what evidence do i need to show nursing home is not providing care

• Loading metrics

Open up Access

Policy Forum

Policy Forum Policy Forum articles provide a platform for wellness policy makers from effectually the world to discuss the challenges and opportunities in improving wellness care to their constituencies.

Meet all article types »

Observational Evidence of For-Profit Commitment and Junior Nursing Habitation Care: When Is There Enough Show for Policy Change?

• Lisa A. Ronald,
• Margaret J. McGregor,
• Charlene Harrington,
• Allyson Pollock,
• Joel Lexchin

x

• Published: April 19, 2016
• https://doi.org/10.1371/journal.pmed.1001995

Figures

Commendation: Ronald LA, McGregor MJ, Harrington C, Pollock A, Lexchin J (2016) Observational Prove of For-Profit Delivery and Junior Nursing Home Care: When Is At that place Plenty Testify for Policy Change? PLoS Med 13(four): e1001995. https://doi.org/x.1371/journal.pmed.1001995

Published: April xix, 2016

Copyright: © 2016 Ronald et al. This is an open admission article distributed nether the terms of the Creative Eatables Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: This enquiry was financially supported by the Social Sciences and Humanities Research Council. The funders had no role in study pattern, data drove and analysis, decision to publish, or grooming of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Abbreviations: CI, conviction interval; HMOs, Health Maintenance Organizations; MDS, Minimum Information Set; RCTs, randomized controlled trials

Provenance: Non commissioned; externally peer-reviewed

Summary Points

• Nursing home residents are a highly vulnerable population, and nursing domicile care quality has been a persistent focus of public business concern.
• There is considerable evidence from observational studies that public funding of care delivered in for-profit facilities is inferior to care delivered in public or nonprofit facilities.
• The by decade has seen many industrialized countries increasing governmental payment for intendance of frail seniors in for-profit nursing homes, leading to questions about whether this leads to inferior care.
• Many of Bradford Hill's guidelines for causation can be found in published studies supporting a causal link betwixt for-turn a profit buying and inferior care.
• The precautionary principle should be practical when developing policy for this fragile and vulnerable population.

Introduction

Nursing homes, also called residential long-term care facilities or aged care homes, are regulated institutions providing effectually-the-clock medical and social care to (mainly) older people who are unable to alive independently due to physical and/or mental disability. Because of the vulnerability of this population and frequent media reports of scandals beyond many industrialized countries [1], nursing home care quality has been a persistent focus of public concern.

Inserted into the discourse on quality has been a trend in many countries to contract care to for-profit–endemic facilities, and there has been considerable endeavor by researchers to empathise the affect of for-turn a profit ownership on care quality. Inquiry into this expanse is not new [2]. O'Brien and colleagues asked the question in a 1983 review in which they included several U.s. studies going back to 1968 [iii]. All the same, recent examples such as the 2011 failure of the largest United Kingdom private disinterestedness nursing home chain, Southern Cross [4], and a report in 2000 that the 5 largest US nursing domicile chains operated under bankruptcy protection [5], have brought this policy question to the forefront.

The result has particular relevance at this time every bit jurisdictions are challenged to intendance for an increasing number of very fragile people over the next two decades [6]. Fifty-fifty with policies to aggrandize care at habitation, it is likely that many countries will require the construction of new nursing home beds [7].

In this paper, we evaluate the prove for an association betwixt for-profit ownership and inferior care, using Bradford Colina's framework for examining causation in observational inquiry. We further frame the issue in terms of the precautionary principle, request, "At what betoken is it is time to shift policy direction based on the bachelor evidence?"

Trends in Nursing Dwelling Ownership and Care Delivery in Industrialized Countries

Nursing homes can exist owned and operated by public (regime or quasi-governmental), nonprofit, or for-turn a profit entities, with differences among countries in financing, regulation, and mix of ownership. Box 1 describes a taxonomy of unlike ownership types. Regardless of the buying and commitment of nursing home intendance, the majority of funding for nursing domicile intendance in industrialized countries comes from public sources [8].

Box 1. Taxonomy of Nursing Dwelling house Ownership

Public ownership: facilities endemic by authorities or quasi-governmental bodies. Municipal governments, health regions, and Veterans Diplomacy would be examples of public and quasi-public owners.

Nonprofit ownership: nongovernmental ownership past religious or community groups or agencies, in which the facilities they operate are run as nonprofit societies. A nonprofit order or entity is constituted with the assumption that any revenue in excess of expenses volition be used to benefit its clients.

For-profit facilities: owned and operated every bit businesses. Here it is assumed that revenue in backlog of expenses can be directed to the owners—or, in the case of shareholder-endemic companies, to shareholders. They include both small provider-owned facilities and large corporate chains whose headquarters are not necessarily in the province, or even the state, where they operate. The stardom between provider ownership and corporate ownership tin be important: when facility owners are also care providers, it is fair to expect that—at to the lowest degree theoretically—their professional person obligation balances the sometimes conflicting motivations of generating profit and providing good-quality care.

Table ane summarizes trends in nursing dwelling ownership beyond a range of years and countries. In the Uk in 2012, 78% of residential care beds were in for-profit–endemic facilities, a ten% increment from 2007 [9]. In Australia, roughly 1-third of nursing home beds are owned by private for-profit companies [ten]. In New Zealand, a survey of New Zealand Care Association members reported that approximately two-thirds of nursing homes were for-turn a profit, a tendency that was increasing [eleven]. In the United states, more than ii-thirds of beds are for-turn a profit, with more than than half owned past corporate chains [12,xiii].

