State variability in indicators of quality of care in nursing facilities

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), we 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. We 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 fisk-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. Our results may be important for state regulators trying to understand and improve quality.