Study reveals that patient care is better in nonprofit nursing homes than in for-profit nursing homes

A major new statistical review of 82 individual research studies has revealed that nonprofit nursing homes deliver, on average, higher quality care than for-profit nursing homes. The findings could have a bearing on the present debate about the role of for-profit firms in U.S. health reform.

"The results are unequivocal and completely consistent with other studies comparing for-profit versus nonprofit care," said Dr. Gordon Guyatt, senior author of the study, professor of medicine at McMaster University in Hamilton, Canada, and a world leader in "evidence-based medicine," a term he coined. The study was published in the online edition of the British Medical Journal earlier this month.

The authors' systematic review compared quality-of-care measurements in 82 individual studies that collected data from 1965 to 2003 involving tens of thousands of nursing homes, mostly in the United States.

In 40 of the 82 studies, all statistically significant comparisons favored nonprofit facilities. In three studies, all significant comparisons favored for-profit facilities. The remaining studies had less consistent findings.

The authors' meta-analysis, i.e. their integration and statistical analysis of the data from the multiple studies, shows that nonprofit facilities delivered higher quality care than for-profit facilities for two of the four most frequently reported quality measures: (1) more or higher quality staffing and (2) less prevalence of pressure ulcers, sometimes called bedsores.

The results also suggest better performance of nonprofit homes in two other quality measures: less frequent use of physical restraints and fewer noted deficiencies (quality violations) in governmental regulatory assessments.

"The reason patients' quality of care is inferior in for-profit nursing homes is that administrators must spend 10 percent to 15 percent of revenues satisfying shareholders and paying taxes," said Guyatt. "For-profit providers cut corners to ensure shareholders achieve their expected return on investment."

About 1.5 million people reside in nearly 16,000 nursing homes in the United States, and more than 3 million Americans will spend at least some time in a nursing home this year, according to the U.S. Centers for Medicare and Medicaid Services. About two-thirds of U.S. nursing home residents live in for-profit facilities.

The findings have significant patient-care implications. For example, the study suggests that of the estimated 80,000 U.S. nursing home residents who presently have bedsores, 7,000 of these cases are attributable to for-profit ownership. Similarly, the results suggest U.S. residents would receive about 500,000 more hours of nursing care per day if nonprofit institutions replaced for-profit nursing homes.

While most of the data in the studies are from U.S. nursing homes, data from Canada and Taiwan were also reviewed. Results were consistent over time.

The authors note that the results are entirely consistent with other studies. Systematic reviews of the evidence have previously shown higher death rates in for-profit versus nonprofit hospitals, and in for-profit versus nonprofit dialysis facilities. Such reviews have also shown higher costs in for-profit hospitals. Studies of outpatient care have shown higher quality of care in not-for-profit settings.

"Our results should raise serious concerns about for-profit care, whether in nursing homes, hospitals, surgi-centers, or other outpatient facilities," Guyatt said. "It is time to base health care policy on evidence, not ideology."

"Quality of care in for-profit and not-for-profit nursing homes: systematic review and meta-analysis," Vikram R Comondore, P J Devereaux, Qi Zhou, Samuel B Stone, Jason W Busse, Nikila C Ravindran, Karen E Burns, Ted Haines, Bernadette Stringer, Deborah J Cook, Stephen D Walter, Terrence Sullivan, Otavio Berwanger, Mohit Bhandari, Sarfaraz Banglawala, John N Lavis, Brad Petrisor, Holger Sch-nemann, Katie Walsh, Neera Bhatnagar, and Gordon H Guyatt. BMJ 2009;339:b2732, doi: 10.1136/bmj.b2732, Aug. 4, 2009.

A copy of the study can be found here: www.pnhp.org/nursing_home

www.mcmaster.ca