Investment In Quality Improvement Research Articles

Association of Hospital System Affiliation with Spending and Postoperative Outcomes: A Longitudinal Study of Hospital Mergers And Acquisitions From 2010 To 2018.

To determine whether hospital system affiliation was associated with changes in surgical episode spending or postoperative outcomes. Over 70% of US hospitals are now part of a hospital system. The presumed benefits of hospital consolidation include concentrating volume and expertise, care integration, and investment in quality improvement. However, there is conflicting evidence as to whether expanding hospital systems are actually reducing health spending or improving quality. These observations call into question whether systems are leveraging their collective volume and experience to standardize care and maximize efficiencies. The American Hospital Association Annual Survey was used to identify whether a hospital was part of a system and in which year a hospital joined the respective system. Using 100% Medicare claims data, we identified fee-for-service Medicare patients undergoing elective inpatient coronary artery bypass graft colon resection, lung resection, hip replacement, or knee replacement from 2010 to 2018. We used a difference-in-differences framework to evaluate hospital spending and outcomes before and after joining a system. The primary outcome was Medicare 30-day episode spending, with specific attention to the total episode payment, index hospitalization, and post-acute care components. Secondary outcomes included serious complications, 30-day mortality, and 30-day readmission. The cohort included 3,395,565 Medicare beneficiaries who underwent surgery between 2010 and 2018. Patients were treated at 3961 hospitals, of which 1097 (27.7%) were never in a system, 2262 (57.1%) were always in a system, and 602 (15.2%) joined a system during the study period. By 1 year after system affiliation, 30-day episode spending had decreased by $303 (95% CI: 63, 454, P=0.01), and after 5 years, 30-day episode spending decreased by $429 (95% CI: 5, 853, P=0.04). One year after system association, index hospitalization spending was not statistically different from before system affiliation ($-30, 95% CI: -160, 100, P=0.65). Conversely, 1 year after system association, postacute care spending decreased by $268 (95% CI: 107, 429, P<0.01) and remained lower for ≥5 years. There was no significant change in hospitals serious complications (-0.14, 95% CI: -0.40, 0.11, P=0.27), 30-day readmission (-0.14, 95% CI:-0.52, 0.25, P=0.48), or 30-day mortality (-0.08, 95% CI: -0.18, 0.03, P=0.17), 1 year after joining a system; similar patterns were observed at three and ≥5 years. system affiliation was associated with a small decrease in 30-day episode spending, driven by decreased spending in postacute care services. Notably, there was no difference in postoperative outcomes after system affiliation.

R&D investment and network effects: A dynamic model of the search engine market

ABSTRACT This paper considers R&D investment for quality improvement in a dynamic duopoly game in the search engine market. The aim is to determine the circumstances under which asymmetry between search engines (in terms of quality) tends to increase or decrease over time. I show that when the future sufficiently matters, the low-quality search engine can catch up with the high-quality engine by investing in quality. In contrast, when only the present matters, the high-quality search engine wins and the structure of the market transitions to a monopoly. I also show that a shift in asymmetry between firms can result in either an increase or decrease in consumer welfare, depending on the degree of substitutability between the two search engines.

Implementation of large, multi-site hospital interventions: a realist evaluation of strategies for developing capability

