Nursing home star ratings and new onset of depression in long-stay nursing home residents

Abstract

Objectives

To examine the association between nursing home (NH) quality and new onset of depression and severity of depressive symptoms in a national cohort of long-stay NH residents in the United States (U.S.)

Design

Cohort study.

Setting and Participants

129,837 long-stay residents without indicators of depression admitted to 13,921 NHs.

Methods

NH quality was measured by Nursing Home Compare star ratings (overall, health inspection, staffing, quality measures) closest to admission. Study outcomes at 90 days from the Minimum Data Set 3.0 included depression diagnosis and severity of depressive symptoms (Minimal; Mild; Moderate; Moderately Severe/Severe). Symptoms were measured by resident self-report Patient Health Questionnaire (PHQ-9) or a staffreport observational version (PHQ-9-OV). Logistic and multinomial logistic models with generalized estimating equations were used to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI).

Results

At 90 days post-admission, 14.1% of residents had a new diagnosis of depression and odds did not differ across star ratings. Nearly 90% of these residents had minimal depressive symptoms with only 8.5% reporting mild symptoms and 2.6% with moderate to severe symptoms. Using minimal depressive symptoms as the reference, residents in NHs with 5-star overall ratings were 12% less likely than those in 3-star NHs to experience mild (95%CI: 0.81 – 0.96) and 31% less likely to experience moderate symptoms (95%CI: 0.58 – 0.82). In NHs with 1-star staffing compared to 3-star, residents had 37% higher odds of moderate symptoms (95%CI: 1.14 – 1.64) and 57% higher odds of moderately severe/severe depressive symptoms (95%CI: 1.17 – 2.12). The odds of any above-minimal depressive symptoms decreased as quality measure ratings increased.

Conclusions and Implications

Lower NH quality ratings were associated with more severe depressive symptoms. Further investigation is warranted to identify potential mechanisms for a targeted intervention to improve quality and provide more equitable care.

Brief summary:

90 days after nursing home admission, 1 in 7 residents had new depression diagnosis and 1 in 9 had new onset of depressive symptoms. Lower ratings were associated with more severe depressive symptoms.

Introduction

Depression is the most prevalent mental health disorder in nursing homes (NHs) and affects nearly half of all residents.¹ For older adults admitted to NHs without depression, 9.3% to 14.2% are diagnosed with depression after 90 days^{2, 3} and 21.6% after one year.³ Little is known about the factors that may influence the new onset of depression and depressive symptoms after NH admission.

NH quality may play a role.^2–5 The Nursing Home Compare (NHC) star ratings, established by the Centers for Medicare & Medicaid Services (CMS), is one way to quantify NH quality. NHC contains three domains: (1) health inspection: onsite annual surveys by trained inspectors on NH compliance with federal requirements, (2) staffing: average number of hours of care per resident per day (risk-adjusted for resident casemix), and (3) quality measures (QMs): selected validated health outcome indicators from MDS 3.0 and Medicare claims.⁶ (Appendix A: NHC methodology) As the only publicly-available repository on quality for all U.S. Medicare-/Medicaid-certified NHs, NHC provides a benchmark for providers to improve quality and a resource for consumers to select NHs.

The development of depression and depressive symptoms after admission may differ across NH quality as measured by NHC star ratings. This study aimed to examine the association between NH star ratings and new diagnosis of depression as well as new onset of depressive symptoms in a national cohort of long-stay NH residents.

Methods

Data

We used NHC and 2013 Minimum Data Set (MDS) 3.0, a mandated assessment for Medicaid/Medicare-certified NHs on residents’ demographic and clinical profiles at admission, quarterly, annually, and when a significant change in health status occurs.⁷ Assessments included “admission” and “90-day,” defined as the assessment closest to 90 days after admission with a +/−31-day window.

For NHC, each domain (health inspection, staffing, and QMs) receives a rating on a 5-star scale. An overall rating is calculated with health inspection rating as the base, and adding or subtracting stars according to staffing and QMs ratings sequentially.⁶ NHC star ratings are updated every quarter. We used data from the most recent quarter prior to residents’ admission.