The past decade has besides seen the movement of private equity and other investor-owned firms into the nursing home sector, in both the US and other industrialized countries [4,thirteen,16]. Some accept termed this a "caretelization" of the nursing habitation industry, whereby large corporate providers have gained greater market share through the process of mergers, acquisitions, and takeovers [4].

Evaluating the Observational Evidence Using Bradford Hill'due south Guidelines

In that location are challenges to measuring care quality (Box 2). Still, three systematic reviews have concluded that for-turn a profit nursing homes had poorer care quality than nonprofit-owned homes [17–xix]. A big meta-analysis found that two of four outcomes were significantly superior in nonprofit compared to for-profit homes [17]: more than or college quality staffing (ratio of outcome 1.xi, 95% confidence interval [CI]: ane.07 to 1.xiv), and lower pressure ulcer prevalence (0.91, 95% CI: 0.83 to 0.98). Non-pregnant results were found for the ii other outcomes: fewer deficiencies in governmental regulatory assessments (0.ninety, 95% CI: 0.78 to 1.04) and lower physical restraint use (0.93, 95% CI: 0.82 to 1.05). The authors estimated that residents would receive 42,000 and 500,000 additional hours of nursing care per year, and have 600 and 7,000 fewer pressure ulcers in Canada and the U.s., respectively, if these services were provided solely past nonprofit facilities [17]. In forty of the 82 studies reviewed, all statistically significant measures of quality favored nonprofit facilities, compared to only three studies in which all measures favored for-turn a profit facilities [17].

Box ii. How Is Care Quality Measured in Nursing Homes?

Measurement of care quality in nursing homes is multidimensional, with numerous definitions, a vast range of indicators, and no aureate standard for measurement [20,21]. Examples of different quality indicators include structural (such equally staffing levels and training), procedure (such as inspection violations, continuity of intendance, prevalence of daily physical restraints, and indwelling catheters), and outcome indicators (such equally prevalence of pressure sores, urinary tract infections, avoidable hospital admissions and dehydration) [20]. There is also growing recognition that, beyond staffing measures, in that location has been fiddling progress in measuring resident- and family-reported experience of care [22,23], which is arguably one of the most meaningful measures in this population [23].

While no unmarried indicator represents the overall quality of a nursing domicile, a disadvantage of using multiple quality indicators is that findings can be inconsistent [24]. A detection bias tin besides occur whereby rates of adverse outcomes may exist higher in nursing homes or jurisdictions that actively "look for" problems [24]. Pocket-size numbers of events and small-scale average facility size can limit the power of statistical analyses to find an effect [24]. This can lead to wide confidence intervals around estimates and conclusions that observed trends are not statistically pregnant [24]. Confounding can as well consequence when comparing indicators between facilities, since patient case mix can vary between facilities [24]. Finally, many nursing homes are measured on self-reported indicators, leading to potential reporting bias for some indicators.

An editorial accompanying the above-described meta-analysis implied that the observational evidence is too weak for policy decisions, and that because of the impossibility of conducting randomized controlled trials of turn a profit versus nonprofit status, causation cannot be proven [25]. This brings us to a theoretical debate nearly how nosotros determine a link is causal when all nosotros have, and all nosotros are ever likely to have, is evidence from observational studies.

We employ the Bradford Hill framework to appraise whether there is sufficient evidence to suggest causation [26]: the presence of plausibility, temporality, experiment, dose-response, coherence, analogy, consistency, magnitude of effect, and specificity (Box 3):

Box three. Bradford Colina's Guidelines for Assessing Causation

Information technology is unremarkably accepted that high-quality randomized controlled trials (RCTs) are able to overcome bias and confounding and, therefore, superlative the evidence bureaucracy to provide sufficient evidence to establish a causal link betwixt exposure and issue [27]. However, properly conducted RCTs in many areas are rare—trials can be underpowered, unsuccessfully blinded, and suffer from undetected biases [27]. Furthermore, not all research questions tin be investigated using RCTs. In the case of nursing homes, information technology would exist neither ethical nor viable to randomly assign facility buying or care delivery to for-profit versus public or nonprofit status. Thus, we rely on observational studies to evaluate the relationships between quality of intendance and ownership, in which we observe rather than assign exposures. Criticisms of observational studies, however, are that they are more prone to bias and confounding.

Some suggest that guidelines for causation can be a useful tool for assessing if at that place is sufficient evidence before concluding causation [27]. The British epidemiologist, Sir Austin Bradford Hill, developed guidelines to evaluate evidence for a causal event [26]. These guidelines, offset published in 1965, in part to address the link betwixt tobacco and lung disease, provide a useful framework for assessing evidence for a causal effect. Specifically, Bradford Hill suggested that nine relevant factors should be considered before concluding causation [26]:

Plausibility: The crusade-and-effect interpretation of an clan should fit with the known facts of the natural history and biology of the disease.

Temporality: A necessary criterion for a causal association is that the exposure must precede the outcome.

Experiment: Causation is more probable if evidence is based on randomized experiments.

Biological gradient or dose-response: The likelihood of a causal association is increased if a dose-response bend tin be demonstrated.

Coherence: A causal determination should not contradict nowadays noun knowledge.

