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

BMJ 2009; 339 doi: (Published 04 August 2009) Cite this as: BMJ 2009;339:b2732
  1. Vikram R Comondore, resident1,
  2. P J Devereaux, associate professor2,
  3. Qi Zhou, statistician2,
  4. Samuel B Stone, resident3,
  5. Jason W Busse, research associate2, scientist4,
  6. Nikila C Ravindran, resident5,
  7. Karen E Burns, staff physician67,
  8. Ted Haines, associate professor2,
  9. Bernadette Stringer, assistant professor2,
  10. Deborah J Cook, professor2,
  11. Stephen D Walter, professor2,
  12. Terrence Sullivan, president and CEO8,
  13. Otavio Berwanger, professor9,
  14. Mohit Bhandari, associate professor2,
  15. Sarfaraz Banglawala, resident3,
  16. John N Lavis, associate professor2,
  17. Brad Petrisor, assistant professor3,
  18. Holger Schünemann, professor210,
  19. Katie Walsh, summer research assistant2,
  20. Neera Bhatnagar, reference librarian11,
  21. Gordon H Guyatt, professor2
  1. 1Department of Medicine, University of British Columbia, Vancouver, BC, Canada V5Z 1M9
  2. 2Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada L8N 3Z5
  3. 3Department of Surgery, McMaster University
  4. 4The Institute for Work and Health, Toronto, ON, Canada M5G 2E9
  5. 5Department of Medicine, Division of Gastroenterology, University of Toronto, Toronto, M5T 2S8
  6. 6St Michael’s Hospital, Toronto, M5B 1W8
  7. 7Keenan Research Centre and Li Ka Shing Knowledge Institute, Toronto, M5B 1W8
  8. 8Cancer Care Ontario, Toronto, M5G 2L7
  9. 9Department of Clinical Epidemiology, Federal University of Rio Grande do Sul, Porto Alegre-RS, Brazil
  10. 10Italian National Cancer Institute Regina Elena, Rome, 00144, Italy
  11. 11Health Sciences Library, McMaster University
  1. Correspondence to: P J Devereaux philipj{at}
  • Accepted 21 April 2009


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.


  • We acknowledge the outstanding work of Deborah Maddock, Denise Healey, Shelley Anderson, Michelle Murray, Monica Owen, and Laurel Grainger who coordinated this study. We thank our foreign article reviewers Janek Brozek, Matthias Briel, Toshi Furukawa, Marjuka Makela, Ben de Mol, Paola Muti, Patricia Smith, Kristian Thorlund, and David Wei. We appreciate the work of Dana Keilty, Navneet Binepal, Tony Soeyonggo, and Minji Kim, who blinded articles for us. We thank Christina Lacchetti, Michael Levy, and Rajesh Hiralal, who reviewed articles for us, and Diane Heels-Ansdell for her statistical help. We also thank the authors of included studies who did additional analyses for our systematic review: Chappin White, Robert Weech-Maldonado, and Ann L. Gruber-Baldini.

  • Contributors: VRC, PJD, GHG, and TS conceived and designed the study. OB, MB, NB, VRC, DJC, PJD, GHG, SB, JWB, KEB, TH, JNL, BP, NCR, HS, BS, SBS, QZ, and KW were involved in data acquisition. VRC, GHG, QZ, and PJD analysed and interpreted the data. VRC drafted the manuscript. GHG, PJD, and QZ critically revised the manuscript for important intellectual content. QZ and SDW provided statistical expertise. VRC, PJD, and GHG are the guarantors.

  • Funding: Atkinson Foundation Grant; the study sponsor did not contribute to the study design. JWB is funded by a Canadian Institutes of Health research fellowship award. DJC, MB, and JNL are supported, in part, by their respective Canada Research chairs. PJD is supported by a Canadian Institutes of Health Research new investigator award. HS is funded by a European Commission: The Human Factor, Mobility and Marie Curie Actions scientist reintegration grant (IGR 42192).

  • Competing interests: None declared.

  • Ethical approval: Not needed.

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