Underreporting of Quality Measures and Associated Facility Characteristics and Racial Disparities in US Nursing Home Ratings

JAMA Netw Open. 2023 May 1;6(5):e2314822. doi: 10.1001/jamanetworkopen.2023.14822.


Importance: The US government rates nursing homes and reports the underlying quality measures on the Nursing Home Care Compare (NHCC) website. These measures are derived from facility-reported data, which research indicates to be substantially underreported.

Objective: To assess the association between nursing home characteristics and reporting of major injury falls and pressure ulcers, which are 2 of 3 specific clinical outcomes reported by the NHCC website.

Design, setting, and participants: This quality improvement study used hospitalization data for all Medicare fee-for-service beneficiaries between January 1, 2011, and December 31, 2017. Hospital admission claims for major injury falls and pressure ulcers were linked with facility-reported Minimum Data Set (MDS) assessments at the nursing home resident level. For each linked hospital claim, whether the nursing home had reported the event was determined and reporting rates were computed. The distribution of reporting across nursing homes and the associations between reporting and facility characteristics were examined. To assess whether nursing homes reported similarly on both measures, the association between reporting of major injury falls and pressure ulcers within a nursing home was estimated, and racial and ethnic disparities that might explain the observed associations were investigated. Small facilities and those that were not included in the sample continuously in each year of the study period were excluded. All analyses were performed throughout 2022.

Main outcomes and measures: Two nursing home-level MDS reporting rates, stratified by long-stay vs short-stay population or by race and ethnicity, were used: fall reporting rate and pressure ulcer reporting rate.

Results: The sample included 13 179 nursing homes where 131 000 residents (mean [SD] age, 81.9 [11.8] years; 93 010 females [71.0%]; 81.1% with White race and ethnicity) experienced major injury fall or pressure ulcer hospitalizations. There were 98 669 major injury fall hospitalizations, of which 60.0% were reported, and 39 894 stage 3 or 4 pressure ulcer hospitalizations, of which 67.7% were reported. Underreporting for both conditions was widespread, with 69.9% and 71.7% of nursing homes having reporting rates less than 80% for major injury fall and pressure ulcer hospitalizations, respectively. Lower reporting rates were associated with few facility characteristics other than racial and ethnic composition. Facilities with high vs low fall reporting rates had significantly more White residents (86.9% vs 73.3%), and facilities with high vs low pressure ulcer reporting rates had significantly fewer White residents (69.7% vs 74.9%). This pattern was retained within nursing homes, where the slope coefficient for the association between the 2 reporting rates was -0.42 (95% CI, -0.68 to -0.16). That is, nursing homes with more White residents had higher reporting rates for major injury falls and lower reporting rates for pressure ulcers.

Conclusions and relevance: Results of this study suggest widespread underreporting of major injury falls and pressure ulcers across US nursing homes, and underreporting was associated with the racial and ethnic composition of a facility. Alternative approaches to measuring quality need to be considered.

Publication types

  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Aged
  • Aged, 80 and over
  • Female
  • Humans
  • Medicare
  • Nursing Homes
  • Pressure Ulcer*
  • Quality Indicators, Health Care
  • Skilled Nursing Facilities
  • United States