Analogy: For coordinating exposures and outcomes, an issue has already been shown.

Consistency: A relationship is observed repeatedly, prospectively and retrospectively, in different populations.

Forcefulness of the association: Strong associations are more probable to be causal than weak associations.

Specificity: If an association is limited to specific groups with a particular environmental exposure or is greatly increased in these groups, then the instance for a causal association is strengthened.

Plausibility

All nursing homes must balance their revenues and expenses in gild to survive. For-profit organizations operate on the principle that profits or net income (acquirement in excess of expenses) is directed to the owners, investors, or shareholders [28]. In nonprofit organizations and publicly owned facilities, net income is used to do good clients [28].

O'Neill describes the merchandise-off between turn a profit and quality: "If increasing quality raises costs more than apace than it does revenues, profits must autumn as quality improves" [29]. In order to generate profits, for-profit homes tend to have lower costs and lower staff-to-patient ratios than nonprofit facilities [30]. Money diverted to shareholders and investors leaves less money to pay for staff, and in turn, having fewer or untrained staff is associated with lower quality [31–34].

The lower level of staffing with for-profit buying [17,18] stands in contrast to the well-established association betwixt college levels of total nursing and registered nursing staff and better care outcomes [31–34]. Nurse staffing levels take a positive impact on both the process and the outcomes of nursing home care, such as reduced resident time in bed, improved feeding assistance, incontinence care, exercise and repositioning [33], fewer regulatory deficiencies [35], and lower rates of force per unit area ulcers [17]. College staffing levels are associated with lower staff turnover [36]—a pre-status for good relational care, which in turn is associated with improved quality of life [23] (i.east., relational care embraces the unabridged relationship between caregiver and intendance recipient, encompassing the concrete, social, emotional, and spiritual dimensions of human connection [37,38]). In a The states study, the largest ten for-turn a profit chains had lower registered nurse and full nurse staffing hours and a 41% higher number of serious deficiencies than government facilities, controlling for other factors [30].

A second plausible machinery proposed for the "for-turn a profit" result of inferior outcomes is that for-profit facilities have a lower threshold for transferring acutely ill residents to acute intendance facilities [39–42]. This higher rate of apply of acute services (emergency department visits and hospital admissions) among residents in for-profit facilities has been a consistent finding and is thought to exist in part related to avoidance of the college costs associated with caring for acutely ill residents [39–42]. Hospital admission for nursing home residents is considered a poor outcome considering information technology puts these residents at risk of iatrogenic infections [43], falls, delirium, and turn down in functional condition and quality of life [44]. Furthermore, there is at present some evidence that illnesses such as pneumonia can be equally well managed within the facility [45].

A third plausible mechanism for the association of nonprofit and/or public facilities with improved quality of care may exist related to their ability to go charitable foundations. In many jurisdictions, this status provides tax breaks and makes them better positioned to mobilize volunteers and solicit donations for equipment [46].

In ideal market place conditions, residents' should exist able to "go out" (leaving the facility) or use "phonation" (complaining) [47]. However, the loftier degree of vulnerability of the nursing dwelling house population and the information asymmetry required for meaningful choice brand these ineffective as counterbalances to behaviors that sacrifice quality [48,49].

Temporality

Temporality has been investigated in several studies by examining conversions between ownership types. Longitudinal observational research from the US [50] and Sweden [51] has institute that nursing homes converting to for-profit ownership demonstrated a subsequent decline in some quality measures. Nursing homes converting from for-profit to nonprofit status more often than not exhibit comeback both before and after conversion [52]. A major challenge to such research is the potentially confounding consequence of unmeasured differences in nursing homes that choose to convert [l] compared to those who do non.

Experiment

While information technology is unlikely that experimental evidence from randomized trials will always exist available to compare nursing habitation ownership and quality, two US studies [39,xl] have recently used a method (instrumental variables analysis) that mimics randomization. This approach tin estimate causal relationships when it is not possible to conduct a randomized trial.

The two studies examined a national cohort of newly admitted residents to curt- [39] and long-stay facilities [twoscore], including almost fourteen,000 United states of america nursing homes. Data were drawn from national standardized clinical information (Minimum Data Set up, MDS) linked to Medicare claims over an 18-month period betwixt 2004 and 2005. Authors mimicked randomization of residents into more or less "exposure" to nonprofit homes by using "differential altitude" to the nearest nonprofit nursing abode relative to the nearest for-profit nursing home. Both studies found higher rates of infirmary admissions and 1 study [39] demonstrated inferior outcomes for mobility, hurting, and part measures among residents living in for-profit facilities compared to nonprofit facilities. The authors ended that the observed effects were likely causal and could not be explained by unmeasured differences in case mix between facilities with different ownership structures.

Dose-Response Outcome

A gradient effect betwixt profit margins and United states of america nursing home inspection violations has been reported [29]. O'Neill and colleagues examined 952 for-turn a profit facilities in California to assess the relationship between profit and the number of full and serious deficiencies reported past regulatory inspectors. Authors divided facilities into four profit categories from the lowest to the highest turn a profit group. After controlling for resident case mix and other facility and market characteristics, the authors found the highest turn a profit group had significantly more total deficiencies than those in the second-highest profit grouping. They likewise constitute that facilities in the highest profit group had significantly more serious deficiencies than the three lower turn a profit groups, suggesting an changed gradient (dose-response) issue of profit on quality [29].

