Accepted for/Published in: JMIR Human Factors
Date Submitted: Feb 17, 2025
Date Accepted: Sep 23, 2025
Demystifying Quality Metrics and Unveiling the True Measure of Quality of Care in Nursing Homes
ABSTRACT
Background:
The regulatory framework for nursing homes has evolved significantly, with a growing emphasis on outcome-based quality indicators. The Minimum Data Set (MDS) underpins the Five-Star Quality Rating System for Nursing Homes, a widely used performance measure with both strengths and limitations.
Objective:
This study examines the validity of the Five-Star Rating System and its associated quality indicators in assessing nursing home care quality.
Methods:
We constructed a panel dataset from three primary sources: (1) COVID-19 nursing home data, (2) payroll-based journal (PBJ) data, and (3) nursing home quality measure snapshots. COVID-19 outcomes—resident and staff cases and death counts from May 2020 to June 2023—were used as dependent variables. Predictor variables included the Five-Star Rating System and its structural, process, and outcome (SPO) quality indicators. We applied hierarchical generalized linear mixed-effects modeling to assess associations between COVID-19 outcomes and SPO quality measures. The dataset comprised 15,416 nursing homes that reported at least one week of COVID-19 data at the facility level.
Results:
Staffing levels, health deficiency scores, COVID-19 hospitalizations, and vaccination rates were significantly associated with COVID-19 outcomes. However, the Five-Star Rating System, Medicaid dependency, and ownership type demonstrated no clear relationship with these outcomes.
Conclusions:
Despite its widespread use, the Five-Star Quality Rating System for Nursing Homes is an unreliable measure of care quality. Policymakers, lawmakers, and industry stakeholders must work toward refining and improving the system to ensure its reliability and effectiveness in assessing nursing home performance.
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