BackgroundThis study presents guidelines for implementation distilled from the findings of a realist evaluation. The setting was local health districts in New South Wales, Australia that implemented three clinical improvement initiatives as part of a state-wide program. We focussed on implementation strategies designed to develop health professionals’ capability to deliver value-based care initiatives for multisite programs. Capability, which increases implementers’ ability to cope with unexpected scenarios is key to managing change.MethodsWe used a mixed methods realist evaluation which tested and refined program theories elucidating the complex dynamic between context (C), mechanism (M) and outcome (O) to determine what works, for whom, under what circumstances. Data was drawn from program documents, a realist synthesis, informal discussions with implementation designers, and interviews with 10 key informants (out of 37 identified) from seven sites. Data analysis employed a retroductive approach to interrogate the causal factors identified as contributors to outcomes.ResultsCMO statements were refined for four initial program theories: Making it Relevant– where participation in activities was increased when targeted to the needs of the staff; Investment in Quality Improvement– where engagement in capability development was enhanced when it was valued by all levels of the organisation; Turnover and Capability Loss– where the effects of staff turnover were mitigated; and Community-Wide Priority– where there was a strategy of spanning sites. From these data five guiding principles for implementers were distilled: (1) Involve all levels of the health system to effectively implement large-scale capability development, (2) Design capability development activities in a way that supports a learning culture, (3) Plan capability development activities with staff turnover in mind, (4) Increased capability should be distributed across teams to avoid bottlenecks in workflows and the risk of losing key staff, (5) Foster cross-site collaboration to focus effort, reduce variation in practice and promote greater cohesion in patient care.ConclusionsA key implementation strategy for interventions to standardise high quality practice is development of clinical capability. We illustrate how leadership support, attention to staff turnover patterns, and making activities relevant to current issues, can lead to an emergent learning culture.

Benefits of Preservation, Green and Quality Improvement Investment for Waste Management in Sustainable Supply Chain under Fuzzy Learning and Inflation

In the modern world, waste management, incorporating the quality of the products, energy consumption, and environmental concern have become significant challenges for supply chain managers. Also, smart devices are essential for daily life in the current socioeconomic environment, and customers primarily contemplate a smart product’s price and energy usage before purchasing that. In this situation, to maintain a balance between the selling price, energy consumption, and carbon emission from supply chain operations becomes necessary. So this study develops a twoechelon sustainable inventory model for deteriorating items with an imperfect production process under energy consumption and selling price dependent demand. The producer makes a rework process and quality improvement investment to mitigate defective products and enhance the quality of the products. The present model develops under the influence of inflation. Also, preservation and green technologies are used to mitigate the rate of deterioration and carbon emission, respectively. Firstly, the model is created in a crisp sense, and then expanded into a fuzzy learning model to examine the impact of the learning effect in an imprecise environment. A numerical analysis is performed to validate the proposed model, and the cost function’s convexity is shown graphically using mathematica software. The result of the proposed model provides significant insights to decision-makers on how to efficiently reduce waste while still minimizing the total cost of the system by investing in high efficiency preservation, quality improvement and green techniques. Also, due to learning in fuzziness, the fuzzy learning model gives the lowest total cost, followed by the fuzzy and crisp model. Finally, for various parameters, a sensitivity analysis is performed to gather valuable observations and management insights.

Consumer rebate strategy for a manufacturer selling price‐quality differentiated products

AbstractIn this study, we consider a scenario where a manufacturer offers two price‐quality differentiated products, which we label “regular” and “upgraded,” through a retailer and uses direct rebates to customers to stimulate sales. Therefore, the critical question posed is: If a customer rebate is provided, should it be on the regular, upgraded, or both products? Consequently, we compare the outcomes of eight options from a manufacturer's perspective. The analysis reveals that the manufacturer's choice is not straightforward. Rebates on both products can lead to higher profit for the manufacturer if the proportion of rebate‐sensitive consumers is moderate. However, product quality becomes critical as the proportion of rebate‐sensitive consumers increases. If the quality of the regular product is too high or too low, then the manufacturer may use a rebate only on the regular product; otherwise, it should be on only an upgraded product. The rebate value on an upgraded product continuously decreases with regular product quality if a rebate is introduced only on an upgraded product, but its nature changes in other contexts. Quality improvement investment is also a critical factor that affects the manufacturer's decision. Because an analytical assessment of the effectiveness of rebate promotion under the price‐quality consideration is still missing in the literature, the decision to initiate a rebate promotion might be considered on an ad hoc basis. Therefore, the explicit thresholds identified in this study can help managers to make rebate decisions comprehensively.