Coherence, Analogy, and Consistency

Parallel studies have found for-profit services in sectors other than residential long-term intendance to be of junior quality, including hemodialysis centers [53] and Health Maintenance Organizations (HMOs) [54]. Outside of the health sector, studies looking at the daycare sector in Canada [55,56] accept plant a like quality gap between for-profit and nonprofit ownership.

The majority of studies evaluating nursing dwelling house ownership and care quality have used US data [17], where the distinction is typically between private for-turn a profit and nonprofit. Studies have too reported the association between for-profit status and junior intendance when compared to either nonprofit or public models in other countries, including Canada [57–60], Israel [61], and Australia [62]. While nearly studies are from industrialized, high-income countries, nosotros detect no reason to expect that testify from low- and heart-income countries would be different.

Forcefulness of the Association

The differences reported in observational studies associated with for-profit condition have generally not been big (with reported relative risks between 1 and 2) [17]. However, the magnitudes of effect are often small in studies of health intendance interventions, reflecting the implementation of interventions within complex systems [63].

Specificity

This term refers to the causative agent resulting in very specific furnishings. This criterion is more relevant to a biomedical (versus a health systems or policy) paradigm—for instance, the assumption that mesothelioma, a very specific type of lung cancer, is simply seen when an individual has been exposed to asbestos [64]. While the concept is of limited application in the health policy arena, the strongest empirical evidence exists for the association of for-turn a profit status and lower staffing levels. Since the number of staff hired is as well the almost costly line detail with the greatest likelihood of affecting profit, 1 might argue that there is some degree of specificity to the association.

Nursing Homes Are Complex Adaptive Systems and Context "Matters"

Nursing homes are complex adaptive systems [65], and wellness policy research, unlike biomedical inquiry, is unlikely to observe one causal link to any system-level outcome. The clan between for-profit ownership and inferior care is not a simple one.

In predominantly for-profit environments, some not-for-profit groups, despite their mandate, operate more every bit competitive market entities, with the focus oftentimes shifting towards increasing revenues at the expense of quality. Conversely, in jurisdictions dominated by the nonprofit or public sector, overall quality for the whole region is generally establish to be ameliorate, including care delivered in for-profit nursing homes [66]. One interpretation is that the predominantly public sector raises the bar for all facilities, thus mitigating the effect of profit-making on quality. Such findings, rather than refuting the plausibility of the observed association, speak to various predisposing and mitigating contextual factors.

Additionally, where comparisons of quality take subdivided nonprofit ownership into governmental (publicly owned) and nonprofit groups, in that location is often a bureaucracy of outcomes, whereby public models are superior to both for-turn a profit and nonprofit models and for-profit models are junior to public and nonprofit owned organizations [58,67,68].

When Is There Sufficient Evidence for Policy Change?

Bradford Hill did not prescribe these guidelines equally rules that must exist fulfilled before an association can be judged every bit causal, but every bit a way of examining if cause and outcome is the reasonable inference [69]. In the current instance, some of the Bradford Hill criteria are clearly met, while others are less clear.

At the very to the lowest degree, the precautionary principle should apply to this highly vulnerable nursing domicile population. The precautionary principle shifts the fence by calling for preventive action, fifty-fifty when there is dubiousness but credible testify of potentially meaning impacts. This shift in brunt of proof is based on the obvious premise that harms to the public'due south health should be avoided and that gild should not have to look for conclusive evidence before acting to protect itself [70]. Taking a precautionary approach emphasizes our responsibility to enquire, when do nosotros know plenty to act equally if something is causal? [71]

What Are the Policy Challenges?

The policy response to the show on facility ownership clearly depends on jurisdictional context. In jurisdictions contemplating construction of new nursing habitation beds, policy makers need to support public and nonprofit facility ownership. Possible policy approaches include the sale of government savings bonds to raise public funds for upper-case letter construction [72], providing back up to nonprofit societies with the necessary expertise for them to brand competitive bids on requests for proposals, and valuing social capital and links with the community in the bidding process [seven].

All jurisdictions should require public funding be earmarked and spent on mandated minimum direct intendance staffing levels consistent with the evidence, with no discretion for facilities to re-directly this money to other monetary items (including profit generation). In countries where a majority of facilities are endemic by big for-profit chains, proposed "downstream" policy approaches include improved fiscal transparency of how public resources are spent and the adoption of cost controls on assistants [73]. Unfortunately, these approaches are costly to implement [74].

Decision-makers accept a responsibility to ensure nursing home public policy is most consistent with the bachelor bear witness and least likely to cause harm. The majority of funding to operate and evangelize intendance in nursing homes is derived from public, taxpayer-funded sources. When provided past the for-turn a profit sector, the prove suggests there is a greater likelihood of inferior care. It is fourth dimension to re-marshal policy with evidence. Our seniors deserve meliorate.

Supporting Information

Acknowledgments

This inquiry was role of the collaborative research initiative "Re-imagining Long-Term Residential Intendance: An International Report of Promising Practices," with Chief Investigator Pat Armstrong. We would similar to admit Louise O'Neill and Ning Ping Yu for translating the Summary Points section to French and Chinese, respectively. We thank Michelle Cox for administrative assistance.

