Skilled Nursing Outcomes Don’t Always Improve Along with Star Rating Gains

Hospitalization rates play into the all-important five-star rating for nursing homes, but a new study finds that the two metrics aren’t necessarily correlated.

Improvements in nursing home star ratings were not matched by improvements in potentially preventable hospitalizations, according to a study recently published in The Journal of Health Care Organization, Provision, and Financing.

Researchers Kira Ryskina of the University of Pennsylvania, R. Tamara Konetzka of the University of Chicago, and Rachel Werner of the Corporal Michael J. Crescenz VA Medical Center measured the change in association between a nursing home’s rating and the number of potentially preventable hospitalizations per 30 days.


The hospitalization numbers were examined before and after the implementation of the Centers for Medicare & Medicaid Services’ Five-Star Quality Care report card in December 2008, controlling for nursing home and patient characteristics.

The researchers used 2007 to 2010 data from nursing home clinical assessments and Medicare claims for the study, which was published last month. The final sample — which excluded Medicare Advantage residents — consisted of 5,208,015 patients admitted to one of 16,046 nursing homes during the study period.

The team found that before the five-star system was released, higher-quality nursing homes exhibited lower hospitalization rates, aligning with the idea that the metric is considered a mark of quality, according to the study.


That changed with the release of the report card system.

“In some cases (among patients receiving post-acute care in 4- and 5-star nursing homes), potentially preventable hospitalization rates actually went up after the 5-star Nursing Home Compare report card was implemented,” the authors wrote.

They also found the effect was concentrated among for-profit nursing homes.

The team noted that the five-star system in general includes more metrics aimed at tracking the quality of long-term care rather than post-acute, which could lead to nursing homes focusing more on long-stay quality over post-acute care quality.

“Nursing homes’ increased attention to 5-star ratings since their release may have resulted in nursing homes making specific improvements that resulted in higher ratings rather than improving broadbased quality that was unmeasured by 5-star (such as potentially preventable hospitalizations),” the authors wrote.

The authors did point out that patient selection could also explain the findings, as more complex and sicker patients may have been increasingly matched to higher-star nursing homes after the release of the 5-star system. They also noted that the weakening of the correlation between outcomes and rating didn’t occur for long-term care stays.

“Nursing homes’ efforts to improve quality may have been shifted toward long-term care because 5-star ratings were weighted toward long-term care measures,” the authors wrote. “One possible solution may be creating two separate 5-star ratings: one for post-acute and one for long-term care in each nursing home.”

Limitations included the fact that the observational, retrospective study did not test whether the 5-star system caused changes in hospitalization rates; the researchers’ inability to adjust for specific market and nursing home characteristics that may influence the correlation between star ratings and hospitalizations; and the fact that potentially preventable hospitalizations could be appropriate.

Written by Maggie Flynn

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