Specialization in Nursing Home Care

描述(申请人提供)：从历史上看，养老院在功能上是相似的，照顾一系列基本健康状况主要来自当地社区的受损居民。然而，随着时间的推移，养老院已经专门为特定类型的慢性病患者提供治疗。特别是，一些家庭现在专门治疗患有痴呆症和/或严重精神疾病的居民。这种专门化既是通过治疗大量患有这些疾病的居民，也是通过专门的单位和设施。到目前为止，关于养老院护理专业化的文献在很大程度上被区分为更多和更少专业化的选择所混淆。例如，住进痴呆症特别护理单元(SCU)的居民的类型可能在许多未被观察到的方面与进入非SCU设施的居民有很大的不同。如果是这样的话，简单地比较SCU和非SCU设置的质量，控制可观察到的特性，可能会产生误导性的估计。当随机化不可行时，就像在这种情况下，社会科学家应用工具变量方法来解释研究人群中未观察到的差异。一种在医疗保健中频繁而成功地使用的“工具”，包括在PI以前的疗养院研究中，是从患者的家到不同的提供者的差别距离。使用工具变量方法，这里提出的研究试图检验与疗养院专门化治疗精神疾病或痴呆症是否改善结果相关的假设。我们把重点放在这两种情况上，因为它们的流行和观察到的疗养院在治疗这些人口方面的专门化。因此，这些条件为研究养老院专业化的利弊提供了一个理想的机会。在目标1中，我们调查疗养院对痴呆症或精神病患者的护理设施内和设施间的差异。也就是说，在家庭之间和家庭内部，痴呆症患者和精神疾病患者是否得到了同等质量的护理？目标2侧重于专业化对质量的独立影响。如果专业化与专业知识相关联，这种专业化将改善护理，如果它与向弱势群体提供更差的护理相关联，专业化的效果将是负面的。目标3认识到，对精神病或痴呆症患者的护理可能会表现出外部性。我们对其他居民的汽车在质量上的溢出进行了量化。在所有三个目标中，我们将重点放在普通和精神卫生保健的护理质量的经验性指标上，通过过程和结果指标衡量。我们使用了强大的1999-2011年全国养老院居民最低数据集(MDS)评估，并结合了联邦医疗保险索赔数据。通过提供迄今为止关于精神疾病和痴呆症患者的专业化治疗的最佳证据，这项提案有可能极大地提高数百万患有痴呆症的居民的护理质量。痴呆症是一种精神疾病，将在未来十年在美国疗养院接受治疗。

DESCRIPTION (provided by applicant): Historically, nursing homes were functionally similar, caring for impaired residents with a range of underlying health conditions largely drawn from the local community. Over time, however, homes have specialized in the treatment of particular types of chronically ill residents. In particular, some homes now specialize in the treatment of residents with dementia and/or severe mental illness. This specialization occurs both by treating a high volume of residents with these conditions and also through dedicated units and facilities. The literature to date on specialization in nursing home care has largely been confounded by differential selection into more and less specialized settings. The type of resident who is admitted to a dementia special care unit (SCU), for example, may be quite different in many unobserved ways from the resident who is admitted to a non-SCU facility. If so, simple comparisons of quality of SCU and non-SCU settings, controlling for observable characteristics, may yield misleading estimates. When randomization is not feasible, as in this case, social scientists have applied instrumental variables methods to account for unobserved differences across study populations. One "instrument" that has been frequently and successfully used in health care, including in the PI's prior nursing home research, is the differential distance from the patient's home to different providers. Using instrumental variables methods, the research proposed here seeks to test hypotheses pertinent to the question of whether specialization by nursing homes in the treatment of mental illness or dementia improves outcomes. We focus on these two conditions because of their prevalence and the observed specialization by nursing homes in the treatment of these populations. Thus, these conditions provide an ideal opportunity to study the positives and negatives of nursing home specialization. In Aim 1, we investigate the within and between-facility variation in care for persons with dementia or mental illness in nursing homes. That is, across homes and within a home, do persons with dementia and mental illness receive comparable quality of care? Aim 2 focuses on the independent effect of specialization on quality. If specialization is associated with expertise, this specialization wll improve care, if it is associated with worse care being offered to a disadvantaged population, the effect of specialization will be negative. Aim 3 recognizes that the care of persons with mental illness or dementia may exhibit externalities. We quantify the spillovers in quality for car of other residents. In all three Aims, we focus on empirical indicators of quality of care, measured by process and outcome indicators, for both general and mental health care. We use the powerful national 1999-2011 Minimum Data Set (MDS) assessments of nursing home residents merged with Medicare claims data. By providing the best evidence to date on specialization in the treatment of residents with mental illness and dementia, this proposal has the potential to greatly improve the quality of care for the millions of residents with dementia an mental illness that will be treated in U.S. nursing homes in the coming decade.