Changes in the quality of post-acute care after the implementation of public reporting

1. 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 HS016478-01)

2. Public Reporting and Quality Improvement • 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: • Giving consumers information needed to shop on quality • Giving providers incentive to compete on quality • Giving providers information and targets for QI

4. Objective • 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. • Changes in average resident-level quality within market • Changes in average within-SNF quality

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

6. Setting: Nursing Home Compare • Launched November 12, 2002 • Publicly release quality information: http://www.medicare.gov/NHCompare • All Medicare- and Medicaid-certified NHs • 17,000 nursing homes • 10 quality measures • 3 post-acute care • 6 chronic care • Staffing, inspections

7. Data • Minimum Data Set (1999-2005) • 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 • Claims data on all non-managed-care Medicare beneficiaries • Used to calculate rehospitalizations and several health risk variables

8. Empirical approach 1 1A. Within market: Qualityit= β1NHCt + βXjt 1B. Within SNF: Qualityjt= β1NHCt + βXjt + j • Qualityj/jt = quality for individual i or SNF j in year t • NHCt = indicator of Nursing Home Compare ▪ pre-post (2000-2002 vs. 2003-2005) ▪ set of year dummy variables • Xj/it = set of control variables • j = SNF fixed effects

9. Empirical Approach 2 • Repeat both analyses but add control group • 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.

10. Controlling for Selection • 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. • 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)

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

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

13. Quality Measures

14. Control variables • 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) • Previously developed risk adjustors for preventable hospitalizations

15. Risk-adjusted trends in post-acute care quality

16. Risk-adjusted trends in post-acute care quality

17. Risk-adjusted trends in post-acute care quality

18. Risk-adjusted trends in post-acute care quality

19. Results 1: Within-market changes

20. Results 2 • 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 • Magnitude of improvement in pain decreased • Magnitude of improvement in walking increased • Rehospitalization rates worsened

21. Summary • 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. • Most of the effect is attributable to within-SNF changes, suggesting that changes in market share played a negligible role

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