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Dr. Margaret McGregor and Lisa Ronald Re-Imagining Residential Long-Term Care Conference

Promising Practice: Better quality in non-profit/publicly delivered nursing homes – Is the association causal?. Dr. Margaret McGregor and Lisa Ronald Re-Imagining Residential Long-Term Care Conference Bergen, Norway May 2014. Background. Population aging

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Dr. Margaret McGregor and Lisa Ronald Re-Imagining Residential Long-Term Care Conference

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  1. Promising Practice: Better quality in non-profit/publicly delivered nursing homes – Is the association causal? Dr. Margaret McGregor and Lisa Ronald Re-Imagining Residential Long-Term Care Conference Bergen, Norway May 2014

  2. Background • Population aging • Mainly publicly funded, delivered by mix of for-profit, non-profit (independent, volunteer sector) and public (government/ quasi-government) facilities • Increasingly complex corporate management structures

  3. How do we measure quality? • Challenges with measuring care quality • Multidimensional • Observational qualitative and quantitative data • No randomized controlled trials • Potential for bias and confounding • Data often collected retrospectively

  4. Policy debate: is quality better in non-profit nursing homes? • Multiple studies - Evidence from 2 systematic reviews - Comondore, (2009), Hillmer (2005) • Konetzka (2009): “Insufficient evidence to assume causality, need randomized controlled trials”

  5. How do we assess if there is a causal association? • Bradford Hill’s guidelines – a useful framework for assessing causation • Sir Austin Bradford Hill: Pioneer of randomized clinical trials, first (with Richard Doll) to show link between smoking and lung cancer • Plausibility, Consistency, Analogy, Temporality, Dose-response, Strength, Experiment, Specificity

  6. Assessing the evidence using Bradford Hill guidelines • Plausibility • Goal is to maximize profits for shareholders • Consistency and Analogy • Across time, jurisdictions, data sources and methods, different quality measures • Similar findings in different sectors • Specificity • Most consistent effect = staffing

  7. Assessing the evidence using Bradford Hill guidelines • Temporality • Conversions between ownership types (Grabowski and Stevenson, 2008) • Experiment • Instrumental variable analysis (Hirth 2013, Grabowski, 2013) • Dose-response • Highest profit group, more serious deficiencies (O’Neill, 2003)

  8. Assessing the evidence using Bradford Hill guidelines • Strength of the association • Modest effect sizes, depends on quality measure • Comondore (2009): systematic review and meta-analysis • Reviewed 82 studies • Global measure of quality: all statistically significant associations favoured NP in 40 studies, mixed results in 37 • Specific measures (eg. deficiencies): most favoured NP • All had trend towards better in NP facilities, 2 of 4 pooled measures (staffing, pressure ulcer prevalence) statistically significantly better

  9. Aligning policy with evidence: how do we move forward? • Apply the precautionary principle • Take precautionary approach when risk of harm • Shifts the burden of proof to the proponents • Highly vulnerable population • Align policy with scientific evidence • “Imperfect knowledge is no excuse for governmental or multinational inaction”.(Annas, 1999)

  10. Acknowledgments • Social Sciences and Humanities Research Council: “Reimagining Long-Term Residential Care: An International Study of Promising Practices” Thank you…..any questions?

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