Selection and the Quality Impact of Nursing Home Ownership

描述(由申请人提供)：为居住在养老院的虚弱老年人提供的护理质量仍然是美国卫生政策中一个重要而令人困惑的问题。鉴于非营利性企业获得的税收优惠，政策制定者和研究人员都对研究非营利性部门是否提供比营利性部门更高的质量很感兴趣。大量文献对这一问题进行了研究，但现有的绝大多数研究都采取了横截面的方法来比较营利性和非营利性质量。然而，选择非营利机构的消费者类型可能在许多未被观察到的方面与选择营利性机构的消费者有很大的不同。如果是这样的话，对营利性和非营利性组织的质量进行简单的比较，控制可观察到的特征，可能会产生误导性的估计。通过使用到最近的非营利性疗养院相对于最近的营利性疗养院的“差别距离”，我们可以模拟居民在估计所有权对护理质量的影响时随机进入非营利性疗养院的或多或少的“暴露”。根据这一方法，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(种族、性别和年龄)和社会经济地位(教育；邮政编码水平收入)，检查营利性和非营利性疗养院的选择和准入差异。目的2：检验到最近的非营利性疗养院与最近的营利性疗养院之间的差异距离对进入非营利性疗养院的可能性的影响。计划中的次级分析包括审查距离和所有权选择在城市/农村市场背景下的作用、拥有亚急性疗养院单元的医院的出院情况以及疗养院患者的不同分组(例如，是否有证据表明少数族裔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才能获得护理，情况可能就是这样)。目的3：使用工具变量分析来检验所有权对风险调整后的人水平的短期质量指标(如日常生活能力下降或30天再住院)和风险调整后的人水平的长期质量指标(如压疮或身体约束)的影响。意义：通过研究疗养院所有权和护理质量之间的联系，这项研究为数百万在养老院接受护理的美国人提供了一个改善护理质量的机会。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差异，这种差异解释了所有权类型之间未观察到的患者差异，也可以用于研究其他设施特征的影响，如连锁所有权。因此，从这项研究中获得的信息有可能为改善所有养老院居民的护理质量而进行重要的研究和政策相关的贡献。公共卫生相关性：政策制定者和研究人员都对研究非营利性疗养院是否提供比营利性疗养院更高的质量感兴趣。通过使用一种新的实证策略来检验这种关系，这项研究为数百万在养老院接受护理的美国人提供了一个改善护理质量的机会。

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.