The urban-rural disparity in nursing home quality indicators: the case of facility-acquired contractures.

As the trends in population aging continues in the United States, the demand for all forms of long-term care is likely to increase in the coming decades. Meeting this rising demand is more challenging for rural areas because rural elderly have greater long-term care needs than their urban counterparts (Fennell and Campbell 2007) and there are well-documented differences in urban and rural long-term care providers (Phillips, Hawes, and Williams 2003; Hutchinson, Hawes, and Williams 2005).1 One dimension in which there are significant differences between urban-rural providers is in the quality of care provided by nursing homes. A series of papers have generally found that rural nursing homes have lower quality than their urban counterparts after adjusting for case-mix (Buchanan et al. 2004; Phillips et al. 2004; Bolin, Phillips, and Hawes 2006; Kang, Meng, and Miller 2011; Temkin-Greener, Zheng, and Mukamel 2012). While these studies have identified potential sources of these differences in the quality of care, few have investigated the relative importance of these sources in explaining the urban-rural disparity. This study aims to quantify and further our understanding of the sources of the urban-rural disparity in the quality of care provided by nursing homes. The Blinder–Oaxaca decomposition technique is used to determine the extent to which the disparity is attributable to differences in facility and aggregate resident characteristics between rural and urban nursing homes. Decomposition techniques have been used to study racial and ethnic disparities in a variety of health service settings (Zuvekas and Taliaferro 2003; Grabowski and McGuire 2009; Bowblis and Yun 2010). To our knowledge, this is the first paper that uses decomposition techniques to study urban-rural disparities in the quality of care provided by nursing homes. In this paper, quality of care is defined as the proportion of residents within a facility that acquire a contracture after admission to the nursing home. A contracture is an abnormal muscle shortening and joint fixation commonly seen among persons with immobility or central nervous system disorders (Adams and Victor 1993; Fergusson, Hutton, and Drodge 2007). There are several reasons for focusing on contractures in this study. First, contractures are considered a measure of quality of care because the development of a contracture is considered a failure on the part of the nursing home to meet federal quality of care standards (§483.25, Centers for Medicare and Medicaid Services (CMS) [CMS] 2010). Also, contractures are often preventable with proper supervision and intervention (Wagner et al. 2008; Jamshed and Schneider 2010). Second, contractures are a highly prevalent condition among nursing home residents. In 1999, 24 percent of nursing home residents had a contracture regardless of its presence at admission, whereas contracture rates are between 28 and 29 percent for the years 2005 to 2009 (Harrington, Carrillo, and LaCava 2006; Harrington et al. 2010). Third, contractures are an understudied measure of nursing home quality that have not received as much attention as other quality measures (Wagner and Clevenger 2010). In addition, contractures can lead to pain, pressure ulcers, infections, and functional disability, and they have a significant impact on quality of life; therefore, contractures are closely linked with other nursing home quality measures (Kane et al. 2008). Finally, contractures are not directly targeted by Quality Improvement Organizations in the recent quality improvement efforts by the CMS. In summary, this study aims to address the gap in our understanding of an important yet understudied aspect of nursing home quality.