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Does risk adjustment of the CMS quality measures for nursing homes matter?

Dana B Mukamel1, Laurent G Glance, Yue Li

  • 1University of California Irvine, Center for Health Policy Research, Irvine, California 92697-5800, USA. dmukamel@uci.edu

Medical Care
|April 29, 2008
PubMed
Abstract

Insights

Enhanced risk adjustment for nursing home quality measures (QMs) significantly alters facility rankings. This improved risk adjustment offers a potential enhancement to current Centers for Medicare and Medicaid Services (CMS) quality reporting.

Area of Science:

  • Gerontology
  • Health Services Research
  • Quality Improvement

Background:

  • The Centers for Medicare and Medicaid Services (CMS) currently utilize 19 clinical quality measures (QMs) for nursing home report cards.
  • These existing QMs incorporate only minimal risk adjustment, potentially affecting accurate quality assessment.

Purpose of the Study:

  • To develop enhanced quality measures (EQMs) with more comprehensive risk adjustment.
  • To evaluate the impact of this advanced risk adjustment on nursing home quality rankings.

Main Methods:

  • Retrospective analysis of individual-level Minimum Data Set (MDS) data from 17,469 nursing homes (2001-2005).
  • Development of risk adjustment models using random effect logistic regression for outcomes including pressure ulcers, physical restraints, and pain.
  • Comparison of newly developed enhanced QMs (EQMs) with existing QMs using Kappa statistics and error rates.

Main Results:

  • Kappa values between QMs and EQMs ranged from 0.63 to 0.90, indicating substantial agreement.
  • False positive and false negative error rates varied from 8% to 37% across measures.
  • Agreement between QMs and EQMs was notably higher for identifying high-quality nursing homes compared to low-quality ones.

Conclusions:

  • Extensive risk adjustment demonstrably alters nursing home quality rankings.
  • The proposed enhanced QMs (EQMs) represent a potential improvement over current CMS quality measures.
  • Further investigation into methodological aspects of QM construction is recommended for optimizing nursing home care evaluation.

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