Selection and the Quality Impact of Nursing Home Ownership

描述（由申请人提供）：在美国卫生政策中，对居住在养老院的体弱老年人的护理质量仍然是一个重要而令人困惑的问题。鉴于给予非营利企业的税收优惠待遇，政策制定者和研究人员都对检验非营利部门是否比营利部门提供更高的质量很感兴趣。大量的文献研究了这个问题，但绝大多数现有的研究都采取了横断面的方法来比较营利性和非营利性的质量。然而，选择非营利性设施的消费者的类型可能在许多未被观察到的方面与选择营利性设施的消费者有很大的不同。如果是这样的话，简单地比较营利性和非营利组织的质量，控制可观察到的特征，可能会产生误导性的估计。通过使用离最近的非营利性养老院相对于离最近的营利性养老院的“差异距离”，我们可以在估计所有权对护理质量的影响时模拟居民或多或少“暴露”于非营利养老院的随机化。基于这种方法，提出了以下具体目标：目标1：使用一系列患者特征，包括付款人类型、敏锐度、人口统计学（种族、性别和年龄）和社会经济地位（教育程度；邮政编码水平收入），检查营利性和非营利性养老院的选择和访问差异。目的2：测试距离最近的非营利性养老院相对于最近的营利性养老院的差异距离对进入非营利性养老院的可能性的影响。计划的子分析包括检查距离和所有权选择在城市/农村市场背景下的作用，从拥有亚急性疗养院单位的医院出院，以及养老院患者的不同子群体（例如，是否有证据表明少数种族或医疗补助接受者之间的关系较弱，如果这些居民更有可能不得不绕过最近的设施以获得护理，情况可能就是如此）。目标3：使用工具变量分析来检验所有权对风险调整后的个人水平短期住院质量指标（如日常生活活动下降或30天再住院）和风险调整后的个人水平长期住院质量指标（如压疮或身体约束）的影响。意义：通过研究养老院所有权与护理质量之间的联系，本研究为数百万在养老院接受护理的美国人提供了提高护理质量的机会。这项研究还将为长期护理研究人员提供一种潜在的新方法来分析营利性和非营利性的差异，这种差异解释了不同所有权类型的未观察到的患者差异，也可以应用于研究其他设施特征（如连锁所有权）的影响。因此，本研究所得的资讯有可能为改善所有养老院居民的照护品质，做出重要的研究和政策相关贡献。公共健康相关性：政策制定者和研究人员都对非营利性养老院是否比营利性养老院提供更高的质量很感兴趣。通过使用一种新颖的实证策略来检验这种关系，本研究为数百万在养老院接受护理的美国人提供了一个提高护理质量的机会。

DESCRIPTION (provided by applicant): The quality of care delivered to frail elders residing in nursing homes remains an important and perplexing issue in American health policy. Given the preferential tax treatment afforded nonprofit firms, there has been much interest among policymakers and researchers alike in examining whether the nonprofit sector provides higher quality relative to its for-profit counterpart. A large literature examines this issue, but the vast majority of the existing studies have taken a cross-sectional approach to compare for-profit and nonprofit quality. However, the type of consumer who chooses a nonprofit facility may be quite different in many unobserved ways from the consumer who selects a for-profit facility. If so, simple comparisons of quality in for-profits and nonprofits, controlling for observable characteristics, may yield misleading estimates. By using "differential distance" to the nearest nonprofit nursing home relative to the nearest for-profit nursing home, we can mimic randomization of residents into more or less "exposure" to nonprofit homes when estimating the effects of ownership on quality of care. Based on this methodology, the following specific aims are proposed: Aim 1: To examine selection and access differences across for-profit and nonprofit nursing homes using a range of patient characteristics, including payer type, acuity, demographics (race, gender and age), and socio- economic status (education; zip code level income). Aim 2: To test the effect of differential distance to the nearest nonprofit nursing home relative to the nearest for-profit nursing home on likelihood of entry into a nonprofit nursing home. Planned sub-analyses include an examination of the role of distance and ownership choice in the context of urban/rural markets, discharges from hospitals with a sub-acute nursing home unit, and different subgroups of nursing home patients (e.g., is there evidence of a weaker relationship among racial minorities or Medicaid recipients, which may be the case if those residents are more likely to have to bypass the nearest facility in order to gain access to care). Aim 3: To use instrumental variables analysis to examine the effect of ownership on risk-adjusted, person-level short-stay measures of quality such as activities of daily living decline or 30-day re-hospitalization and risk- adjusted, person-level long-stay measures of quality such as pressure ulcers or physical restraints. Significance: By examining the link between nursing home ownership and quality of care, this study provides an opportunity to improve the quality of care for the millions of Americans receiving care in nursing homes. This study will also provide long-term care researchers with a potential new approach to analyzing for-profit and nonprofit differences which accounts for unobserved patient differences across ownership types, and which could also be applied to study the impact of other facility characteristics such as chain ownership. Thus, the information derived from this study has the potential to make important research and policy-relevant contributions aimed at improving the quality of care for all nursing home residents. PUBLIC HEALTH RELEVANCE: There has been much interest among policymakers and researchers alike in examining whether nonprofit nursing homes provide higher quality relative to their for-profit counterparts. By examining this relationship using a novel empirical strategy, this study provides an opportunity to improve the quality of care for the millions of Americans receiving care in the nursing home setting.