Determining the relationship between staffing and quality.

The article by Zhang and Grabowski (2004) provides important data relevant to two questions: (a) Did the Nursing Home Reform Act (NHRA) of 1987 result in improved quality of care and staffing levels? and (b) How do staffing data generated by nursing homes (NHs) associate with three quality measures? Zhang and Grabowski (2004) used a sophisticated analytical approach and unique longitudinal secondary data to address these questions. The authors acknowledge that their conclusions may be controversial because of limitations inherent in any design that uses available secondary data to measure staffing and quality. This editorial asserts that a direct intervention paradigm involving prospective data collection is needed to correct these limitations. Zhang and Grabowski (2004) undertook their study in part to address some of the limitations of prior studies of NH quality and staffing, and their article provides a good discussion of the problems that they could not directly address. In particular, one of their conclusions illustrates the assumptions required whenever risk adjustments are made to quality indicators—a controversial topic in this field. Their analyses showed that the NHRA was associated with a statistically significant reduction in the proportion of residents with physical restraints, catheters, and pressure ulcers, even though the absolute proportion of residents with pressure ulcers increased between 1987 (pre-NHRA) and 1993 (post-NHRA)—the study’s time frame. In fact, the pressure-ulcer rate decreased only after controlling for facility, resident, market, and state factors. Herein lies the dilemma. In order to accept that the small risk-adjusted decrease in pressure-ulcer prevalence is due to improved quality of care, one must first accept the notion that the control variables reflect resident acuity and, thus, potential risk for pressure-ulcer development. Most notable of the acuity variables used in the risk adjustment is prevalence of bedfastness, which increased dramatically following the NHRA. If this increase in bedfastness reflects increased resident acuity that was not exacerbated by the same poor care processes that could have influenced pressure-ulcer development, then it is reasonable to argue that pressure-ulcer rates improved following the NHRA. The opposing argument, which may be just as reasonable, is that increased bedfast prevalence is itself an outcome and, like increased pressure-ulcer prevalence, associated with poor care. A more complete discussion of the complexities of risk adjustment is provided by Mor and colleagues (2003). With regard to staffing levels, NHs reported small increases across the preand post-NHRA periods, but these staff increases were not related to improved quality except in those NHs that started with the lowest staffing levels. Zhang and Grabowski (2004) list several factors that might explain this finding, including (a) potential error rates in NH reports of staffing and quality, (b) the absence of quality-of-life measures that might be more sensitive to variations in staffing than clinically focused outcomes, and (c) the fact that few NHs may have adequate levels of staffing to affect quality measures. These three points deserve further discussion because they are often raised as points of controversy when arguments are made about the relationship of staffing and quality. In regard to accuracy, suspicions exist about the accuracy of both staffing and quality measures available in secondary data generated by NH providers. These suspicions would be mitigated if an auditing mechanism were in place to ensure accuracy. However, staffing statistics reported to government agencies are either not audited or only ‘‘desk’’ audited to eliminate outliers (Abt Associates, Inc., 2000). Determining if staffing reports are accurate Address correspondence to John F. Schnelle, PhD, JHA/UCLA Borun Center, 7150 Tampa Avenue, Reseda, CA 91335. E-mail: jschnell@ ucla.edu Department of Medicine and the Borun Center for Gerontological Research, University of California–Los Angeles, Reseda, CA. Geriatric Research Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, CA. Jewish Home for the Aging, Reseda, CA.