Five-Star Ratings Don’t Tell Consumers, Investors About Skilled Nursing Safety

Consumers and investors may rely on the five-star rating system for nursing homes to make key decisions, but a new study suggests that there isn’t much difference in resident safety between buildings along the scale.

“Our results reveal that Nursing Home Compare, a policy initiative aimed at improving quality and empowering consumers to make better choices, does not provide them with much information on which to judge patient safety in nursing homes,” the researchers wrote in the study, published in the November issue of the journal Health Affairs.

The team, led by Daniel Brauner of the University of Chicago’s Department of Medicine, looked to compare a facility’s Five-Star Quality Care rating from the Centers for Medicare & Medicaid Services (CMS) with the prevalence of certain patient-safety incidents: falls, urinary tract infections, pressures sores, and medication errors.


Aside from medication errors — which were substantially lower in five-star buildings than those with a lower CMS rating — the researchers didn’t find much difference between the prevalence of patient safety issues along the spectrum.

“A rating of one star or five stars seemed to give the most information about patient safety, with one-star nursing homes having higher rates of adverse safety events and five-star nursing homes having the lowest rates,” the researchers concluded. “However, for nursing homes in the middle — those with two, three, or four stars — there was no meaningful difference in adverse safety events between nursing homes with different star ratings.”


Part of the divergence, Brauner told Skilled Nursing News, is that the concepts of “quality” and “safety” aren’t necessarily synonymous.

“Quality is a much bigger concept than safety, per se, so we focus on the quality measures that also can be thought of as keeping residents in nursing homes safe,” Brauner said. “That’s a big concern of people who put their loved ones in nursing homes.”

Brauner and the team took particular inspiration from a pair of reports from the Institute of Medicine, which in the 1980s and 19990s helped to spur the Nursing Home Reform Act of 1987 and the growth of the so-called patient safety movement, which focused on protecting patients in the acute care settings. But the authors argue that the push hasn’t quite extended to the post-acute space, which has focused more on the overarching notion of “quality” — and not safety, which is the result of high-quality employees and processes.

While the five-star rating provides a quick shorthand for a facility’s operations, Brauner contends that the true measure of a facility’s efficacy at caring for patients is much more complex.

“Part of the problem with looking at quality measures is, if you dig deeper, they’re very superficial in terms of: It’s either a yes or no,” he said, referring to the health inspections and other metrics that go into the development of the CMS rating. “They have it, or they don’t have it. It’s usually much more complicated.”

Instead, Brauner would prefer to see a rating system that put more weight on individual patient experiences, noting that many quality measures are irrelevant to specific residents’ care needs.

“I would think that a better way of doing it would be to take random people and see how they’re cared for, and do an in-depth look: This person has XYZ. These are their needs, and this is how they’re being met,” he said.

Brauner and the team — which included Rachel Werner, a professor of medicine at the University of Pennsylvania’s Wharton School of Business, and Tetyana P. Shippee of the University of Minnesota — aren’t the first researchers to question the validity of the five-star system, particularly in the middle grounds between one and five stars. PointRight, a data analytics firm that specializes in long-term care, found only a 3% difference between median rehospitalization rates between the highest- and lowest-rated facilities in an analysis performed earlier this year.

“We can grumble about [the star ratings], and there is a clear difference between a five-star facility and a one-star, but it gets a little murky after that,” PointRight chief clinical officer Steven Littlehale said at the time.

Another 2018 study from researchers at the University of Chicago and the University of Pennsylvania found that hospitalization rates at some four- and five-star facilities actually increased after the public release of quality data in December 2008.

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

Written by Alex Spanko

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