Comment on Beyond CMS quality measure adjustments.

To the Editor: We wish to compliment Dr Susan D. Horn and colleagues on their clinical trial, ‘‘Beyond CMS quality measure adjustments: Identifying key resident and nursing home facility factors associated with quality measures.’’ Their summary of the controversies surrounding the quality care improvement efforts assist in paving the way for a clearer vision and methodology to positively impact quality measures for care providers and staff in nursing home facilities. We also applaud the need to adjust for resident admission characteristics, facility characteristics, and state reimbursement systems when creating new quality measures. Quality of care can bemeasured by using either processes or outcomes. Each method has its strength and limitations. Using processes rather than outcomes, according to Shekelle and colleagues, is a more efficient measure of quality care in vulnerable elders, with interdisciplinary team work as a main frame to be followed in geriatric care, especially in nursing homes and in the post acute care settings. Defining clear quality care measures continues to face considerable challenges. Lack of clinical geriatric research trials with a focus on quality measures and the rising cost of nursing homes and medical costs continues to have a significant impact on future outlook. However, there are some points that should be highlighted that are relevant to the article. First, all patients in this study were from for-profit nursing homes. The corporate organization of nursing homes has an affect on quality of care and services provided. Not-forprofit nursing homes may provide higher-quality care than for-profit nursing homes. According to Carter and Porell, nursing home characteristics such as profit status, nurse staffing patterns, facility size, chain affiliation, and percentage of Medicaidand Medicare-reimbursed days significantly influence nursing home residents’ risk. Broader area market factors also appear to contribute. Not-for-profit homes have less pressure to maximize profits compared with for-profit homes. Second, the case mix of residents in this study under the general term of nursing homes should be clarified, because many nursing homes have an interest and focus on post acute care, with skilled care provided to a wide range of medically complex patients. Subacute care settings have medical, rehabilitation, and skilled nursing services provided for patients who are not in the acute phase of their illness but require a higher level of care than can be provided in a long-term care setting. Third, most quality measures need to be condition specific, focusing on how care is received by patients during the study. Clarifying details about each of the 3 quality measures used in the article includes the different stages of pressure ulcers used, the severity and type of urinary incontinence, and the level of impairment in activities of daily living. Also, the level of