, and the impact of case mix.
      The unfair outcome of biased selection is worsening disparity as more desirable facilities recruit more desirable patients, thereby increasing the appearance of quality and thus their desirability.
      • Konetzka R.T.
      • Grabowski D.C.
      • Perraillon M.C.
      • Werner R.M.
      Nursing home 5-star rating system exacerbates disparities in quality, by payer source.
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      References

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        National voluntary consensus standards for nursing home care 2004. Accessed August 22, 2022.
        • Werner R.M.
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        • Stuart E.A.
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        Changes in patient sorting to nursing homes under public reporting: improved patient matching or provider gaming?.
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        Is there evidence of cream skimming among nursing homes following the publication of the Nursing Home Compare report card?.
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        Outmigration for coronary bypass surgery in an era of public dissemination of clinical outcomes.
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        • Dozier A.M.
        • Ling F.S.
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        The influence of public reporting of outcome data on medical decision making by physicians.
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        The "Nursing Home Compare" measure of urinary/fecal incontinence: cross-sectional variation, stability over time, and the impact of case mix.
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        • Konetzka R.T.
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        Nursing home 5-star rating system exacerbates disparities in quality, by payer source.
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      1. The White House briefing room fact sheet: protecting seniors by improving safety and quality of care in the nation's nursing homes.
        (2022. Accessed August 22, 2022)
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