Dual-channel supply chain coordination strategies considering electricity quality

&lt;p style='text-indent:20px;'&gt;The introduction of tradable electricity platforms in China has enriched the channels for consumers to purchase electricity and intensified the competition among channels. The quality of electricity is an essential factor affecting consumer purchasing behavior. This paper mainly focuses on the influence of the competition among channels on electricity quality.We construct a dual-channel electricity supply chain, in which electricity generators sell electricity directly to consumers or resell it through electricity retailers. We use the backward induction method of game theory to solve the equilibrium solutions in centralized, decentralized, and coordinated decisions. By analyzing and comparing the equilibrium solutions, we draw the following conclusions; (1) Electricity quality, electricity price, electricity demand, and profits increase with the sensitivity coefficient of electricity quality and price competition coefficient. (2) Electricity quality, electricity price, electricity demand, and profits decrease with the investment cost coefficient of quality improvement. (3) The increase in transmission and distribution costs reduces the electricity quality while increasing the electricity price through both channels. Furthermore, the increase leads to an increase in electricity demand and the profit of the electricity retailer through the resale channel. However, it reduces the electricity demand and the profit of the electricity generator through the direct sales channel. (4) A combined contract consisting of revenue sharing and quality improvement investment cost-sharing can lead to coordination.&lt;/p&gt;

Influence of Perceived Quality and Brand Awareness on Brand Loyalty: Examining the Mediating Role of Brand Trust Within Biscuit Industry in Sri Lanka

Building and managing consumer brand relationships to foster Brand Loyalty is a challenge for marketers. As Biscuit manufacturing is a major industry in Sri Lanka, it is essential to investigate the behavior of consumer brand relationships. Furthermore, identifying the influencing ability of Perceived Quality on Brand Loyalty is an emergent need in the biscuit industry in Sri Lanka since there is a growing trend of investments in quality improvements without investigating the effectiveness in terms of Brand Loyalty. By referring to relevant literature and accepted theories, the conceptual framework of this research is developed in order to examine the influence of Perceived Quality and Brand Awareness on Brand Loyalty. The research also examined the mediating effect of Brand Trust on the relationship between Perceived Quality and Brand Loyalty, as well as the relationship between Brand Awareness and Brand Loyalty. This research follows the deductive approach and cross-sectional time horizon. The study was carried out under quantitative strategy through survey method by using a structured questionnaire. Subsequent to the assurance of validity and reliability measures of the scale through the pilot study, 389 respondents contributed to the final data collection. The data were analyzed by using the multiple regression method. The results indicate that there is no significant positive influence of Perceived Quality on Brand Loyalty, while there is a significant positive influence of Brand Awareness on Brand Loyalty. Similarly, there is a significant positive influence of Brand Trust on Brand Loyalty. In addition, the results emphasize that there is a full mediation effect of Brand Trust on the impact of Perceived Quality on Brand Loyalty, while it engages in the impact of Brand Awareness on Brand Loyalty as a partial mediation. This research contributes to the literature on consumer-brand relationships with empirical evidence from Sri Lanka. Further, this study provides direction for marketers in the Biscuit Industry to enhance Brand Loyalty to become competitive in the market.

A single-stage cleaner production system with waste management, reworking, preservation technology, and partial backlogging under inflation

Waste management and reworking are very crucial issues in the cleaner production system. The adaptation of preservation mechanism in inventory control is also a key aspect from an economic and environmental point of view. In the current study, an inventory model for a cleaner production system is modelled considering all these practical issues and inflation. Deterioration process takes place in the production system. In the model, market demand is viewed sales team efforts and selling price dependent. Here, rate of production along with the unit production cost are taken as variables. An investment in preservation technology is made with the goal to lower the percentage of defective products. Further, partial backordering is considered. In order to demonstrate the model, numerical example is provided. A Hessian matrix is used to establish the concavity of the objective function. A theoretical result is provided to obtain the concavity of the objective function. Sensitivity analysis along with managerial implications is also provided in the manuscript. Results indicate that by implementing high-efficiency preservation technology, the detrimental effects of deterioration on profit can be mitigated. Due to this, 1.6% rise in profit is observed. Thus, selection of right preservation technology is crucial for both financial and environmental sustainability. In addition to this, higher reworking rates and capital investment in quality improvement result in high profit for the system.

