Nursing Home Quality and Disparities of Care
Alex Laberge, MBA, PT
Department of Health Services Research, Management & Policy
Project Team
University of Florida Robert Weech-Maldonado, Ph.D. Zhou Yang, Ph.D. Lloyd Dewald, MS
Texas A&M Christopher Johnson, Ph.D.
Collaboration with USF (Kathy Hyer, Ph.D.) and Florida State University (David McPherson, Ph.D.)
Acknowledgement: Supported in part by the Administration on Aging and the UCLA Center for Health Improvement
in Minority Elders (CHIME)/Resource Centers for Minority Aging Research, National Institute on Aging (AG-02-004)
Research Question Are there racial/ethnic and language
differences in the provision of nursing home stroke rehabilitation care after controlling for between-facility effects?
Stroke and Rehab Care Stroke
3rd leading cause of death Most common neurological reason for hospital
admission Leading cause of adult disability
Majority of stroke survivors need rehabilitation services that enhance their recovery and minimize their disability
Nursing Homes and Rehab Care Rehabilitation services offered through a variety
of acute and post-acute settings, such as hospitals, inpatient rehabilitation facilities, nursing homes, and home health agencies
Nursing homes increasingly expanding their role in the provision of rehabilitation care and post-acute care
Minorities make up 21% of those diagnosed with stroke in nursing homes in 2002
Medicare and Rehab Care Medicare the primary payer for post-acute
rehabilitation care in nursing homes Medicare provides 100% coverage of the first 20 days
and 80% of the next 80 days of eligible nursing home stays
Case-mix adjustment based on the Resource Utilization Group (RUG III) classification of a patient as reflected by the MDS
Rehabilitation RUG levels determined by the amount of therapy services. The incremental change in reimbursement between RUG levels is set so that a facility will benefit financially from providing more therapy
Racial/Ethnic Differences in Nursing Home Care
Prior research suggests the presence of racial/ethnic disparities in nursing home care Christian et al. (2003)- racial/ethnic minorities in
nursing homes less likely to receive medications for secondary prevention of stroke
Baumgarten et al. (2004)- Blacks had a higher incidence of nursing home acquired pressure sores
Racial/Ethnic Differences in Nursing Home Care
The observed racial/ethnic differences in nursing home quality of care may be a combination of Minorities receiving lower quality of care than Whites
within the same facility (within-facility differences) Minorities being clustered in facilities with lower
quality of care (between-facility differences). Prior research has found between-facilities disparities
in the nursing home industry E.g., Grabowski et al. (2004), Mor et al. (2004),
Smith et al. (2007)-segregation still exists in U.S. nursing homes with Blacks being much more likely to be placed in nursing homes with serious deficiencies, lower staffing ratios and greater financial vulnerability
Language Differences in Nursing Home Care ~ 47 million people in the U.S. speak a language
other than English at home, and over 21 million are limited English proficient (LEP) (US Census 2000)
Prior studies suggest that language barriers have a greater negative effect on patient experiences than race/ethnicity among Hispanics and Asians (Weech-Maldonado et al. 2001, 2003, and 2004)
3,279 (5.1%) of the nursing home stroke rehabilitation patients who had a MDS 14 day assessment had a language other than English as their first language.
