Quality of care in for-profit and not-for-profit nursing homes: systematic review and meta-analysis

Abstract

Objective: To compare quality of care in for-profit and not-for-profit nursing homes.

Design: Systematic review and meta-analysis of observational studies and randomised controlled trials investigating quality of care in for-profit versus not-for-profit nursing homes.

Results: A comprehensive search yielded 8827 citations, of which 956 were judged appropriate for full text review. Study characteristics and results of 82 articles that met inclusion criteria were summarised, and results for the four most frequently reported quality measures were pooled. Included studies reported results dating from 1965 to 2003. In 40 studies, all statistically significant comparisons (P<0.05) favoured not-for-profit facilities; in three studies, all statistically significant comparisons favoured for-profit facilities, and the remaining studies had less consistent findings. Meta-analyses suggested that not-for-profit facilities delivered higher quality care than did for-profit facilities for two of the four most frequently reported quality measures: more or higher quality staffing (ratio of effect 1.11, 95% confidence interval 1.07 to 1.14, P<0.001) and lower pressure ulcer prevalence (odds ratio 0.91, 95% confidence interval 0.83 to 0.98, P=0.02). Non-significant results favouring not-for-profit homes were found for the two other most frequently used measures: physical restraint use (odds ratio 0.93, 0.82 to 1.05, P=0.25) and fewer deficiencies in governmental regulatory assessments (ratio of effect 0.90, 0.78 to 1.04, P=0.17).

Conclusions: This systematic review and meta-analysis of the evidence suggests that, on average, not-for-profit nursing homes deliver higher quality care than do for-profit nursing homes. Many factors may, however, influence this relation in the case of individual institutions.

Fig 1 Flow chart of steps in systematic review

Fig 2 Ratio of effect sizes for staffing quality in for-profit (FP) and not-for-profit (NFP) nursing homes. Ratios listed represent effect size in NFP homes compared with that in FP homes. Ratio >1 indicates that NFP homes had more, or higher quality, staffing (that is, favours NFP)

Fig 3 Odds ratios (OR) comparing pressure ulcer prevalence in for-profit (FP) and not-for-profit (NFP) nursing homes. OR <1 indicates lower risk of pressure ulcers in NFP facilities than in FP facilities, suggesting that NFP facilities deliver higher quality care

Fig 4 Odds ratios (OR) comparing physical restraint prevalence in for-profit (FP) and not-for-profit (NFP) nursing homes. OR <1 represents less physical restraint use in NFP facilities than FP facilities, suggesting that NFP facilities deliver higher quality care

Fig 5 Ratio of effect sizes for regulatory deficiencies in for-profit (FP) and not-for-profit (NFP) nursing homes. Ratios listed represent effect size in NFP facilities compared with that in FP facilities. Ratio <1 represents fewer deficiencies in NFP homes, suggesting that NFP homes deliver higher quality care