Specialization in Nursing Home Care

描述（由申请人提供）：从历史上看，养老院在功能上是相似的，照顾有一系列潜在健康状况的受损居民，主要来自当地社区。然而，随着时间的推移，家庭已经专门治疗特定类型的慢性病居民。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。这种专业化既通过治疗大量患有这些疾病的居民，也通过专门的单位和设施来实现。迄今为止，关于养老院护理专业化的文献在很大程度上被不同的选择所混淆。例如，入住痴呆症特殊护理病房（SCU）的居民的类型可能在许多未被观察到的方面与入住非SCU设施的居民有很大不同。如果是这样，简单比较SCU和非SCU设置的质量，控制可观察的特征，可能会产生误导性的估计。在这种情况下，当随机化不可行时，社会科学家就会应用工具变量方法来解释研究人群中未观察到的差异。在医疗保健中，包括在PI之前的养老院研究中，经常成功使用的一种“工具”是从病人家到不同提供者的不同距离。使用工具变量方法，本文提出的研究旨在检验与养老院在治疗精神疾病或痴呆症方面的专业化是否能改善结果有关的假设。我们专注于这两种情况，因为他们的患病率和观察专业化养老院在治疗这些人群。因此，这些条件提供了一个理想的机会来研究养老院专业化的积极和消极。在目标1中，我们调查了养老院中痴呆症或精神疾病患者护理的内部和机构之间的差异。也就是说，在不同的家庭和家庭内部，患有痴呆症和精神疾病的人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承认，对患有精神疾病或痴呆症的人的护理可能表现出外部性。我们量化了其他居民汽车质量的溢出效应。在所有三个目标中，我们重点关注一般和精神卫生保健的护理质量的经验指标，通过过程和结果指标来衡量。我们使用强大的1999-2011年国家最低数据集（MDS）评估养老院居民与医疗保险索赔数据合并。通过提供迄今为止关于精神疾病和痴呆症患者治疗专业化的最佳证据，该提案有可能在未来十年中大大提高数百万患有痴呆症和精神疾病的居民的护理质量，这些居民将在美国养老院接受治疗。

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.