Measuring social capital of hospital management boards in European hospitals: A validation study on psychometric properties of a questionnaire for Chief Executive Officers

BackgroundThe commitment of hospital managers plays a key role in decisions regarding investments in quality improvement (QI) and the implementation of quality improvement systems (QIS). With regard to the concept of social capital, successful cooperation and coordination among hospital management board members is strongly influenced by commonly shared values and mutual trust. The purpose of this study is to investigate the reliability and validity of a survey scale designed to assess Social Capital within hospital management boards (SOCAPO-B) in European hospitals.MethodsData were collected as part of the EU funded mixed-method project “Deepening our understanding of quality improvement in Europe (DUQuE)” from 210 hospitals in 7 European countries (France, Poland, Czech Republic, Germany, Portugal, Spain, and Turkey). The Chief Executive Officers (CEOs) completed the SOCAPO-B scale (six-item survey, numeric scale, 1=‘strongly disagree’ to 4=‘strongly agree’) regarding their perceptions of social capital within the hospital management board. We investigated the factor structure of the social capital scale using exploratory and confirmatory factor analyses. Internal consistency was assessed using Cronbach’s alpha, while construct validity was assessed through Pearson’s correlation coefficients between the scale items.ResultsA total of 188 hospitals participated in the DUQuE-study. Of these, 177 CEOs completed the questionnaire(172 observations for social capital) Hospital CEOs perceive relatively high social capital among hospital management boards (average SOCAPO-B mean of 3.2, SD = 0.61). The exploratory factor analysis resulted in a 1-factor-model with Cronbach’s alpha of 0.91. Pearson’s correlation coefficients between the single scale items ranged from 0.48 to 0.68.ConclusionsThe SOCAPO-B−scale can be used to obtain reliable and valid measurements of social capital in European hospital management boards, at least from the CEO’s point of view. The brevity of the scale enables it to be a cost-effective and tool for measuring social capital in hospital management boards.Trial registrationThis validation study was not registered.

Strategies for Sustaining High‐Quality Pediatric Asthma Care in Community Hospitals

