文章基本信息

标题：Making Difficult Decisions: The Role of Quality of Care in Choosing a Nursing Home
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作者：Irena Pesis-Katz ; Charles E. Phelps ; Helena Temkin-Greener 等
期刊名称：American journal of public health
印刷版ISSN：0090-0036
出版年度：2013
卷号：103
期号：5
页码：e31-e37
DOI：10.2105/AJPH.2013.301243
语种：English
出版社：American Public Health Association
摘要：Objectives. We investigated how quality of care affects choosing a nursing home. Methods. We examined nursing home choice in California, Ohio, New York, and Texas in 2001, a period before the federal Nursing Home Compare report card was published. Thus, consumers were less able to observe clinical quality or clinical quality was masked. We modeled nursing home choice by estimating a conditional multinomial logit model. Results. In all states, consumers were more likely to choose nursing homes of high hotel services quality but not clinical care quality. Nursing home choice was also significantly associated with shorter distance from prior residence, not-for-profit status, and larger facility size. Conclusions. In the absence of quality report cards, consumers choose a nursing home on the basis of the quality dimensions that are easy for them to observe, evaluate, and apply to their situation. Future research should focus on identifying the quality information that offers the most value added to consumers. Quality of care in nursing homes continues to concern patients, their families, and policymakers. 1 The attributes of quality that are important to long-stay nursing home residents and their families are often different from and more diverse than those that are important to hospitalized persons and their families in acute medical care settings. 2 Because it is a home and not a temporary residence, the physical environment of the nursing home plays an important role in resident and family judgments regarding such things as safety, privacy, freedom, and mobility, which affect general quality of life. Appropriate clinical care can help prevent and treat pressure ulcers, malnutrition, incontinence, declines in activities of daily living, pain, and falls. 3 Thus, the concern about nursing home quality encompasses both clinical care services and the hotel aspects of the social and physical environment. In 2002, the Centers for Medicare and Medicaid Services (CMS) initiated the publication of the federal nursing home report card, Nursing Home Compare. 4 This report card provides information about several clinical dimensions of quality, such as change in activities of daily living, prevalence of pressure ulcers, and use of physical restraints, and allows consumers to compare rankings of these measures for each facility and with regard to national and state averages. Studies that examined the impact of the nursing home report card show quality improvements at the nursing home level in response to the publication and even a shift of resources from hotel services to support clinical dimensions of quality. 5–8 However, it is not clear that the publication of the nursing home report card has had any effect on consumers’ choice of a nursing home. Although some studies show that high clinical quality increases a nursing home’s market share for short-stay residents, 9 others show that the nursing home report card has not affected consumer demand. 10 Although nursing home consumers may care as much about the clinical as the hotel aspects of care, their ability to assess them is not the same. Evaluation of hotel services often is easier and less costly; it can be accomplished by personal visits to the facility or by friends’ or acquaintances’ prior experience and reports. However, evaluation of clinical care quality is typically more difficult because it may require specialized knowledge and broader opportunities to observe the facility and access information about it. Many consumers will not understand the relationship between processes of care and care outcomes, be able to factor in the impact of their individual risk profile, and anticipate what their clinical care needs will be when they are in the nursing home. 11 Thus, they may find it very difficult, if not impossible, to assess nursing home clinical care quality on their own—or even to evaluate it using the current federal quality report card. In fact, studies find that these resources are not being widely used when selecting a nursing home. 12,13 We examined quality of care as a factor in choosing a nursing home from among its competitors once the decision to enter a nursing home was made. We focused on 2 dimensions of quality of care to investigate the impact of their differential observability on choice. We have used the term “clinical care” to refer to all aspects of personal care and clinical and therapeutic services and “hotel services” to refer to room and board and aspects of care that relate to the physical and social environment and that affect safety and quality of life. We hypothesized that consumers’ choice of nursing homes would be more sensitive to the aspects of quality that can be more easily evaluated or observed—that is, hotel services—than to the masked and more difficult to interpret clinical dimensions of quality. Our study extends the literature in 2 ways. First, most previous studies have focused on the choice of nursing home versus alternative care settings 14–17 rather than the choice of a nursing home from among its competitors. The few studies that have examined choosing nursing homes for long-term care relied on surveys or small samples 18–20 or were not consistent in their findings. 9,10 We analyzed observed choice patterns of all long-term nursing home residents in 4 large states, thus offering more robust and generalizable information. Second, to date, none of the studies that examined the impact of quality on choice differentiated between the clinical and hotel dimensions of quality. We hypothesized that different dimensions of quality would affect choice differently because of the differences in consumers’ ability to access, understand, and evaluate them. Examining this issue empirically offers new insights that are not available from prior studies.