Abstract

Background: In the late 1990s, the US Centers for Medicare and Medicaid Services started publishing Nursing Home Compare (NHC), an online resource for information about nursing home quality. The goals were to help consumers make more informed decisions and to incent providers to improve the quality of care delivered. Since then, NHC has experienced several major changes, including the addition of clinical quality measures in 2002 and a five-star composite rating system in 2008. A substantial and growing body of research has examined whether and how consumers use the information, whether providers have responded by improving quality, and whether any unintended consequences have emerged.

Objectives: The objective of this study is to describe the NHC system; review the evidence on its effects; discuss the implications for quality, efficiency, and equity; and propose key directions for future research.

Methods: We conducted a systematic review of the literature to find empirical articles assessing NHC. An initial search on PubMed resulted in 50 articles that met inclusion criteria. Use of additional databases and checking of reference sections of all the articles already identified resulted in an additional 6 articles that met our inclusion criteria. We read the 56 included articles to assess methodology and findings, classifying articles according to whether they mainly assessed consumer response, provider response, or issues related to the construction and validity of the reported measures.

Results: Our review found evidence that consumers respond to NHC, with caveats. Consumer response has grown over time as people increasingly turn to the Internet for information about nursing homes and awareness of NHC spreads. Response to the five-star system has been stronger than response to the prior system without a composite summary measure. However, the evidence reveals heterogeneity. More affluent and more educated consumers are more likely to use the ratings to choose higher-quality providers.

On the provider side, quantitative studies show improvement on performance over time for many of the included measures. Qualitative studies reveal that nursing home managers closely monitor their scores and employ multiple strategies to improve them, some of which result in better care and some of which are simply coding-related strategies that do not change care. Providers facing less competition and higher occupancy put forth less effort to improve scores, and little improvement is seen in the lowest tier of quality.

Limitations: In terms of the NHC measures, gaps and problems exist. Risk-adjustment is imperfect, leading to incentives for selection of healthier residents, although research shows that competing incentives to fill beds likely outweigh the desire to select healthier residents except in the highest-quality nursing homes. Important domains of performance such as consumer satisfaction and end-of-life care are missing.

Conclusions: NHC is generally meeting its goals of influencing consumer choice and incenting quality improvement. Continuous refinement is necessary to increase consumer awareness and usefulness of the system and to counter incentives for providers to game the system. Finally, NHC must be only one part of a multifaceted approach to improving the quality of nursing home care.