This week's Journals: Care homes - not for Profit v.Profit

Reading my BMJ this week I found a meta-analysis asking whether a nursing home that was 'for profit' or 'not for profit' makes a difference to quality of care. Of course to a dyed in the wool socialist like me the answer is obvious: if you are making profit then that means that profit is being made, and if profit is made then there is money going to shareholders that could go back to improving care. 

If you are less of a mad leftie than I am - then you can see that 'for profit' companies are often more effective that 'not for profit' charities.

The most obvious thing is 'How you do define good quality care in a Nursing Home?' Surely the answer to this depends on the question you ask. For instance do you define a good quality nursing home as one where the care is well documented? Or one where the residents have no bedsores. Or one where they don't have to share rooms.

I've not critically appraised a systematic review before. As Mark Crislip of Puscast is apt to say 'crap in, crap out' If you put together a lot of poor quality studies into a systematic review you get a poor quality systematic review. So I thought I should use a critical appraisal tool like this one. I didn't publish the full critical appraisal here, but I did work through most of it. 

This meta-analysis looked a studies with the outcomes of

1. Pressure ulcers. 

Seems sensible enough. Good quality care means you get less pressure ulcers, pressure ulcers are avoidable and painful. 

2. Quality / training of staff. 

Just having a nursing degree doesn't necessarily mean you are a better carer than someone who doesn't. But one could assume that it probably would mean you had more of a clue on how to nurse. 

3. Physical Restraint

The physical restraint thing is an interesting issue - would a nursing home that uses less physicial restraint have more falls, or would it use more sedative drugs. 

4. Regulatory Deficiencies 

This seems a valid way of comparing nursing homes. A poor nursing home would be picked up as poor by the regulatory body much more often. But this rather depends on who the regulators are and how they regulate. It would be difficult to compare regulatory assessments in the US in the 1970s to Holland in the 2000s. 

So what did it show?

Well not-for-profit owned homes were slightly better staffed and slightly less likely to have pressure sores, both of those results were statistically significant. The other outcomes didn't reach statistical significance. 

There was a big variation between the studies.  In lots of studies there wasn't any statistically significant difference between 'for-profit' and 'not-for-profit'.  I think that this must mean that there is a lot of overlap. Ie: that there are plenty of good 'for-profit' nursing homes and  plenty of poor 'not-for-profit' ones. I suspect it also means that at different times and different places things are difficult. 

I also thought it was interesting that this really only looks at quanitative outcomes, things you can measure. Would it be interesting to look at qualative outcomes? How happy were the clients? Difficult to assess in clients with dementia, I admit. 

Though if I was a relative the big question that I would want to ask would be:

'Do the staff care about my relative? - Not just go through the motions of care, but do they talk to her? do they care?' 

'Will she be happy there?' 

'Will the home smell of urine?' 

'Would I want to end my days here?'

Will this study change my practice?

No, not really. If a relative were to ask me 'Doctor, do you think I should choose a care home ran by a company or one ran by a charity?' I would say that it really depends on the home, there are good ones run by companies and poor ones ran by chairities. 

Also you know your relative the best. The most important thing to your relative might be close to home so their friends can visit them, or a home where they can continue to go to church in a taxi.