Primary Care

Quality of care for elderly residents in nursing homes and elderly people living at home: controlled observational study

BMJ 2003; 326 doi: (Published 15 March 2003) Cite this as: BMJ 2003;326:580
  1. Tom Fahey, professor of primary care medicine (t.p.fahey{at},
  2. Alan A Montgomery, lecturer in primary care health services researchb,
  3. James Barnes, registrarc,
  4. Jo Protheroe, MRC training fellow in health services researchd
  1. a Tayside Centre for General Practice, University of Dundee, Dundee DD2 4AD
  2. b Division of Primary Health Care, University of Bristol, Bristol BS6 6JL
  3. c Bradgate Surgery, Bristol BS10 6SP
  4. d National Primary Care Research and Development Centre, University of Manchester, Manchester M13 6PL
  1. Correspondence to: T Fahey
  • Accepted 21 January 2003


Objectives: To assess the quality of care given to elderly people and compare the care given to residents in nursing homes with those living in their own homes.

Design: Controlled observational study.

Setting: Primary care, Bristol.

Subjects: Elderly individuals (aged 65 years) registered with three general practices, of whom 172 were residents in nursing homes (cases) and 526 lived at home (matched controls).

Main outcome measures: The quality of clinical care given to patients was measured against explicit standards. Quality indicators were derived from national sources and agreed with participating general practitioners.

Results: The overall standard of care was inadequate when judged against the quality indicators, irrespective of where patients lived. The overall prescribing of beneficial drugs for some conditions was deficient—for example, only 38% (11/29) (95% confidence interval 20% to 58%) of patients were prescribed β blockers after myocardial infarction. The proportion of patients with heart disease or diabetes who had had their blood pressure measured in the past two years (heart disease) or past year (diabetes) was lower among those living in nursing homes: for heart disease, 74% (17/23) v 96% (122/127) (adjusted odds ratio 0.18, 0.04 to 0.75); for diabetes, 62% (8/13) v 96% (50/52) (adjusted odds ratio 0.05, 0.01 to 0.38). In terms of potentially harmful prescribing, significantly more patients in nursing homes were prescribed neuroleptic medication (28% (49/172) v 11% (56/526) (3.82, 2.37 to 6.17)) and laxatives (39% (67/172) v 16% (85/526) (2.79, 1.79 to 4.36)). Nursing home residents were less likely to have the appropriate diagnostic Read code linked to their prescribed neuroleptic drug (0.22, 0.07 to 0.71).

Conclusions: The quality of medical care that elderly patients receive in one UK city, particularly those in nursing homes, is inadequate. We suggest that better coordinated care for these patients would avoid the problems of overuse of unnecessary or harmful drugs, underuse of beneficial drugs, and poor monitoring of chronic disease.

What is already known on this topic

What is already known on this topic Doctors too often prescribe harmful drugs and too seldom prescribe beneficial drugs for elderly people

The quality of medical care for those living in nursing and residential homes has also been questioned

What this study adds

What this study adds Elderly people in one UK city receive inadequate care when judged against explicit quality indicators

Those living in nursing homes receive poorer care than those living at home in terms of underuse of beneficial drugs, poor monitoring of chronic disease, and overuse of inappropriate or unnecessary drugs


  • Funding This study was funded through an extended registrar contract for JB and through additional research funding from an NHS R&D primary care career scientist award for TF. The guarantor accepts full responsibility for the conduct of the study, had access to the data, and controlled the decision to publish.

  • Competing interest None declared.

  • Ethical approval Ethical approval for the study was obtained from the local research ethics committee.

  • Accepted 21 January 2003
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