Study Contributions To date there have been no studies examining
Within-facility differences Racial/ethnic differences in rehab care Language differences in nursing home care
Behavioral Model of Health Services Utilization (Andersen, 1998)
Predisposing
Enabling
Need
Utilization of Rehab Services
Data
2002 Nursing Home Minimum Data Set (MDS) 14-day Medicare MDS assessments
64,174 residents Sample limited to those with a stroke diagnosis,
whose care was paid by Medicare Part A Exclude hospital-based facilities Include only residents admitted from hospitals
Dependent Variables Therapy utilization for speech, occupational, and
physical therapy Number of minutes of therapy provided to the resident in
the 7-day observation period
Independent Variables Predisposing variables
Race/ethnicity and language White
English Non-English
Black Hispanic
English Spanish
Asian English Non-English
Age Gender
Enabling variables Support person Desire to be discharged Education BMI (> 30) Type of secondary insurance
Need variables (Stroke severity) Cognitive Performance
Scale ADL Function Scale
Analysis Two-part model of health services utilization of
rehabilitation services First part: logistic regression to estimate the probability of
any use of services within the population State fixed effects
Second part: multivariate regression analysis to predict utilization conditional on whether the enrollee used any rehab therapy services Facility fixed effects
Huber/White correction to account for potential correlation among observations from the same facility
Descriptive Statistics
Dependent Variables White
English(n=51713)
White Non-
English(n=987)
Hispanic
English(n=669)
Hispanic Spanish(n=1714)
Asian English
(n=255)
Asian
Non- English
(n=578)
Black(n=8640)
Speech 58.0 48.9 48.1 43.4 52.4 48.2 52.7F=14(0.00)
Physical Therapy 194.4 181.2 180.7 161.1 186.4 165.2 161.9
F=141 (0.00)
Occupational Therapy 170.6 154.7 158.1 133.5 155.4 138.5 145.9
F=104 (0.00)
Number of Minutes
Logistic Regression Results Odd Ratios (Confidence Intervals)
Compared to English speaking Whites; *p< 0.10 **p<0.05 ***p<0.01
Race/Ethnicity Physical Therapy OccupationalTherapy
Speech Therapy
White Non English
0.94(0.76- 1.16)
0.94(0.78-1.13)
1.05(0.90-1.23)
Hispanic English
0.94(0.74- 1.19)
0.94(0.76- 1.16)
0.86(0.72-1.04)
Hispanic Spanish
0.67***(0.53 – 0.84)
0.69***(0.56-0.86)
0.62***(0.50-0.76)
Asian English 0.92(0.62- 1.38)
0.87(0.61-1.24)
0.88(0.65- 1.20)
Asian Non English
0.75*(0.54- 1.04)
0.87(0.65-1.17)
0.73**(0.56- 0.96)
Black 0.77 ***(0.71- 0.84)
0.87***(0.80-0.93)
0.81***(0.75- 0.86)
Results
White English speakers have greater odds of receiving therapy services when compared to Black, Hispanic Spanish and Asian Non-English nursing home residents with stroke
30% greater odds for PT, 15% greater odds for OT, and 23% greater odds for ST than Blacks
49% greater odds for PT, 45% greater odds for OT, and 61% for ST than Hispanic Spanish
33% greater odds for PT and 37% greater odds for ST than Asians
Predicted Therapy Utilization (Minutes)
Dependent Variables
White
English
White
Non-
English
Hispanic
English
Hispanic
Spanish
Asian
English
Asian
Non-
English Black
Physical Therapy 199.2 197.1** 197.1** 193.4** 197.3* 191.7** 192.4**
Occupational Therapy 175.8 174.7* 172.0** 169.5** 178.8** 172.1** 169.0**
SpeechTherapy 67.4 68.2* 59.2** 50.2** 63.3** 53.9** 58.6**
*p<0.01**p<0.001
Results Racial/ethnic minorities with stroke generally received
less therapy minutes than White English speakers in nursing homes across all therapy types
Among Hispanics, Asians, and Whites, non-English speakers generally received less therapy minutes than their English counterparts
Examples Blacks received 7 minutes less PT, 7 minutes less OT, and 9
minutes less ST Hispanic Spanish speakers received 6 minutes less PT, 6
minutes less OT, and 17 minutes less ST Asian non-English speakers received 8 minutes less PT, 4
minutes less OT, and 14 minutes less ST
Conclusions Racial/ethnic and language minorities are less likely to
receive any rehabilitation service among Medicare nursing home residents with stroke
Of those who actually receive some rehabilitation service, minorities tend to receive less therapy minutes even after controlling for between-facility effects, as well as predisposing, enabling and need factors
Nursing homes should address the observed racial/ethnic and language differences in processes of care as part of their quality improvement efforts
Future Research Causes for the observed racial/ethnic and language
differences in the use of rehabilitation services Lack of racial/ethnic and language concordance
between residents and therapists Lack of access to interpreter services Differences in health beliefs or cultural preferences Systemic bias
Impact of the observed lower utilization of nursing home rehabilitation therapies on outcomes of care among racial/ethnic and language minorities with stroke Walk improvement ADL improvement