State Variability in Indicators of Quality of Care in Nursing Facilities

Published in: The Journals of Gerontology, v. 60, no. 9, Sep. 2005, p. 1173-1179

Posted on on January 01, 2005

by Nicholas G. Castle, Howard Degenholtz, John Engberg

Read More

Access further information on this document at

This article was published outside of RAND. The full text of the article can be found at the link above.

BACKGROUND: The objective of this research was to profile and compare state-level physical restraint use, urethral catheterization, contractures, pressure ulcers, and psychoactive medication use as indicators of quality of care in nursing facilities. METHODS: Using nationally representative data from the Online Survey, Certification, and Reporting system for 2000 (N = 17,072), the authors calculated predicted quality scores using risk-adjusted models based on aggregate resident variables generated by hierarchical linear regression models for each of the five quality indicators. RESULTS: The authors observed significant variation in both the actual and risk-adjusted quality measures. The average risk-adjusted physical restraint quality score ranged from 8.4% to 12.8%; the average risk-adjusted catheterization quality score ranged from 3.6% to 7.7%; the average risk-adjusted contractures quality score ranged from 19.0% to 31.6%; the average risk-adjusted pressure ulcer quality score ranged from 3.8% to 7.6%; and the average risk-adjusted psychoactive medication quality score ranged from 47.8% to 56.9%. Eleven states had quality measures better than the risk-adjusted expectation for at least four of the five measures, and eight states were worse than expected in at least four of the five. CONCLUSIONS: This study provides evidence that there is variation in quality indicators across states. These differences exist even after risk adjustment. their results may be important for state regulators trying to understand and improve quality.

This report is part of the RAND Corporation External publication series. Many RAND studies are published in peer-reviewed scholarly journals, as chapters in commercial books, or as documents published by other organizations.

Our mission to help improve policy and decisionmaking through research and analysis is enabled through our core values of quality and objectivity and our unwavering commitment to the highest level of integrity and ethical behavior. To help ensure our research and analysis are rigorous, objective, and nonpartisan, we subject our research publications to a robust and exacting quality-assurance process; avoid both the appearance and reality of financial and other conflicts of interest through staff training, project screening, and a policy of mandatory disclosure; and pursue transparency in our research engagements through our commitment to the open publication of our research findings and recommendations, disclosure of the source of funding of published research, and policies to ensure intellectual independence. For more information, visit

The RAND Corporation is a nonprofit institution that helps improve policy and decisionmaking through research and analysis. RAND's publications do not necessarily reflect the opinions of its research clients and sponsors.