Research ObjectiveHospitals make significant investments in quality improvement (QI) initiatives to improve clinicians' guideline adherence and care quality. However, the majority of studies report adherence declines after such initiatives end. Our objective was to identify strategies associated with sustained guideline adherence and high‐quality pediatric asthma care in community hospitals, which care for &gt;70% of hospitalized children in the US.Study DesignPathways for Improving Pediatric Asthma Care (PIPA) was a national QI initiative. In a prior quantitative study, data from 34 community hospitals in PIPA were analyzed to identify sites with higher and lower performance in sustaining clinicians' guideline adherence over a 2‐year period during and after the initiative. In this qualitative study, we conducted semi‐structured interviews with clinicians from these higher‐ and lower‐performing hospitals. We used constant comparative methods to identify strategies associated with sustained guideline adherence.Population StudiedMulti‐disciplinary clinicians (e.g., physicians, nurses, respiratory therapists).Principal FindingsClinicians (n = 19) from 5 higher‐ and 3 lower‐performing hospitals participated. In higher‐performing hospitals, dedicated local champions used several strategies to promote sustained high‐quality care, including: (1) providing ongoing reminders of evidence‐based practices; (2) delivering ongoing education on evidence‐based practices; and (3) modifying the electronic health record (EHR) to provide decision support, often via order sets. Higher‐performing sites also had access to resources for quality monitoring, as well as a culture of firm expectation that evidence‐based practices would be adopted and followed without exception. In lower‐performing hospitals, participants described unique barriers to sustaining high‐quality care, including delays in modifying the EHR and lack of automation of EHR tools (requiring clinicians to remember and perform new EHR tasks without automated prompts to do so). Barriers to sustainability for all hospitals included: (1) challenges maintaining quality monitoring; (2) decreasing focus of local champions over time; and (3) ongoing difficulties developing consensus around evidence‐based practices.ConclusionsWe outline several strategies associated with sustaining high‐quality pediatric asthma care in community hospitals. Several of these rely on a dedicated, long‐term local champion.Implications for Policy or PracticeSupporting a dedicated local champion long‐term may be critical to reap returns on QI investments. Strategy Exemplary Quotes Providing ongoing reminders of evidence‐based practices “And then for the residents, we have our guidelines where they can find them, and we have them just posted visibly in the call room as well as on a couple of different sites on our internal website.” Delivering ongoing education/training on evidence‐based practices “When a new employee comes on during their orientation, they're educated on [the pediatric asthma] pathway… so that education piece is truly never gone away.” Modifying the electronic health record (EHR) to provide decision support “And then the other part of it is, it has to be easy to do. So, somebody shouldn't have to remember something on a regular basis because things are easy to forget and needs to be right there in their face. Every time they're ordering the asthma order set it's right there.” Primary Funding SourceAgency for Healthcare Research and Quality.

A sustainable production-inventory model with imperfect quality under preservation technology and quality improvement investment

Incorporating qualities and environmental concerns have received significant attention in the literature on production and inventory management for deteriorating items; however, scarce papers have emphasized these two concurrently. Therefore, it is required to incorporate these two aspects for deteriorating items to fill this gap in the literature and provide a better insight into practice. This paper elaborates a sustainable production inventory model for poor quality deteriorating items which (a) items deteriorate at a constant rate and the deterioration progress can be controlled by investing in preservation technology; (b) carbon is emitted due to production operations, and it can be controlled by investing in carbon reduction technology; (c) a fraction of manufacture items are imperfect, and the quality can be enhanced by investing in quality improvement. The paper aims to discuss the impact of preservation and carbon reduction technologies on the total profit to help decision-makers make more efficient replenishment and pricing decisions. An algorithm is proposed to determine optimal values for five decision variables. A numerical experiment is illustrated to validate the mathematical formulation, and the impact of parameters on total profit and managerial insights are discussed using sensitivity analysis.

Integrated inventory model involving quality improvement investment and advance-cash-credit payments

This paper investigates the effects of investment and inspection policies on an integrated production–inventory model involving defective items and upstream advance-cash-credit payment provided by the supplier. In this model, retailers offer customers a downstream credit period. Furthermore, the defective rate of the item can be improved through capital co-investment by the supplier and retailer. The objective of this study was to determine the optimal shipping quantity, order quantity, and investment alternatives for maximizing the supply chain’s joint total profit per unit time. An algorithm was developed to obtain the optimal solution for the proposed problem. Several numerical examples are used to demonstrate the proposed model and analyze the effects of parameters changes on the optimal solutions. Finally, management implications for relevant decision makers are obtained from the numerical examples.

An Equity Lens for Identifying and Addressing Social Needs Within Pediatric Value-Based Care.

