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Quality measurement and nursing homes: measuring what matters
  1. Robert E Burke1,2,
  2. Rachel M Werner1,2
  1. 1 Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center, Philadelphia, PA, USA
  2. 2 Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
  1. Correspondence to Dr Robert E Burke, Corporal Crescenz VA Medical Center, Philadelphia, PA 19104, USA; burkerob{at}

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The USA has measured the quality of care delivered in nursing homes for decades.1 While these efforts represent important steps towards a more transparent and accountable health system, specific successes of these measurement efforts are more difficult to pinpoint. One consistent message from the many studies that have examined nursing home quality is that our quality measures do not always measure what matters. In this issue of BMJ Quality & Safety, Xu and colleagues2 provide more evidence of the weak and unpredictable relationship between nursing home quality measures and an important patient outcome that does matter—hospitalisation. Using an expanded set of quality measures collected in Minnesota nursing homes, the authors find that the 23 metrics they examine showed neither strong nor consistent associations with risk of hospitalisation in a population of Medicaid residents—neither the overall rate of hospitalisation nor potentially preventable hospitalisations.2 Further, while some associations were expected (eg, nursing homes with lower usage of urinary catheters had fewer hospitalisations for urinary tract infections), some were not. For instance, more antipsychotic treatment was associated with less hospital use, while ‘improving bladder continence’ was associated with more hospitalisations.

This timely evaluation by Xu et al occurs in the context of an important ongoing national debate about the value of quality measurement.3 On one hand, investments in electronic medical records and the rise of big data have accelerated the development of quality measures (which some have labelled the ‘quality measurement industrial complex’),3 4 meaning more can be measured than ever before. On the other hand, little evidence demonstrates that these measurement efforts have mattered. Accumulating research suggests that tying quality …

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