Author Contributions

Wrote the first draft of the manuscript: LAR MJM. Contributed to the writing of the manuscript: LAR MJM. Agree with the manuscript'due south results and conclusions: LAR MJM CH AP JL. Provided feedback and comments on all drafts: CH AP JL. All authors accept read, and confirm that they meet, ICMJE criteria for authorship.

References

1. 1. Lloyd 50, Banerjee A, Harrington C, Jacobsen F, Szebehely Yard. It's A Scandal! Comparison the Causes and Outcome of Nursing Home Media Scandals in 5 Countries. International Journal of Sociology and Social Policy 2014;34(i/2):two–18.
   • View Article
   • Google Scholar
2. 2. Constitute of Medicine (US) Committee on Implications of For-Turn a profit Enterprise in Health Intendance. Affiliate 6: Quality of Care. Cover of For-Profit Enterprise in Health Care For-Profit Enterprise in Health Care. In: BH Chiliad, ed.: Washington (DC): National Academies Press (US), 1986.
3. 3. O'Brien J, Saxberg BO, Smith HL. For-turn a profit or not-for-profit nursing homes: does it affair? The Gerontologist 1983;23(4):341–eight. pmid:6352419
   • View Commodity
   • PubMed/NCBI
   • Google Scholar
4. 4. Scourfield P. Caretelization revisited and the lessons of Southern Cross. Disquisitional Social Policy 2012;32 (1):137–48.
   • View Article
   • Google Scholar
5. 5. U.S. Full general Bookkeeping Office. Nursing Homes: Aggregate Medicare Payments Are Adequate Despite Bankruptcies. Testimony earlier the Special Committee on Aging, U.South. Senate. GAO/T-HEHS-00-192. Washington, DC, September five, 2000 (accessed October 26, 2014).
6. 6. Jagger C, Collerton JC, Davies K, Kingston A, Robinson LA, Eccles MP, et al. Adequacy and dependency in the Newcastle 85+ accomplice written report. Projections of future care needs. BMC geriatrics 2011;11:21. pmid:21542901
   • View Article
   • PubMed/NCBI
   • Google Scholar
7. 7. McGregor Yard, Ronald L. Residential Long-Term Intendance for Canadian Seniors: Not-turn a profit, For-profit or Does information technology Matter? (Rep. No. xiv). Montreal: IRPP Plant for Research in Public Policy., 2011.
8. viii. Canadian Found for Health Information. Exploring The 70:thirty Split: How Canada'southward Health Care System is Financed. 2005. https://secure.cihi.ca/estore/productFamily.htm?pf=PFC588&lang=fr&media=0 (accessed October 26, 2014).
9. ix. Grant Thornton. Residential elderly care UK sector review pp. 1–24. http://world wide web.grant-thornton.co.u.k./Documents/Private-Residential-Elderly-Care-Great britain-sector-review.PDF (Accessed March xviii, 2016). 2014.
10. 10. Australian Authorities, Productivity Commission. Trends in Aged Intendance Services: some implications. http://www.pc.gov.au/__data/assets/pdf_file/0004/83380/aged-care-trends.pdf. September 2008, pp. 1–267. Accessed March 18, 2016.
11. 11. Grant Thornton New Zealand Ltd. Aged Residential Care Service Review. September 2010, pp i–222. http://www.grantthornton.co.nz/avails/documents/home/anile-residential-care-service-review.pdf (accessed March eighteen, 2016)
12. 12. Harrington C, Carrillo H, Blank BW. Nursing Facilities, Staffing, Residents, and Facility Deficiencies, 2003–08. University of California, San Francisco. pp 1–146. http://theconsumervoice.org/uploads/files/issues/OSCAR_complete_2009.pdf (Accessed February 21, 2015). 2009.
13. 13. Harrington C, Hauser C, Olney B, Rosenau PV. Ownership, financing, and management strategies of the ten largest for-profit nursing dwelling house bondage in the The states. International journal of health services: planning, administration, evaluation 2011;41(4):725–46.
    • View Article
    • Google Scholar
14. 14. Canadian Union of Public Employees. Residential Long-Term Care in Canada: Our Vision for Better Seniors' Care. Oct 2009 (with updated appendix in 2011). pp 1–101. http://cupe.ca/residential-long-term-care-canada-our-vision-better-seniors-care (Accessed Feb 21, 2015).
15. 15. Marketisation in Nordic Eldercare: A Research Study on Legislation, Oversight, Extent and Consequence. Stockholm University. pp. i–289. Editors: Gabrielle Meagher and Marta Szebehely. http://www.normacare.cyberspace/wp-content/uploads/2013/09/Marketisation-in-nordic-eldercare-webbversion-med-omslag1.pdf (Accessed February 21, 2015).
16. 16. Lakhani N, Whittell R. Who owns the care homes—and why are they then in debt? The Independent. Monday 05 November 2012.
17. 17. Comondore VR, Devereaux PJ, Zhou Q, Stone SB, Busse JW, Ravindran NC, et al. Quality of care in for-profit and non-for-profit nursing homes: systematic review and meta-analysis. BMJ 2009;339:b2732. pmid:19654184
    • View Article
    • PubMed/NCBI
    • Google Scholar
18. xviii. Hillmer MP, Wodchis WP, Gill SS, Anderson GM, Rochon PA. Nursing home profit status and quality of care: is there any evidence of an association? Medical Care Enquiry and Review 2005;62(two):139–66. pmid:15750174
