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Nursing Home Staffing Variability and Quality: Assessing Alternative Measures of Daily Staffing Level Variation
Christopher S Brunt1, John R Bowblis2
1Department of Economics, Georgia Southern University, Statesboro, GA, USA.
Journal of the American Medical Directors Association
|March 2, 2025
Summary
Median-based measures, especially median-CDMAD, best predict nursing home quality outcomes. Incorporating daily staffing variation into the Centers for Medicare and Medicaid
Area of Science:
- Gerontology
- Health Services Research
- Nursing Home Quality
Background:
- Daily nursing staffing variability is linked to nursing home quality.
- Calls exist to include staffing variation in the Centers for Medicare and Medicaid's (CMS) staffing star rating.
- Optimal measures of staffing variation are needed to assess quality outcomes.
Purpose of the Study:
- To evaluate six distinct daily nursing staffing level variation measures.
- To determine the most valid measure for explaining nursing home quality outcomes.
- To identify an optimal variation measure for inclusion in the CMS staffing star rating.
Main Methods:
- Analysis of secondary data from CMS Care Compare and Payroll-Based Journal (2022Q1-2023Q3).
- Evaluation of six variation measures: CV, TOD, LOD, CQV, mean-CDMAD, and median-CDMAD.
- Statistical validity assessed using linear regression against 9 patient-based quality outcomes, examining significance, correlation, goodness of fit, and monotonicity.
Main Results:
- Median-CDMAD showed superior statistical properties, achieving the best goodness of fit in 56%-67% of quality outcomes.
- Median-CDMAD, mean-CDMAD, and CV demonstrated superior monotonicity, indicating robustness against outliers and gaming.
- These median-based measures showed greater validity in explaining quality outcomes compared to other measures.
Conclusions:
- Median-based variation measures, particularly median-CDMAD, are highly valid for predicting nursing home quality.
- These measures are suitable for the CMS staffing star rating system.
- Including daily staffing variation can enhance transparency and incentivize quality improvement in nursing homes.
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