* Abbreviations: SDOH — : social determinant of health VBC — : value-based care Socioeconomic disparities in health outcomes have proven to be persistent in the United States. For example, the mortality rate for Black infants is twice as high as it is for white infants, and low-income children are more likely to experience developmental delays as compared with their peers.1 Emerging data reveal striking racial and socioeconomic inequities in coronavirus disease 2019 outcomes. Healthy People, the national framework for population health, has identified reduction of health disparities and achievement of health equity as crucial goals. However, despite substantial investments, the nation is no closer to achieving these key societal aims, with alarming evidence of widening health disparities in recent years.2 Over the past decade, the US health care delivery system has undertaken a large-scale transformation aligned with achieving the triple aim (improving quality, reducing costs, and enhancing experience of care).3 Pediatricians have made important investments in quality improvement, medical home certification, primary care redesign, and electronic health record adoption to advance these aims. The financing of pediatric care has also evolved with a rapid movement toward value-based care (VBC), whereby pediatricians receive incentives for lowering costs and improving quality. In 2016, approximately half of pediatricians participated in VBC, and that amount has likely increased in recent years.4 Pediatric VBC programs are often focused on addressing the social determinants of health (SDOHs) that strongly correlate with adverse physical, emotional, and … Address correspondence to Alon Peltz, MD, MBA, MHS, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Harvard University, 401 Park Dr, Suite 401 East, Boston, MA 02215. E-mail: alon_peltz{at}harvardpilgrim.org

Nursing Home Responses to Performance-based Accountability: Results of a National Survey.

The Centers for Medicare & Medicaid Services (CMS) Nursing Home Quality Initiative aims to improve quality through performance measurement. We describe quality improvement (QI) changes that skilled nursing facilities (SNFs) reported making in response to CMS performance measurements and whether reported QI changes were associated with better performance on CMS performance measures. Nationally representative survey. A total of 15,475 SNFs that reported quality performance on Nursing Home Compare in 2016. A total of 1,182 SNFs (58% of random sample of 2,045 SNFs). Adoption of 22 possible QI changes, grouped into seven categories (organizational culture, health information technology, care process redesign, provider incentives, changes to staffing responsibilities, performance monitoring, and measure-specific QI initiatives and technical assistance); performance on the CMS Nursing Home Compare Five-Star Quality Rating System's quality measure rating. SNFs reported making an average of 13 QI changes (interquartile range = 11-16 changes). SNFs mostly commonly reported becoming a learning organization (87%) and providing training to staff on QI strategies (87%). After controlling for patient and facility characteristics, larger SNFs were more likely to obtain assistance on measure reporting from QI organizations and use provider champions than smaller SNFs by 14 and 11 percentage points, respectively. Rural SNFs and SNFs with higher proportions of disabled, black, or Hispanic residents adopted QI changes at similar rates as other SNFs. Of the 22 QI changes, 20 were considered at least somewhat helpful by more than 80% of adopting SNFs. Implementation of all 22 QI changes (vs no changes) was associated with a .48-star higher quality measure rating (95% confidence interval = .003-.98 stars; P = .05). In response to CMS measurement programs, SNFs reported making substantial QI investments that were associated with better performance on CMS quality measures. To guide future SNF investments in QI, work is needed to identify the QI changes that yield the greatest performance improvements.

Two echelon supply chain with permissible delay in payments under exponential lead time involving investment for quality improvement and ordering cost reduction

This paper deals with continuous review inventory policy under permissible delay in payments with investment for quality improvement and ordering cost reduction. The supplier offers a credit period that is less than the average duration of the inventory model. The lead time of receiving products from the vendor to a buyer is a variable which is controllable by adding extra crashing cost. A mathematical model is derived to investigate the effects of ordering cost reduction, permissible delay in payments and investment for quality improvement and it can be achieved by optimising the order quantity, lead time and total number of deliveries in one production run simultaneously with the objective of minimising joint expected total cost (JETC). Furthermore, the sensitivity analysis is included and the numerical examples are given to illustrate the results. Finally, graphical representation is presented to illustrate the model.

