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Med Care. 2013 Jul;51(7):582-8. doi: 10.1097/MLR.0b013e31828dbae4.

Quality improvement under nursing home compare: the association between changes in process and outcome measures.

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Center for Health Equity Research and Promotion, Philadelphia VAMC and Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA.



Changes in resident outcomes may be driven by many factors, including changes in nursing home care processes. Understanding what processes, if any, lead to successful improvements in resident outcomes could create a stronger case for the continued use of these outcome measures in nursing home report cards.


To test the extent to which improvements in outcomes of care are explained by changes in nursing home processes, a setting where, to our knowledge, this link has not been previously studied. RESEARCH DESIGN/MEASURES: We describe facility-level changes in resident processes and outcomes before and after outcomes were publicly reported. We then assess the extent to which the changes in outcomes are associated with changes in nursing home processes of care, using the public release of information on nursing home outcomes as a source of variation in nursing home outcomes to identify the process-outcome relationship.


All 16,623 US nursing homes included in public reporting from 2000 to 2009 in Online Survey, Certification and Reporting and the nursing home Minimum Data Set.


Of the 5 outcome measures examined, only improvements in the percentage of nursing home residents in moderate or severe pain were associated with changes in nursing home processes of care. Furthermore, these changes in the measured process of care explained only a small part of the overall improvement in pain prevalence.


A large portion of the improvements in nursing home outcomes were not associated with changes in measured processes of care suggesting that processes of care typically measured in nursing homes do little to improve nursing home performance on outcome measures. Developing quality measures that are related improved patient outcomes would likely benefit quality improvement. Understanding the mechanism behind improvements in nursing home outcomes is key to successfully achieving broad quality improvements across nursing homes.

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