Biological Sciences Division, Department of Public Health Sciences, University of Chicago, Chicago, Illinois.
JAMA Netw Open. 2023 May 1;6(5):e2314822. doi: 10.1001/jamanetworkopen.2023.14822.
The US government rates nursing homes and reports the underlying quality measures on the Nursing Home Care Compare (NHCC) website. These measures are derived from facility-reported data, which research indicates to be substantially underreported.
To assess the association between nursing home characteristics and reporting of major injury falls and pressure ulcers, which are 2 of 3 specific clinical outcomes reported by the NHCC website.
DESIGN, SETTING, AND PARTICIPANTS: This quality improvement study used hospitalization data for all Medicare fee-for-service beneficiaries between January 1, 2011, and December 31, 2017. Hospital admission claims for major injury falls and pressure ulcers were linked with facility-reported Minimum Data Set (MDS) assessments at the nursing home resident level. For each linked hospital claim, whether the nursing home had reported the event was determined and reporting rates were computed. The distribution of reporting across nursing homes and the associations between reporting and facility characteristics were examined. To assess whether nursing homes reported similarly on both measures, the association between reporting of major injury falls and pressure ulcers within a nursing home was estimated, and racial and ethnic disparities that might explain the observed associations were investigated. Small facilities and those that were not included in the sample continuously in each year of the study period were excluded. All analyses were performed throughout 2022.
Two nursing home-level MDS reporting rates, stratified by long-stay vs short-stay population or by race and ethnicity, were used: fall reporting rate and pressure ulcer reporting rate.
The sample included 13 179 nursing homes where 131 000 residents (mean [SD] age, 81.9 [11.8] years; 93 010 females [71.0%]; 81.1% with White race and ethnicity) experienced major injury fall or pressure ulcer hospitalizations. There were 98 669 major injury fall hospitalizations, of which 60.0% were reported, and 39 894 stage 3 or 4 pressure ulcer hospitalizations, of which 67.7% were reported. Underreporting for both conditions was widespread, with 69.9% and 71.7% of nursing homes having reporting rates less than 80% for major injury fall and pressure ulcer hospitalizations, respectively. Lower reporting rates were associated with few facility characteristics other than racial and ethnic composition. Facilities with high vs low fall reporting rates had significantly more White residents (86.9% vs 73.3%), and facilities with high vs low pressure ulcer reporting rates had significantly fewer White residents (69.7% vs 74.9%). This pattern was retained within nursing homes, where the slope coefficient for the association between the 2 reporting rates was -0.42 (95% CI, -0.68 to -0.16). That is, nursing homes with more White residents had higher reporting rates for major injury falls and lower reporting rates for pressure ulcers.
Results of this study suggest widespread underreporting of major injury falls and pressure ulcers across US nursing homes, and underreporting was associated with the racial and ethnic composition of a facility. Alternative approaches to measuring quality need to be considered.
美国政府对养老院进行评级，并在养老院护理比较（NHCC）网站上报告潜在的质量指标。这些指标是根据机构报告的数据得出的，研究表明这些数据严重少报。
评估养老院特征与主要伤害性跌倒和压疮报告之间的关联，这是 NHCC 网站报告的 3 个特定临床结果中的 2 个。
设计、设置和参与者：这项质量改进研究使用了 2011 年 1 月 1 日至 2017 年 12 月 31 日期间所有医疗保险按服务付费受益人的住院数据。主要伤害性跌倒和压疮的住院入院索赔与居住在养老院居民层面的机构报告最小数据集（MDS）评估相关联。对于每个相关联的住院索赔，确定了养老院是否报告了该事件，并计算了报告率。检查了报告在养老院之间的分布情况，以及报告与机构特征之间的关联。为了评估养老院是否在这两项措施上同样报告，估计了养老院内部主要伤害性跌倒和压疮的报告率，并调查了可能解释观察到的关联的种族和民族差异。排除了小设施和那些在研究期间每年都未连续纳入样本的设施。所有分析均在 2022 年进行。
使用了两种养老院层面 MDS 报告率，按长期居住者与短期居住者或按种族和民族分层：跌倒报告率和压疮报告率。
样本包括 13179 家养老院，其中有 130000 名居民（平均[标准差]年龄为 81.9[11.8]岁；93010 名女性[71.0%]；81.1%为白种人）经历了主要伤害性跌倒或压疮住院治疗。有 98669 例主要伤害性跌倒住院治疗，其中 60.0%得到报告，有 39894 例 3 或 4 期压疮住院治疗，其中 67.7%得到报告。这两种情况的漏报都很普遍，分别有 69.9%和 71.7%的养老院报告率低于主要伤害性跌倒和压疮住院治疗的 80%。除了种族和民族构成外，较低的报告率与其他设施特征无关。报告率较高的设施与报告率较低的设施相比，白人居民比例明显较高（86.9% vs 73.3%），报告率较高的设施与报告率较低的设施相比，白人居民比例明显较低（69.7% vs 74.9%）。这种模式在养老院内部得到保留，主要伤害性跌倒和压疮报告率之间的斜率系数为-0.42（95%CI，-0.68 至-0.16）。也就是说，白人居民比例较高的养老院，主要伤害性跌倒的报告率较高，压疮的报告率较低。
这项研究的结果表明，美国养老院普遍存在主要伤害性跌倒和压疮漏报，漏报与设施的种族和民族构成有关。需要考虑替代衡量质量的方法。