Two echelon supply chain with permissible delay in payments under exponential lead time involving investment for quality improvement and ordering cost reduction

Two echelon supply chain with permissible delay in payments under exponential lead time involving investment for quality improvement and ordering cost reduction

Quality investment, and the contract manufacturer’s encroachment

This paper studies a supply chain in which the incumbent original equipment manufacturer is the quality leader and the encroaching contract manufacturer is the quality follower acting as a free rider for the former’s investment in quality improvement. Investigations were made into the contract manufacturer’s encroaching conditions and the original equipment manufacturer’s strategies of investment in quality improvement to deter the contract manufacturer’s encroachment. Results show that, different from the traditional encroachment, the contract manufacturer always has the incentive to encroach on the original equipment manufacturer’s final market if there is no quality investment opportunity. However, if quality investment is attainable for the original equipment manufacturer, there exists a threshold for the contract manufacturer’s imitating capability, in excess of which the contract manufacturer will encroach on the original equipment manufacturer’s final market. The structure of quality improvement plays a critical role regarding deterring the contract manufacturer’s imitation and encroachment, and the encroachment is conditional when the contract manufacturer’s imitating ability is relatively weak. Moreover, the threat of the potential entrant will facilitate the original equipment manufacturer’s quality investment, even though the quality investment per se is unprofitable. Under certain conditions with quality investment, the contract manufacturer’s encroachment can improve the original equipment manufacturer’s profit, thus achieving a win–win outcome.

Assessing quality in payment reform initiatives

Rising healthcare costs and increasing evidence of variation in quality of healthcare have spurred payment reform initiatives that tie reimbursement to the quality of care provided. Success in these initiatives will require identification of valid and reliable measures of quality and rigorous evaluation of the effects of payment reform implementation on these quality metrics. Despite the support and investment in quality improvement through payment reform, results of these improvement initiatives have been mixed. Providers and researchers must remain invested in the development, evaluation, and selection of quality measures for healthcare policy reform.

The impacts of port infrastructure and logistics performance on economic growth: the mediating role of seaborne trade

Considering 91 countries with seaports, this study conducted an empirical inquiry into the broader economic contribution of seaborne trade, from a port infrastructure quality and logistics performance perspective. Investment in quality improvement of port infrastructure and its contribution to economy are often questioned by politicians, investors and general public. A structural equation model (SEM) is used to provide empirical evidence of significant economic impacts of port infrastructure quality and logistics performance. Furthermore, analysis of a multi-group SEM is performed by dividing countries into developed and developing economy groups. The results reveal that it is vital for developing countries to continuously improve the quality of port infrastructure as it contributes to better logistics performance, leading to higher seaborne trade, yielding higher economic growth. However, this association weakens as the developing countries become richer.

Association Between 5-Star Nursing Home Report Card Ratings and Potentially Preventable Hospitalizations.

Nursing homes’ publicly reported star ratings increased substantially since Centers for Medicare & Medicaid Services’s Nursing Home Compare adopted a 5-star rating system. Our objective was to test whether the improvements in nursing home 5-star ratings were correlated with reductions in rates of hospitalization. We hypothesized that increased attention to 5-star star ratings motivated nursing homes to make changes that improved their star ratings but did not affect their hospitalization rate, resulting in a weakened association between ratings and hospitalizations. We used 2007-2010 Medicare hospital claims and nursing home clinical assessment data to compare the correlation between nursing home 5-star ratings and hospitalization rates before versus after 5-star ratings were publicly released. The correlation between the rate of hospitalization and a nursing home’s 5-star rating weakened slightly after the ratings became publicly available. This decrease in correlation was concentrated among patients receiving post-acute care, who experienced relatively more hospitalizations from best-rated nursing homes. The improvements in nursing home star ratings after the release of Medicare’s 5-star rating system were not accompanied by improvements in a broader measure of outcomes for post-acute care patients. Although this dissociation may be due to better matching of sicker patients to higher-quality nursing homes or superficial improvements by nursing homes to increase their ratings without substantial investments in quality improvement, the 5-star ratings nonetheless became less meaningful as an indicator of nursing home quality for post-acute care patients.