Changes in the quality of post-acute care after the implementation of public reporting Rachel M. Werner R. Tamara Konetzka Elizabeth Stuart Edward Norton Jeongyoung Park June 2008 Funding: AHRQ (R01 HS )

Public Reporting and Quality Improvement History of problems with nursing home quality, in part due to absence of typical market attributes History of problems with nursing home quality, in part due to absence of typical market attributes –Difficult for consumers to judge quality –Little incentive for providers to compete on quality Public reporting of quality is intended to improve quality by: Public reporting of quality is intended to improve quality by: –Giving consumers information needed to shop on quality –Giving providers incentive to compete on quality –Giving providers information and targets for QI

Objective Examine the effect of publicly reporting quality information on post-acute care quality. Examine the effect of publicly reporting quality information on post-acute care quality. Assess the extent to which changes in quality may be consumer-driven vs. provider-driven. Assess the extent to which changes in quality may be consumer-driven vs. provider-driven. –Changes in average resident-level quality within market –Changes in average within-SNF quality

Contribution Others have found modest improvement in reported quality of nursing home care Others have found modest improvement in reported quality of nursing home care We improve upon the existing literature by: We improve upon the existing literature by: –Better control for patient selection –Control for secular trends –Assess changes in overall quality

Setting: Nursing Home Compare Launched November 12, 2002 Launched November 12, 2002 Publicly release quality information: Publicly release quality information: All Medicare- and Medicaid-certified NHs All Medicare- and Medicaid-certified NHs –17,000 nursing homes 10 quality measures 10 quality measures –3 post-acute care –6 chronic care Staffing, inspections Staffing, inspections

Data Minimum Data Set ( ) Minimum Data Set ( ) –All Medicare- and Medicaid-certified nursing homes –Detailed clinical data –Source to calculate quality measures for Nursing Home Compare –Used to calculate quality measures over study period MedPAR MedPAR –Claims data on all non-managed-care Medicare beneficiaries –Used to calculate rehospitalizations and several health risk variables

Empirical approach 1 1A. Within market: Quality it = β 1 NHC t + βX jt 1B. Within SNF: Quality jt = β 1 NHC t + βX jt +  j –Quality j/jt = quality for individual i or SNF j in year t –NHC t = indicator of Nursing Home Compare ▪ pre-post ( vs ) ▪ set of year dummy variables –X j/it = set of control variables –  j = SNF fixed effects

Empirical Approach 2 Repeat both analyses but add control group Repeat both analyses but add control group Small SNFs (roughly 30%) were excluded from Nursing Home Compare. Small SNFs (roughly 30%) were excluded from Nursing Home Compare. –They are different from large SNFs –But estimates not biased as long as secular trends over time are same Estimate difference-in-differences model which uses trend in small SNFs as measure of secular trend in large SNFs. Estimate difference-in-differences model which uses trend in small SNFs as measure of secular trend in large SNFs.

Controlling for Selection Challenge: Potential bias. Challenge: Potential bias. –Case-mix may be different before and after NHC –Differences may be due to provider selection Solution: Matched cohorts of SNF residents pre- and post-NHC using propensity scores. Solution: Matched cohorts of SNF residents pre- and post-NHC using propensity scores. –Avoids dependence on correctly specifying functional form of case-mix controls. –Corrects for unobserved case-mix if correlated with observed case-mix. Matching done within-SNF and within-market (Dartmouth Atlas definition of health care service area) Matching done within-SNF and within-market (Dartmouth Atlas definition of health care service area)

Reported quality measures Technical definitions of measures from CMS Technical definitions of measures from CMS Follow CMS conventions Follow CMS conventions –2 quarters –14-day assessment –Facilities with more than 20 cases during target period 8,137 SNFs 8,137 SNFs

30-day Preventable Rehospitalizations Unreported Unreported Good measure of overall SNF quality Good measure of overall SNF quality Based on all SNF admissions, not just those with 14-day assessments Based on all SNF admissions, not just those with 14-day assessments Used AHRQ prevention QIs that were applicable to 65+ Used AHRQ prevention QIs that were applicable to 65+ –Bacterial pneumonia –COPD –Dehydration –Heart failure –Hypertension –Short-term diabetic complications –Uncontrolled diabetes –UTI

Quality Measures

Control variables All variables used in the propensity scores to adjust for remaining small difference All variables used in the propensity scores to adjust for remaining small difference Prior residential history for delirium (as specified by CMS for this measure) Prior residential history for delirium (as specified by CMS for this measure) Previously developed risk adjustors for preventable hospitalizations Previously developed risk adjustors for preventable hospitalizations

Risk-adjusted trends in post-acute care quality

Results 1: Within-market changes

Results 2 Within-SNF results similar Within-SNF results similar –Most of the observed quality improvements attributable to provider-driven changes as opposed to consumers choosing high-quality facilities –Some inconsistent results for rehospitalization Using small SNFs as a control Using small SNFs as a control –Magnitude of improvement in pain decreased –Magnitude of improvement in walking increased –Rehospitalization rates worsened

Summary Measured post-acute care quality improved after NHC Measured post-acute care quality improved after NHC –Statistically significant but small changes (4% pain; 6% walking) Results for unmeasured overall quality – preventable rehospitalizations – were inconsistent and less promising. Results for unmeasured overall quality – preventable rehospitalizations – were inconsistent and less promising. Most of the effect is attributable to within-SNF changes, suggesting that changes in market share played a negligible role Most of the effect is attributable to within-SNF changes, suggesting that changes in market share played a negligible role

Implications and Next Steps Public reporting can play a positive but – so far – limited role in improving quality of post-acute care. Public reporting can play a positive but – so far – limited role in improving quality of post-acute care. Will explicitly examine: Will explicitly examine: –Changes in market share –Role of market competition and facility attributes –Selective discharge –Selective admissions