Nursing Homes Underreport Falls Requiring Hospitalization

Diana Swift

January 14, 2020

Finding a safe nursing home for your loved one may be harder than you think. It appears that data used to assess the safety and quality of nursing homes across the country are inaccurate, thanks to systemic underreporting of residents' serious fall-related injuries.

That finding emerges from a comparison of Medicare hospital inpatient claims to a Minimum Data Set (MDS) assessment provided by nursing homes. Of 150,828 Medicare hospital claims for major injury falls, nursing homes reported just 57.5% on the MDS measurement item used by Nursing Home Compare (NHC), a resource that Medicare.gov provides for patients.

The study by Prachi Sanghavi, PhD, assistant professor of public health sciences, the University of Chicago, Illinois, and colleagues was published online December 29 in Health Services Research.

Launched by the Centers for Medicare & Medicaid Services in 1998, NHC collects patient safety data using information self-reported by nursing homes. These data allow comparisons of the quality of care at more than 15,000 Medicare- and Medicaid-certified US nursing homes.

"The accuracy of these data has long been a concern to academics and policy makers, based on inconsistencies with measures from other sources and small validation exercises," the authors write.

In other notable disparities, the analysis reveals a racial divide: serious-injury falls by white residents were reported more often than falls by nonwhite residents (black, Hispanic, Asian, and other race/ethnicity): 59% vs 46.4%. And whereas 62.9% of such falls were reported for long-stay residents on the MDS item, only 47.2% were reported for their short-stay counterparts. The reporting rate was highest for long-stay white residents, at 64.5%, and was lowest for short-stay nonwhite residents, at 37.4%.

Underreporting Worse for Underserved Populations

The investigators reviewed records of Medicare claims for fall injuries serious enough to warrant hospitalization from 2011 to 2015. They compared these data to contemporaneous assessments submitted to MDS by care providers.

The relevant MDS item, JI900C, stipulates that if a nursing home resident is admitted to the hospital with a major injury after a fall, the nursing home should report the fall under J1900C on a discharge assessment.

The correlation between fall rates based on 2014 Medicare claims vs those on MDS was just 0.22. Similarly, correlations were weak between claims-based fall rates and the NHC's five-star quality-rating system: 0.05

"The poor correlation between our claims-based fall rates and the MDS-based NHC-reported fall rates indicates the MDS not only underreports but also may not be informative for comparing nursing homes," Sanghavi and associates write.

The investigators note that a 1986 Institute of Medicine report warned that in many nursing homes, the quality of care fell seriously short. Since the 1990s, federal efforts at improving the quality of care have focused on the NHC public reporting initiative.

"Our study indicates an urgent need to assess the value and limits of patient safety measurement that is based on the MDS," the authors write.

Furthermore, in light of the amount of research that is based on the MDS, the current understanding of nursing home quality of care should be reexamined. "For example, given underreporting was worse for underserved populations in our analysis, disparities in these settings may currently be poorly estimated," the investigators write.

They call for the development of alternative approaches to monitoring and measuring patient safety in these facilities.

The research was funded by the Agency for Healthcare Research and Quality. The authors have disclosed no relevant financial relationships.

Health Serv Res. Published online December 29, 2019. Full text

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