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Promising Practice: Better quality in non-profit/publicly delivered nursing homes – Is the association causal? Dr. Margaret McGregor and Lisa Ronald Re-Imagining.

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Presentation on theme: "Promising Practice: Better quality in non-profit/publicly delivered nursing homes – Is the association causal? Dr. Margaret McGregor and Lisa Ronald Re-Imagining."— Presentation transcript:

1 Promising Practice: Better quality in non-profit/publicly delivered nursing homes – Is the association causal? Dr. Margaret McGregor and Lisa Ronald Re-Imagining Residential Long-Term Care Conference Bergen, Norway May 2014

2 2 Background Population aging Mainly publicly funded, delivered by mix of for-profit, non-profit (independent, volunteer sector) and public (government/ quasi- government) facilities Increasingly complex corporate management structures

3 3 How do we measure quality? Challenges with measuring care quality –Multidimensional –Observational qualitative and quantitative data No randomized controlled trials Potential for bias and confounding Data often collected retrospectively

4 4 Policy debate: is quality better in non-profit nursing homes? Multiple studies - Evidence from 2 systematic reviews - Comondore, (2009), Hillmer (2005) Konetzka (2009): “Insufficient evidence to assume causality, need randomized controlled trials”

5 5 How do we assess if there is a causal association? Bradford Hill’s guidelines – a useful framework for assessing causation –Sir Austin Bradford Hill: Pioneer of randomized clinical trials, first (with Richard Doll) to show link between smoking and lung cancer –Plausibility, Consistency, Analogy, Temporality, Dose-response, Strength, Experiment, Specificity

6 6 Assessing the evidence using Bradford Hill guidelines Plausibility –Goal is to maximize profits for shareholders Consistency and Analogy –Across time, jurisdictions, data sources and methods, different quality measures –Similar findings in different sectors Specificity –Most consistent effect = staffing

7 7 Assessing the evidence using Bradford Hill guidelines Temporality –Conversions between ownership types (Grabowski and Stevenson, 2008) Experiment –Instrumental variable analysis (Hirth 2013, Grabowski, 2013) Dose-response –Highest profit group, more serious deficiencies (O’Neill, 2003)

8 8 Assessing the evidence using Bradford Hill guidelines Strength of the association –Modest effect sizes, depends on quality measure –Comondore (2009): systematic review and meta-analysis Reviewed 82 studies Global measure of quality: all statistically significant associations favoured NP in 40 studies, mixed results in 37 Specific measures (eg. deficiencies): most favoured NP All had trend towards better in NP facilities, 2 of 4 pooled measures (staffing, pressure ulcer prevalence) statistically significantly better

9 9 Aligning policy with evidence: how do we move forward? Apply the precautionary principle –Take precautionary approach when risk of harm –Shifts the burden of proof to the proponents –Highly vulnerable population Align policy with scientific evidence –“Imperfect knowledge is no excuse for governmental or multinational inaction”.(Annas, 1999)

10 10 Acknowledgments –Social Sciences and Humanities Research Council: “Reimagining Long-Term Residential Care: An International Study of Promising Practices” Thank you…..any questions?


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