    • View Article
    • PubMed/NCBI
    • Google Scholar
19. 19. Xu D, Kane RL, Shamliyan TA. Effect of nursing home characteristics on residents' quality of life: a systematic review. Archives of Gerontology and Elderliness 2013;57(2):127–42. pmid:23623273
    • View Article
    • PubMed/NCBI
    • Google Scholar
20. xx. Castle NG, Ferguson JC. What is nursing dwelling quality and how is it measured? The Gerontologist 2010;fifty(four):426–42. pmid:20631035
    • View Commodity
    • PubMed/NCBI
    • Google Scholar
21. 21. Spilsbury Yard, Hewitt C, Stirk 50, Bowman C. The relationship betwixt nurse staffing and quality of care in nursing homes: a systematic review. International Periodical of Nursing Studies 2011;48(6):732–l. pmid:21397229
    • View Article
    • PubMed/NCBI
    • Google Scholar
22. 22. Kane RA, Kling KC, Bershadsky B, Kane RL, Giles K, Degenholtz HB, et al. Quality of life measures for nursing home residents. The journals of gerontology. Series A, Biological sciences and medical sciences 2003;58(3):240–viii. pmid:12634291
    • View Article
    • PubMed/NCBI
    • Google Scholar
23. 23. Ramage-Morin P. Successful crumbling in healthcare institutions. Statistics Canada 2006;Written report # 82–003.
24. 24. Mor V, Berg K, Angelelli J, Gifford D, Morris J, Moore T. The quality of quality measurement in U.S. nursing homes. The Gerontologist 2003;43 Spec No 2:37–46. pmid:12711723
    • View Commodity
    • PubMed/NCBI
    • Google Scholar
25. 25. Konetzka RT. Do not-for-profit nursing homes provide better quality? BMJ 2009;339:b2683. pmid:19654183
    • View Commodity
    • PubMed/NCBI
    • Google Scholar
26. 26. Colina AB. The Environs and Illness: Association or Causation? Proceedings of the Royal Society of Medicine 1965;58:295–300. pmid:14283879
    • View Article
    • PubMed/NCBI
    • Google Scholar
27. 27. Howick J, Glasziou P, Aronson JK. The evolution of evidence hierarchies: what can Bradford Colina's 'guidelines for causation' contribute? Periodical of the Majestic Social club of Medicine 2009;102(five):186–94. pmid:19417051
    • View Article
    • PubMed/NCBI
    • Google Scholar
28. 28. Weech-Maldonado R, Laberge A, Pradhan R, Johnson CE, Yang Z, Hyer M. Nursing home financial performance: the role of ownership and chain affiliation. Health Care Management Review 2012;37(3):235–45. pmid:22261667
    • View Article
    • PubMed/NCBI
    • Google Scholar
29. 29. O'Neill C, Harrington C, Kitchener Chiliad, Saliba D. Quality of care in nursing homes: an analysis of relationships amidst profit, quality, and buying. Medical Care 2003;41(12):1318–30. pmid:14668664
    • View Commodity
    • PubMed/NCBI
    • Google Scholar
30. 30. Harrington C, Olney B, Carrillo H, Kang T. Nurse staffing and deficiencies in the largest for-profit nursing dwelling house bondage and chains owned by private equity companies. Health Services Inquiry 2012;47(1 Pt 1):106–28. pmid:22091627
    • View Commodity
    • PubMed/NCBI
    • Google Scholar
31. 31. Bates-Jensen BM, Schnelle JF, Alessi CA, Al-Samarrai NR, Levy-Storms Fifty. The effects of staffing on in-bed times of nursing habitation residents. Journal of the American Geriatrics Society 2004;52(6):931–8. pmid:15161457
    • View Article
    • PubMed/NCBI
    • Google Scholar
32. 32. Munroe DJ. The influence of registered nurse staffing on the quality of nursing home care. Research in Nursing and Health 1990;13(iv):263–lxx. pmid:2374834
    • View Article
    • PubMed/NCBI
    • Google Scholar
33. 33. Schnelle JF, Simmons SF, Harrington C, Cadogan M, Garcia East, B MB-J. Human relationship of nursing home staffing to quality of care. Health Services Research 2004;39(ii):225–50. pmid:15032952
    • View Article
    • PubMed/NCBI
    • Google Scholar
34. 34. Centers for Medicare and Medicaid Services (CMS). 2001. Report to Congress: Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes: Phase II Final Report. Baltimore: CMS. http://www.allhealth.org/briefingmaterials/abt-nursestaffingratios%2812-01%29-999.pdf (accessed September 20, 2014).
35. 35. Harrington C, Zimmerman D, Karon SL, Robinson J, Beutel P. Nursing home staffing and its relationship to deficiencies. Journals of Gerontology Series B-Psychological Sciences & Social Sciences 2000 Sep;55(v):S278–S287. pmid:10985299
    • View Article
    • PubMed/NCBI
    • Google Scholar
36. 36. Harrington C, Swan JH. Nursing home staffing, turnover, and case mix. Medical care inquiry and review 2003;sixty(3):366–92; discussion 93–nine. pmid:12971234
    • View Commodity
    • PubMed/NCBI
    • Google Scholar
37. 37. Canadian Aboriginal AIDS Network. Relational Care: A Guide to Health Intendance and Support for Ancient People Living with HIV/AIDS, 2008, p.viii http://caan.ca/wp-content/uploads/2012/05/Relational-Care-20081.pdf (Accessed March 18, 2016).
