Patient safety measures aren't weighted strongly enough to sway the star ratings nursing homes receive on CMS' Nursing Home Compare website, according to a new analysis.
The study, published Monday in Health Affairs, found six patient safety measures the CMS considers in the star-rating methodology don't have a strong influence on the overall rating a nursing home is assigned.
"There are many great things about Nursing Home Compare, but I think it needs refinement," said R. Tamara Konetzka, an author of the study and professor in the departments of public health sciences and medicine at the University of Chicago. "In order to be a good tool for consumers, it needs to reflect what consumers care about and one thing consumers care about is patient safety."
Using a correlation model, the authors found that for nursing homes with two, three or four stars, there wasn't a meaningful difference in adverse safety events that occurred among them. However, they did find the nursing homes categorized as the worst and best—or those with one or five stars—had a stronger correlation with patient safety. One-star nursing homes reported more safety events and five-star nursing homes reported fewer. The study used star-rating data from the first quarter of 2017.
Nursing homes have received star ratings from the CMS since 2008, as the agency tried to give consumers a way to compare quality of care. In the latest release of the ratings in October, the majority of the nursing homes—4,369—received five stars while just 1,853 nursing homes got a one-star rating. All in all, 15,396 nursing homes received a star rating from the CMS in October. The ratings are updated monthly.
In order for the star ratings to better reflect patient safety events, Konetzka and her colleagues suggested the CMS place nursing homes' performance on the patient safety measures in a separate subset on Nursing Home Compare.
"Raising the visibility of patient safety measures should serve not only to inform consumers but also to provide a stronger incentive for nursing homes to improve on these measures," the authors wrote.
Dr. David Gifford, vice president of quality and regulatory affairs at the American Health Care Association, which represents nursing homes in the U.S., said he agrees that Nursing Home Compare "needs to provide information in a format that allows consumers to prioritize what information is more important to them."
But patient safety measures are self-reported and there is evidence that nursing homes don't report them accurately, said Charlene Harrington, professor emeritus in the department of social and behavioral sciences at the University of California at San Francisco. "I've reviewed many nursing home legal cases, and it's so frequent that they don't report pressure sores, urinary tract infections and falls, so that is an underlying problem," Harrington said.
Considering this, Harrington said the best objective source of information consumers have right now to assess nursing home quality is their staffing ratios. A provision in the Affordable Care Act is now in effect in which payroll data is used to report nursing home staff levels, which means they can't be easily modified by nursing homes.
"Right now, for consumers, staffing is such an important measure. We just have to educate consumers that staffing is the No. 1 issue. All of these falls stem from low staffing," Harrington said.
Another limitation the authors mentioned with patient safety measures in nursing homes is that poor performance on the measures doesn't necessarily mean care is subpar. A higher fall rate could mean the nursing homes are allowing patients to have greater autonomy, Konetzka said.
"In the nursing home setting, there may be trade-offs between patient and safety and quality of life. If you really want to prevent falls and other patient safety incidents, you can just restrain people, but that is going to be a horrible quality of life," she said.
The authors suggested that one way the CMS can assess for that is to get patients' perspective about their quality of life through surveying.
However, Harrington said surveying patients can be difficult considering that some patients have poor cognitive function.
"It's very hard for them (the patients) to rate quality," she said. "And some families go to nursing homes every day and they know what's going on, and other families go very rarely."
Taking into account the site's limitations, "the CMS five-star quality rating system should not be used as the sole judge of a center's quality, which is consistent with CMS' own statement on the Nursing Home Compare site," Gifford at the American Health Care Association said. "Choosing the right center is a process that should be conducted both on- and off-line."
