Published 4 August 2009, doi:10.1136/bmj.b2732
Cite this as: BMJ 2009;339:b2732

Research

Quality of care in for-profit and not-for-profit nursing homes: systematic review and meta-analysis

Vikram R Comondore, resident1, P J Devereaux, associate professor2, Qi Zhou, statistician2, Samuel B Stone, resident3, Jason W Busse, research associate, scientist2,4, Nikila C Ravindran, resident5, Karen E Burns, staff physician6,7, Ted Haines, associate professor2, Bernadette Stringer, assistant professor2, Deborah J Cook, professor2, Stephen D Walter, professor2, Terrence Sullivan, president and CEO8, Otavio Berwanger, professor9, Mohit Bhandari, associate professor2, Sarfaraz Banglawala, resident3, John N Lavis, associate professor2, Brad Petrisor, assistant professor3, Holger Schünemann, professor2,10, Katie Walsh, summer research assistant2, Neera Bhatnagar, reference librarian11, Gordon H Guyatt, professor2

1 Department of Medicine, University of British Columbia, Vancouver, BC, Canada V5Z 1M9, 2 Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada L8N 3Z5, 3 Department of Surgery, McMaster University, 4 The Institute for Work and Health, Toronto, ON, Canada M5G 2E9, 5 Department of Medicine, Division of Gastroenterology, University of Toronto, Toronto, M5T 2S8, 6 St Michael’s Hospital, Toronto, M5B 1W8, 7 Keenan Research Centre and Li Ka Shing Knowledge Institute, Toronto, M5B 1W8, 8 Cancer Care Ontario, Toronto, M5G 2L7, 9 Department of Clinical Epidemiology, Federal University of Rio Grande do Sul, Porto Alegre-RS, Brazil, 10 Italian National Cancer Institute Regina Elena, Rome, 00144, Italy, 11 Health Sciences Library, McMaster University

Correspondence to: P J Devereaux philipj{at}mcmaster.ca

Objective To compare quality of care in for-profit and not-for-profit nursing homes.

Design Systematic review and meta-analysis of observational studies and randomised controlled trials investigating quality of care in for-profit versus not-for-profit nursing homes.

Results A comprehensive search yielded 8827 citations, of which 956 were judged appropriate for full text review. Study characteristics and results of 82 articles that met inclusion criteria were summarised, and results for the four most frequently reported quality measures were pooled. Included studies reported results dating from 1965 to 2003. In 40 studies, all statistically significant comparisons (P<0.05) favoured not-for-profit facilities; in three studies, all statistically significant comparisons favoured for-profit facilities, and the remaining studies had less consistent findings. Meta-analyses suggested that not-for-profit facilities delivered higher quality care than did for-profit facilities for two of the four most frequently reported quality measures: more or higher quality staffing (ratio of effect 1.11, 95% confidence interval 1.07 to 1.14, P<0.001) and lower pressure ulcer prevalence (odds ratio 0.91, 95% confidence interval 0.83 to 0.98, P=0.02). Non-significant results favouring not-for-profit homes were found for the two other most frequently used measures: physical restraint use (odds ratio 0.93, 0.82 to 1.05, P=0.25) and fewer deficiencies in governmental regulatory assessments (ratio of effect 0.90, 0.78 to 1.04, P=0.17).

Conclusions This systematic review and meta-analysis of the evidence suggests that, on average, not-for-profit nursing homes deliver higher quality care than do for-profit nursing homes. Many factors may, however, influence this relation in the case of individual institutions.


This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/2.0/ and http://creativecommons.org/licenses/by-nc/2.0/legalcode.

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