38. 38. McGilton KS, Pringle DM, O'Brien-Pallas LL, Wynn F, Streiner D. Development and psychometric testing of the Relational Intendance Scale. Journal of Nursing Measurement 2005;thirteen(1):51–64. pmid:16315570
    • View Commodity
    • PubMed/NCBI
    • Google Scholar
39. 39. Grabowski DC, Feng Z, Hirth R, Rahman M, Mor V. Effect of nursing home buying on the quality of post-acute care: an instrumental variables approach. Journal of Health Economics 2013;32(one):12–21. pmid:23202253
    • View Article
    • PubMed/NCBI
    • Google Scholar
40. 40. Hirth RA, Grabowski DC, Feng Z, Rahman M, Mor V. Effect of nursing habitation ownership on hospitalization of long-stay residents: an instrumental variables approach. International Periodical of Health Intendance Finance and Economic science 2013.
    • View Article
    • Google Scholar
41. 41. McGregor MJ, Tate RB, McGrail KM, Ronald LA, Broemeling AM, Cohen Yard. Care outcomes in long-term care facilities in British Columbia, Canada. Does ownership matter? Medical Care 2006;44(10):929–35. pmid:17001264
    • View Article
    • PubMed/NCBI
    • Google Scholar
42. 42. Menec VH, Nowicki Due south, Blandford A, Veselyuk D. Hospitalizations at the end of life amidst long-term care residents. The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences 2009;64(3):395–402. pmid:19196640
    • View Article
    • PubMed/NCBI
    • Google Scholar
43. 43. Boockvar KS, Gruber-Baldini AL, Burton L, Zimmerman S, May C, Magaziner J. Outcomes of infection in nursing home residents with and without early hospital transfer. Journal of the American Elderliness Society 2005;53(4):590–half-dozen. pmid:15817003
    • View Article
    • PubMed/NCBI
    • Google Scholar
44. 44. Gillick MR, Serrell NA, Gillick LS. Adverse consequences of hospitalization in the elderly. Social Science and Medicine 1982;16(x):1033–eight. pmid:6955965
    • View Article
    • PubMed/NCBI
    • Google Scholar
45. 45. Dosa D. Should I hospitalize my resident with nursing home-caused pneumonia? Journal of the American Medical Directors Association 2005;vi(5):327–33. pmid:16165074
    • View Commodity
    • PubMed/NCBI
    • Google Scholar
46. 46. Arai S, Hutchison P, Pedlar A, Lord J, Sheppard 5. Shared Values, Networks and Trust Amidst Canadian Consumer Driven Disability Organizations. Disability Studies Quarterly 2008;28.
    • View Article
    • Google Scholar
47. 47. Hirschman A. Go out, Vocalisation, and Loyalty: Responses to Decline in Firms, Organizations, and States. Harvard University Press: Cambridge, Usa. pp. 1–176. 1970.
48. 48. Grabowski DC. Consumer complaints and nursing dwelling house quality. Medical Care 2005;43(2):99–101. pmid:15655422
    • View Article
    • PubMed/NCBI
    • Google Scholar
49. 49. Hirth RA, Banaszak-Holl JC, Fries BE, Turenne MN. Does quality influence consumer choice of nursing homes? Evidence from nursing home to nursing home transfers. Inquiry: a journal of medical intendance system, provision and financing 2003;forty(4):343–61. pmid:15055834
    • View Article
    • PubMed/NCBI
    • Google Scholar
50. 50. Bowbliss JL. Ownership Conversion past Nursing Homes and the Quality of Intendance. Department of Economics, Miami University # 2009 10 2009 [cited 2009 December vii];1–39. http://world wide web.fsb.muohio.edu/fsb/ecopapers/docs/bowblijr-2009-10-paper.pdf 2009.
51. 51. Arfwidsson J, Westerberg J. Turn a profit seeking and the quality of elder care—an empirical written report of individual disinterestedness'southward impact on the Swedish eldercare market: implications for financial performance and quality of care. Master's Thesis—Stockholm Schoolhouse of Economics 2014;1–47.
52. 52. Grabowski DC, Stevenson DG. Ownership conversions and nursing home performance. Health Services Enquiry 2008;43(4):1184–203. pmid:18355255
    • View Article
    • PubMed/NCBI
    • Google Scholar
53. 53. Devereaux PJ, Schunemann HJ, Ravindran N, Bhandari Chiliad, Garg AX, Choi PT, et al. Comparison of mortality betwixt private for-profit and private not-for-turn a profit hemodialysis centers: a systematic review and meta-analysis. Periodical of the American Medical Clan 2002;288(19):2449–57. pmid:12435258
    • View Commodity
    • PubMed/NCBI
    • Google Scholar
54. 54. Himmelstein DU, Woolhandler S, Hellander I, Wolfe SM. Quality of care in investor-endemic vs not-for-turn a profit HMOs. Journal of the American Medical Association 1999;282(2):159–63. pmid:10411197
    • View Article
    • PubMed/NCBI
    • Google Scholar
55. 55. Japel C, Tremblay J, Côté S. Quality Counts! Assessing the quality of daycare services based on the Quebec Longitudinal Study of Child Development. IRPP Choices eleven (v). http://irpp.org/wp-content/uploads/assets/vol11no5.pdf (Accessed March 27, 2015). 2005.
