clinical pathologist

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In addition to using the federal Medicare comparison information, Janelle Carter of the Associated Press offers other suggestions for choosing a nursing home. Consumers should ask nursing home residents and families, community advocacy groups, personal physicians, and clergy about area facilities. She also recommends that consumers visit several nursing homes at varying times of day and on weekends, when staff and services may be less. Each state is also supposed to have a long-term care ombudsman''s office, which acts as an advocate for those in assisted living or nursing homes. The ombudsman may have information about problems with individual facilities. The National Citizen''s Coalition for Nursing Home Reform (www.nursinghomeaction.com or 202-332-2275) tells how to contact the state ombudsman and provides guidance on choosing a facility as well as how to ensure quality care.

The most noticeable patterns in Table 4 are that, after controlling for endogeneity, (1) having a regular doctor has a greater impact on only two services than having a regular site and is as effective as having a regular site for the other three services, and (2) the magnitude of the impact of having a usual source of care differs by service. In descending order of the impact magnitude, having a regular doctor affected: cholesterol level checkups, pap smears, blood pressure checkups, flu shots, and mammograms. The ordered sequence for the impact magnitude of having a regular site was: pap smears, cholesterol level checkups, mammograms, blood pressure checkups, and flu shots. A regular doctor outperformed a regular site in ensuring that individuals have blood pressure and cholesterol level checkups. No significant differences were found in the effects of having a regular doctor and having a regular site on an individual''s receiving flu shots, mammograms, and pap smears.

Similar approaches, although limited in number, have been applied to nursing homes. Several clinical trials of QI have not been encouraging (Schnelle et al. 1998; McKenna, Moyers, and Feurberg 1998). Additionally, Zinn et al. (1997) found no association between QI adoption as determined from a survey of nursing home administrators, and two outcome measures: percent of residents with pressure ulcers and percent with contractures. However, these outcome measures were limited in that prevalence (as opposed to incidence) of these conditions may be more influenced by admission patterns than by care actually provided in the nursing home, and the measures were not risk-adjusted. We address this issue in testing the hypothesis: [H.sub.5]: Quality improvement implementation in nursing homes is associated with better risk-adjusted patient outcomes.

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