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Agency for Healthcare Research Quality

Long-term Care

Author: Mukamel DB, Spector WD.
Title: Nursing home costs and risk-adjusted outcome measures of quality.
Publication: Med Care 38(1):78-89.
Date: 2000
Abstract: The inadequacy of quality of care in nursing homes has been and continues to be a focus of public concerns. Understanding the relationship between quality and costs can offer guidance to policies designed to encourage high quality. The study's objectives were to investigate the relationship between costs and quality of care in nursing homes, and to test the hypothesis that higher quality may be associated with lower costs. Statistical regression techniques were used to estimate nursing home variable-cost functions that included three risk-adjusted outcome measures of quality. Quality measures were based on decline in functional status, worsening pressure ulcers, and mortality. The study hypothesis was tested by an F test for the exclusion of nonlinear quality variables in the cost functions. The study included 525 free-standing private and public nursing homes in New York State, or 84 percent of all nursing homes in the state during 1991. F tests rejected the hypotheses that the three quality measures could be excluded from the cost function and that the association between costs and quality was linear. An inverted U-shape relationship between quality and costs suggests that there are quality regimens in which higher quality is associated with lower costs. Policies that encourage research to identify care protocols and management strategies leading to better outcomes and lower costs, as well as policies that encourage dissemination of such practices, may prevent decline in quality despite the continued financial constraints faced by nursing homes.
Availability: AHRQ Publication No. 00-R019 is available from the AHRQ Publications Clearinghouse.

Authors: Spector W, Fortinsky R.
Title: Pressure ulcer prevalence in Ohio nursing homes: Clinical and facility correlates.
Publication: Journal of Aging and Health 10(1):62-80.
Date: 1998
Abstract: This article examines pressure sore risk factors in a large sample of nursing home residents in Ohio in 1994. The study finds that many nursing home residents remain at great risk of developing pressure sores. After controlling for clinical factors, residents in rural facilities were less likely to have a pressure sore.
Availability: AHCPR Publication No. 98-R027 is available from the AHRQ Publications Clearinghouse.

Authors: Spector W, Mukamel D.
Title: Using outcomes to make inferences about nursing home quality.
Publication: Evaluation of the Health Professions 1998;21(3):291-315.
Date: 1998
Abstract: Recent concerns about containing the growth of public expenditures on nursing home care and the development of prospective and case-mix reimbursement systems with incentives for cost containment have increased the importance of monitoring quality in nursing homes. The current view is that quality assurance systems should include more outcome measures to improve quality. This article discusses why it is difficult to develop facility-level outcome measures that can be used to evaluate and compare the quality of care of nursing homes. The article places the current interest in outcomes measures in its historical policy context and reviews important conceptual and methodological issues associated with outcome-based quality assessment. The authors discuss the difficulty in isolating the facility effect when studying nursing home outcomes and implications of using different estimation approaches. In conclusion, they discuss the need to integrate research with outcome-based quality assurance systems to allow ongoing evaluation and quality improvement.
Availability: AHCPR Publication No. 98-R083 is available from the AHRQ Publications Clearinghouse.

Authors: Spector W, Selden T, Cohen J.
Title: Impact of ownership type on nursing home outcomes.
Publication: Health Economics 7:639-53.
Date: 1998
Abstract: This article examines the sorting of residents between for-profit and nonprofit nursing homes and the health outcomes of residents conditional on ownership type. Results suggest that nonprofit facilities are more likely to attract residents who have the highest cost of monitoring quality, place the greatest weight on quality, and face the fewest constraints in their choice of home. Outcome results suggest that ownership type can affect quality of care for at least some residents.

Authors: Binstock R, Spector W.
Title: Five priority areas for research on long term care.
Publication: Health Services Research 32(5):715-30.
Date: 1997
Abstract: This article presents five priority areas for research in long-term care given the context of rapidly shifting health care market forces and political pressures to contain Medicare and Medicaid expenditures. Areas recommended include quality of care measures, the linkage of costs and quality of care, appropriateness of care in the many types of long-term care settings that have emerged in recent years, evaluation of innovations in care provision with respect to impact on cost and quality, and research on the evolution of managed care and its effects on long-term care provision.
Availability: AHCPR Publication No. 98-R020 is available from the AHRQ Publications Clearinghouse.

Author: Fraser I.
Title: Research on health care organizations and markets—The best and worst of times.
Publication: Health Services Research 32(5):669-78.
Date: 1997
Abstract: This article contains reflections from four short papers commissioned by AHCPR in January 1997 to identify central managed care research questions in the areas of health care markets, access, chronic illness, and long term care.
Availability: AHCPR Publication No. 98-R019 is available from the AHRQ Publications Clearinghouse.

Authors: Jackson M, Spector W, Rabins P.
Title: Risk of behavior problems among nursing home residents in the United States.
Publication: Journal of Aging and Health 9(4):451-72.
Date: 1997
Abstract: This article represents the first report of risk factors associated with behavior problems in nursing homes in a nationally representative sample using multivariate techniques. The findings show, not surprisingly, that cognitive impairment is a major risk factor, but also show the importance of ADLs, incontinence, mobility and psychoses. Estimates are made separately for all behaviors, aggressive behaviors, collecting behaviors, wandering, and delusions and hallucinations.
Availability: AHCPR Publication No. 98-R011 is available from the AHRQ Publications Clearinghouse.

Authors: Spector W, Gage B.
Title: AHCPR research on long-term care.
Publication: Rockville (MD): AHCPR.
Date: 1997
Abstract: This program note highlights research findings of long-term care research conducted and funded by AHRQ since 1990 and provides a complete list of such research. The program note is organized into six broad themes: use, cost, and financing; access and quality of care; organization and delivery of care; consumer and caregiver behavior; special populations; and data development and methodology.
Availability: AHCPR Publication No. 97-0054 is available from the AHRQ Publications Clearinghouse.

Author: Spector W, Cohen J.
Title: The effect of Medicaid reimbursement on quality of care in nursing homes.
Publication: Journal of Health Economics 1996;15:23-48.
Date: 1996
Abstract: This study uses a nationally representative sample of nursing homes and nursing home residents to examine the effect of Medicaid reimbursement on quality of care. The analysis shows that both reimbursement approach and level affect nursing home quality, as measured by case-mix adjusted staff to resident ratios. The analysis also shows that staffing ratios have an impact on resident outcomes, and these impacts vary by professional category of staff.
Availability: AHCPR Publication No. 96-R116 is available from the AHRQ Publications Clearinghouse.

Authors: Spector W, Reschovsky J, Cohen J.
Title: Appropriate placement of nursing home residents in lower levels of care.
Publication: Milbank Quarterly 1996;74(1):139-60.
Date: 1996
Abstract: This article discusses why clinically inappropriate residents in nursing homes continue to be placed there, updates and improves estimates of the number of persons who based on clinical criteria may be place in lower levels of care, discusses other factors that should enter into estimates of appropriate placement, and the reasons why potential savings that these estimates suggest may be difficult to achieve.
Availability: AHCPR Publication No. 96-R067 is available from the AHRQ Publications Clearinghouse.

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