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December 2022: Methodological Considerations in Classifying Nursing Homes Based on Resident Composition

In various academic studies, outcomes for individual patients are not available. Therefore researchers rely on classifying facilities based on the composition of the patients the facility serves. This is particularly true when studying racial/ethnic disparities. For example, to statistically identify racial/ethnic disparities, researchers may calculate the proportion of Black patients and then use an arbitrary proportion as a threshold to classify the facility as serving a high-proportion of Black patients. They then compare facilities serving a high-proportion of Black patients to all other facilities. The validity of this analysis depends on the threshold used by the researcher to classify facilities.


In a recently published paper in Medical Care Research and Review, Dr. Bowblis and colleagues examined different methodologies to identify nursing homes with different resident compositions. They examined different thresholds to define "high-proportion": first, based on the percentile threshold used to define “high-proportion”; and second, whether that percentile threshold is state-specific or national. The key findings of the paper are the specific threshold used should primarily be determined by the objective of the study and whether the analysis will be adjusted for other resident and facility factors. The paper also describes the advantages and disadvantages of using each of threshold.


The reference for the article is: Bowblis JR, Akosionu O, Ng W, Shippee T. Identifying Nursing Homes with Diverse Racial and Ethnic Compositions: The Importance of Geographic Heterogeneity and Geographic Context. Medical Care Research & Review, forthcoming.


A copy of the article is available at the journal’s website.

April 2022: The Economics of a Hypothetical Nursing Home Staffing Regulation: "Expected" Staffing Levels

The Centers for Medicare and Medicaid Services (CMS) reported a staffing star rating on the Nursing Home Compare website. Between 2011 and March of 2018, this staffing star rating was adjusted for resident acuity using the Staff Time Measurement (STM) studies conducted by CMS in the 1990s. In technical documentation, CMS referred to this adjustment factor as an "expected" staffing level. In 2020, some nursing advocates suggested that CMS should require nursing homes to staff to these "expected" staffing levels. This is despite the fact that the STM  studies conducted by CMS were not designed for and did not assess the adequacy of nursing staff.

In a recently published paper in Innovation in Aging, Dr. Bowblis examined what would happen if CMS considered these "expected" or STM staffing levels as a hypothetical requirement. The key findings were nursing homes and nursing home regulators did not consider "expected" staffing levels a relevant benchmark. Moreover, if CMS adopted the "expected" staffing levels as a requirement, it would be economically infeasible for most nursing homes to staff to this hypothetical benchmark. Without additional funding, the majority of the nursing home industry would become insolvent. 

The reference to the article is: Bowblis JR. 2022. The Need for an Economically Feasible Nursing Home Staffing Benchmark: Evaluating an Acuity-Based Nursing Staff Benchmark. Innovation in Aging 6(4): 1-11.

A copy of the article is available at: The Need for an Economically Feasible Nursing Home Staffing Regulation


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