People might want to think twice before relying on federal quality ratings to help choose a nursing home for an elderly or frail relative, a new study warns.
The U.S. Centers for Medicare and Medicaid Services (CMS) established the Nursing Home Compare website in the 1990s to publicly report patient safety indicators for every nursing facility in the nation.
But the site appears to drastically underreport the number and severity of bedsores suffered by Medicare residents in specific nursing homes, researchers reported recently in the journal Medical Care.
These findings jibe with a 2020 study that found similar underreporting of nursing home falls that resulted in a major injury, said senior researcher Prachi Sanghavi, an assistant professor of public health sciences at the University of Chicago.
In both studies, researchers compared data from the CMS site directly against claims that hospitals filed with Medicare to reimburse treatment for either falls or bedsores, Sanghavi said.
“We're actually taking an individual person's claim and linking it to that individual person's nursing home assessment,” she said. “We know they had a fall because we have a hospital claim saying this is the reason for their admission. Then we say, did the nursing home report it?”
The new study found that about 30% of bedsores suffered by short-term nursing home residents and about 40% of bedsores in long-term residents were not reported to the Nursing Home Compare database, Sanghavi said.
Similarly, the 2020 study found that more than 40% of major injury falls that resulted in hospitalization weren't reported, the researchers said in background notes.
“These measures that CMS publicly reports really are substantially underreported and inaccurate,” Sanghavi said. “And so they should come up with other ways to get a different, more objective measure of patient safety in nursing homes.”
The researchers also found no consistency in the underreporting — the number of hospitalizations for bedsores did not seem to track at all with a nursing home's overall rating.
“If everybody was consistently underreporting across nursing homes, then whatever CMS is putting up could still be useful because it allows you to still make comparisons. Everybody's underreporting, but consistently,” Sanghavi said. “Of the nursing homes in 2017 that have the most [bedsore hospitalizations], about 22% of them have a four- or five-star rating.”
The American Health Care Association/National Center for Assisted Living (AHCA/NCAL) — the nation's largest association representing long-term care providers — took exception to the new report.
“We do not believe this study is an accurate representation of our nursing homes that are filled with dedicated, heroic caregivers,” said Dr. David Gifford, chief medical officer at AHCA/NCAL. “Nursing homes have made dramatic improvements on all quality measures over the past decade and continue to focus on improving the quality of life for our residents. The progress nursing homes have made should be acknowledged.”
There is no question, he said, that health care in any setting involves continual improvement.
“Lawmakers and health policy officials must work with us to implement lasting change by providing resources necessary to further enhance care,” Gifford added.
Sanghavi and her team are now researching the accuracy of Nursing Home Compare data on urinary tract infections and pneumonia, the two most common infections among nursing home residents prior to COVID-19. That paper is expected to be published next year.
The data for the Nursing Home Compare website is drawn from the Minimum Data Set, an assessment of individual patients that nursing homes must forward to CMS at least every three months.
In most cases, the assessments are conducted by licensed health care professionals employed by the nursing home, according to the CMS. The assessments identify health problems and gauge each resident's functional capabilities.
It could be that nursing homes are deliberately underreporting problems like bedsores or falls, Sanghavi said.
“There's clearly a disincentive to report, right? Anything you report gets publicly reported. You're competing with other nursing homes, and people are looking at those reports,” she said.
But, Sanghavi added, the underreporting could also be caused by some sort of administrative mistake or paperwork mishandling.
“There could be a whole host of things going on,” Sanghavi said. “I don't think these problems are easy to solve, or certainly easy to solve in the very near future.”
She said the CMS website could change its methodology to something similar to her team's approach, in which hospitalization claims data would be factored into a nursing home's rating.
“I don't think inventing a new system is necessary,” Sanghavi said. “They could easily work with what they have and supplement or replace these self-reported measures.”
In the meantime, people shopping for a nursing home should look at other factors like inspections ratings rather than rely on the Nursing Home Compare site, Sanghavi said.
The U.S. Centers for Medicare and Medicaid Services has more about the Nursing Home Compare program.
SOURCES: Prachi Sanghavi, PhD, assistant professor, public health sciences, University of Chicago; David Gifford, MD, MPH, chief medical officer at American Health Care Association/National Center for Assisted Living, Washington, D.C.; Medical Care, Aug. 9, 2022