摘要：Objectives. The movement to publicly report data on provider quality to inform consumer choices is predicated on assumptions of equal access and knowledge. We examine the validity of this assumption by testing whether minority/less educated Medicare patients are at greater risk of being discharged from a hospital to the lowest-quality nursing homes in a geographic area. Methods. We used the 2002 national Minimum Data Set to identify 62601 new Medicare admissions to nursing homes in 95 hospital service areas with at least 4 freestanding nursing homes and at least 50 African Americans aged 65 years or older with Medicare admissions to nursing homes. Results. The probability of African Americans’ being admitted to nursing homes in the lowest-quality quartile in the area was greater (relative risk [RR]=1.26; 95% confidence interval [CI]=1.0, 8.45) in comparison with Whites. Individuals without a high-school degree were also more likely to be admitted to a low-quality nursing home (RR=1.22; 95% CI=1.0, 1.46). Conclusions. African American and poorly educated patients enter the worst-quality nursing facilities. This finding raises concerns about the usefulness of the current public reporting model for certain consumers. The publication of nursing home quality data is intended to promote quality competition. 1 Advocates of publicly reporting quality measures for nursing homes argue that efforts to give elders and their families more information will promote better care, ultimately reducing disparities through the mechanism of expanded consumer choice. However, actual choice when it comes to nursing home selection is limited by demand—side factors such as local geography (proximity to family and neighborhood), supply-side factors such as the availability of skilled nursing home beds, and the reality that the majority of initial nursing home placement decisions are mediated by hospital discharge planners and the options they present. In 1997, 61% of nursing home residents were admitted from a hospital. 2 Because hospital discharge planners act as patients’ agents in guiding nursing home choice, it is important to ascertain whether referrals are made equitably or if race and education play a role in perpetuating disparities in the quality of nursing home care. Ethnic/racial disparities persist across the health care spectrum, and nursing home care is no exception. 3 Nursing homes have been shown to be more racially segregated than hospitals. 4 Because African Americans are known to use nursing homes less 5 , 6 and later, 7 than non-Hispanic Whites, and because segregated access to nursing home care is thought to be a major contributor to differential nursing home use, 8 , 9 the association between a nursing home’s quality and its ethnic/racial composition is an important consideration. The relevance of the phenomenon of nursing home segregation is readily seen in the increasing evidence that ethnic/racial minority residents are less likely to receive appropriate care. Past research has found that ethnic/racial minority residents are less likely than non-Hispanic Whites to receive medically appropriate pharmacological treatments in nursing homes 10 and are less likely to receive physical therapy when admitted to nursing homes after hospitalization. 11 Other studies suggest that African American and Hispanic elders are more likely to receive care in facilities with documented problems related to cleanliness and maintenance, 12 and ethnic/racial minority elders nationwide are more likely to be treated in nursing homes that have a higher number of health deficiencies as determined by state regulators. 13 Non-White race is also associated with a greater use of feeding tubes in nursing home residents. 14 Minority elders are more likely to have significantly longer delays in discharge from hospitals. 15 The role of education in guiding nursing home decisionmaking has emerged as an important area of interest as the consumer choice model of long-term care continues to develop. 16 The competitive marketplace of health insurers, managed care plans, and nursing home providers poses special challenges to the less educated current cohort of older persons. 17 Thus, differences in both education and race may play a role in perpetuating existing disparities in the quality of nursing home care. There has been a renewed call for hospital management to take a more active role in reducing disparities in health care settings. 18 Developing a system of evidence-based discharge planning that includes information about the quality of nursing home care may help reduce disparities at discharge. However, because the majority of choices are made locally, understanding the effect of new public reporting efforts requires baseline documentation of ongoing disparities within geographic areas —in this case hospital service areas (HSAs). Thus, we tested the hypothesis that racial and ethnic minorities and less educated individuals are more likely than non-Hispanic Whites and more educated patients to enter freestanding nursing homes that are in the worst quartile (in a given HSA) in terms of publicly available quality-inspection information in 2002. Because all new admissions were Medicare reimbursed, the impact of differential payment levels between Medicaid and private pay, which reflects patient wealth, was quite limited in our analysis.
