title: The effect of state regulatory stringency on nursing home quality.
abstract: OBJECTIVE
  To test the hypothesis that more stringent quality regulations contribute to better quality nursing home care and to assess their cost-effectiveness.
  
  
  METHODS
  Primary and secondary data from all states and U.S. nursing homes between 2005 and 2006.
  
  
  METHODS
  We estimated seven models, regressing quality measures on the Harrington Regulation Stringency Index and control variables. To account for endogeneity between regulation and quality, we used instrumental variables techniques. Quality was measured by staffing hours by type per case-mix adjusted day, hotel expenditures, and risk-adjusted decline in activities of daily living, high-risk pressure sores, and urinary incontinence.
  
  
  METHODS
  All states' licensing and certification offices were surveyed to obtain data about deficiencies. Secondary data included the Minimum Data Set, Medicare Cost Reports, and the Economic Freedom Index.
  
  
  RESULTS
  Regulatory stringency was significantly associated with better quality for four of the seven measures studied. The cost-effectiveness for the activities-of-daily-living measure was estimated at about 72,000 in 2011/ Quality Adjusted Life Year.
  
  
  CONCLUSIONS
  Quality regulations lead to better quality in nursing homes along some dimensions, but not all. Our estimates of cost-effectiveness suggest that increased regulatory stringency is in the ballpark of other acceptable cost-effective practices.
authors.affiliation: Health Policy Research Institute, University of California, Irvine, 100 Academy, Suite 110, Irvine, CA 92697-5800, USA. dmukamel@uci.edu
authors.forename: Dana B
authors.initials: DB
authors.lastname: Mukamel
authors.forename: David L
authors.initials: DL
authors.lastname: Weimer
authors.forename: Charlene
authors.initials: C
authors.lastname: Harrington
authors.forename: William D
authors.initials: WD
authors.lastname: Spector
authors.forename: Heather
authors.initials: H
authors.lastname: Ladd
authors.forename: Yue
authors.initials: Y
authors.lastname: Li
mesh_terms: D000203:Activities of Daily Living; D003362:Cost-Benefit Analysis; D033161:Government Regulation; D006801:Humans; D016018:Least-Squares Analysis; D009735:Nursing Homes / Q000191:economics / Q000331:legislation & jurisprudence* / Q000592:standards; D010561:Personnel Staffing and Scheduling / Q000706:statistics & numerical data; D003668:Pressure Ulcer / Q000453:epidemiology; D019984:Quality Indicators, Health Care / Q000706:statistics & numerical data; D011787:Quality of Health Care / Q000331:legislation & jurisprudence* / Q000592:standards; D013219:State Government; D014481:United States; D014549:Urinary Incontinence / Q000453:epidemiology; D000078329:Workforce