    • View Article
    • Google Scholar
56. 56. Cleveland Thou, Forer B, Hyatt D, Japel C, Krashinsky M. New Evidence about Child Intendance in Canada: Use Patterns, Affordability and Quality. IRPP Choices fourteen (12). http://irpp.org/research-studies/choices-vol14-no12/ (Accessed March 27, 2015). 2008.
    • View Article
    • Google Scholar
57. 57. McGregor MJ, Abu-Laban RB, Ronald LA, McGrail KM, Andrusiek D, Baumbusch J, et al. Nursing home characteristics associated with resident transfers to emergency departments. Canadian Journal on Aging 2014;33(i):38–48. pmid:24398137
    • View Commodity
    • PubMed/NCBI
    • Google Scholar
58. 58. McGregor MJ, Cohen M, Stocks-Rankin CR, Cox MB, Salomons K, McGrail KM, et al. Complaints in for-turn a profit, non-turn a profit and public nursing homes in ii Canadian provinces. Open Medicine 2011;v(4):e183–92. pmid:22567074
    • View Article
    • PubMed/NCBI
    • Google Scholar
59. 59. Tanuseputro P, Chalifoux M, Bennett C, Gruneir A, Bronskill SE, Walker P, et al. Hospitalization and Bloodshed Rates in Long-Term Intendance Facilities: Does For-Profit Status Matter? Journal of the American Medical Directors Association 2015;xvi(10):874–83. pmid:26433862
    • View Article
    • PubMed/NCBI
    • Google Scholar
60. 60. Shapiro E, Tate RB. Monitoring the outcomes of quality of care in nursing homes using administrative information. Canadian Journal of Aging 1995;fourteen(iv):755–68.
    • View Commodity
    • Google Scholar
61. 61. Clarfield AM, Ginsberg One thousand, Rasooly I, Levi S, Gindin J, Dwolatzky T. For-profit and not-for-turn a profit nursing homes in Israel: do they differ with respect to quality of care? Archives of Gerontology and Elderliness 2009;48(2):167–72. pmid:18295359
    • View Article
    • PubMed/NCBI
    • Google Scholar
62. 62. Baldwin R, Chenoweth Fifty, Dela Rama M, Liu Z. Quality failures in residential anile care in Commonwealth of australia: The relationship between structural factors and regulation imposed sanctions. Australasian Periodical on Ageing 2014.
    • View Article
    • Google Scholar
63. 63. Burton C. Heavy tailed distributions of effect sizes in systematic reviews of complex interventions. PLoS ONE 2012;7(iii):e34222. pmid:22479569
    • View Article
    • PubMed/NCBI
    • Google Scholar
64. 64. Britton M. The epidemiology of mesothelioma. Seminars in Oncolology 2002;29(1):18–25.
    • View Commodity
    • Google Scholar
65. 65. Miller JH, Page SE. Circuitous Adaptive Systems: An Introduction to Computational Models of Social Life: Princeton University Press, 2007.
66. 66. Grabowski DC, Hirth RA. Competitive spillovers across non-turn a profit and for-turn a profit nursing homes. J Health Econ 2003;22(ane):1–22. pmid:12564715
    • View Article
    • PubMed/NCBI
    • Google Scholar
67. 67. Berta W, Laporte A, Valdmanis 5. Observations on institutional long-term care in Ontario: 1996–2002. Canadian Journal of Crumbling 2005;24(i):seventy–84.
    • View Article
    • Google Scholar
68. 68. McGregor MJ, Cohen M, McGrail G, Broemeling AM, Adler RN, Schulzer Yard, et al. Staffing levels in not-for-profit and for-profit long-term care facilities: does type of ownership matter? Canadian Medical Association Journal 2005;172(five):645–ix. pmid:15738489
    • View Article
    • PubMed/NCBI
    • Google Scholar
69. 69. Lucas RM, McMichael AJ. Clan or causation: evaluating links between "environment and disease". Bulletin of the World Health Organization 2005;83(ten):792–5. pmid:16283057
    • View Article
    • PubMed/NCBI
    • Google Scholar
70. seventy. Annas GJ. Burden of proof: judging scientific discipline and protecting public health in (and out of) the courtroom. American Journal of Public Health 1999;89(four):490–three. pmid:10191788
    • View Article
    • PubMed/NCBI
    • Google Scholar
71. 71. Kriebel D. The reactionary principle: inaction for public health. Occupational and Environmental Medicine 2007;64(9):573–4. pmid:17704201
    • View Article
    • PubMed/NCBI
    • Google Scholar
72. 72. Regime of Alberta. News release: Accommodations for seniors volition exist priority for new bonds. http://alberta.ca/release.cfm?xID=275309828DE4A-07EF-D0FE-8354B971D1CCAC47. December sixteen, 2009.
73. 73. Harrington C, Armstrong H, Halladay Yard, Havig A, Jacobsen F, MacDonald K. Comparison of nursing home financial transparency and accountability in four locations. Ageing International 2015;November 19 (online):ane–23.
74. 74. Grabowski DC, Castle NG. Nursing homes with persistent high and low quality. Medical Care Research and Review 2004;61(i):89–115. pmid:15035858
    • View Commodity
    • PubMed/NCBI
    • Google Scholar

cannonbrince.blogspot.com

Source: https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001995

Share this post