Sample

Residents admitted in 2013 were included if they did not have a diagnosis of depression at admission; were not using antidepressants; had none or minimal depressive symptoms based on Patient Health Questionnaire (PHQ-9) or its observational version (PHQ-9-OV); and their NH stay exceeded 90 days. Residents were excluded if, in admission or 90-day assessments, they had: diagnosis of bipolar depression or schizophrenia; were comatose; or lived in NHs with missing ratings. For eligible residents with multiple admissions to the same NH during 2013, we randomly selected one visit. The final sample included 129,837 residents from 13,921 NHs. (Appendix B: Figure A1)

Exposure

Overall, health inspection, staffing and QMs ratings were analyzed separately as ordinal variables from 1 to 5 stars with 1-star increments. The reference is “3 stars” as CMS considers it “average” quality.⁶

Outcomes

Two study outcomes were derived from the 90-day assessment: (1) depression diagnosis (Section I: Active Diagnoses) and (2) severity of depressive symptoms (Section D: Mood).⁷ For residents diagnosed with depression, we also examined their receipt of antidepressants during the last 7 days (Section N: Medications).⁷ Symptoms were assessed by self-report PHQ-9 or staff-report PHQ-9-OV.⁷ Both scales have high specificity in assessing NH residents’ depressive symptoms NH.⁸ Severity of depressive symptoms summary score was categorized into: minimal (PHQ-9/PHQ-9-OV: 0–4), mild (PHQ-9/PHQ-9-OV: 5–9), moderate (PHQ-9/PHQ-9-OV: 10–14) and moderately severe/severe (PHQ-9: 15–27; PHQ-9-OV: 15–30).

Covariates

From the admission assessment, we extracted residents’ demographic characteristics: age, gender, race/ethnicity, and marital status; and health characteristics: body mass index (BMI), comorbidities (anxiety, arthritis, diabetes, hypertension, cancer, stroke, congestive heart failure, chronic obstructive pulmonary disease, dementia, Alzheimer’s disease, Parkinson’s disease), any presence of pain, physical function (activities of daily living (ADL) scale), and cognitive function (Cognitive Function Scale).^{3, 4, 9–11} We examined NH facility characteristics: ownership, number of certified beds, and occupancy rate,¹⁰ and geographic characteristics: region and urbanicity.¹⁰

Analysis

We described sample characteristics at admission, and depression diagnosis and severity of depressive symptoms at 90-day in percentages, by overall ratings. Since trivial differences could be statistically significant given the large sample size, an absolute difference of ≥ 5% was considered noteworthy.

We examined the association of star ratings with depression diagnosis using logistic regression, and with severity of depressive symptoms using multinomial logistic regression. Both models were estimated using generalized estimating equations to account for two levels of clustering: the clustering of residents in the same facility and the clustering of NHs in the same state. Both models adjusted for all study covariates. In the multinomial model, we further adjusted for whether PHQ-9 or PHQ-9-OV was used. Effect estimates are presented as adjusted odds ratios (aOR) with 95% confidence intervals (95%CI). We used Type III sum of squares test to examine the overall association between star ratings and study outcomes. Moreover, we treated the ordinal ratings as continuous in the models above to assess linear trend.

In sensitivity analyses, we used +/−14-day and +/−45-day windows to select the “90-day assessment”. With the same eligibility criteria, we identified respective study samples (+/−14-day: 115,058 residents from 13,777 NHs; +/−45-day: 136,438 residents from 13,959 NHs) and applied the same analytic approach.

Analyses were conducted in SAS 9.4.¹²

Results

Of 129,837 eligible residents, 13.6% were admitted to NHs with 1-star overall ratings. NHs with 1-star overall had higher proportions of residents who were younger, male, and non-Hispanic Black compared to NHs with more stars, despite similar distribution of health characteristics and most comorbid conditions. More 1-star NHs were for-profit, larger, with lower occupancy rate, and in the South than those with better ratings. (Appendix B: Table A1)

Ninety days after admission, 14.1% of residents had a diagnosis of depression. The majority of residents with depression diagnosis received antidepressants (86.9%). About 8.5% experienced mild and 2.6% moderate to severe depressive symptoms. The distributions of depression diagnosis and of depressive symptoms were similar across overall ratings (Table 1).

Table 1.

Diagnosis of depression and severity of depressive symptoms at residents’ 90-day stay by nursing home overall star rating

	Total‡	Overall star rating
		1 star	2 stars	3 stars	4 stars	5 stars
	(%)			(%)
Diagnosis of depression	14.1	14.0	13.6	14.1	14.3	14.3
Use of antidepressants*	86.9	86.2	87.0	86.8	86.8	87.4
Severity of depressive symptoms†
Minimum	89.0	88.6	89.1	88.4	88.9	89.8
Mild	8.5	8.5	8.4	8.8	8.6	8.2
Moderate	2.0	2.3	2.0	2.2	2.0	1.6
Moderately severe/severe	0.6	0.6	0.6	0.6	0.6	0.4

Note:

^*Number of residents with MDS 3.0 documented antidepressant use at 90 days divided by number of residents with depression diagnosis at 90 days.

^†Severity of depressive symptoms was measured by PHQ-9 or PHQ-9-OV: minimal (PHQ-9/PHQ-9-OV: 0 – 4), mild (PHQ-9/PHQ-9-OV: 5 – 9), moderate (PHQ-9/PHQ-9-OV: 10 – 14) and severe symptoms (PHQ-9: 15 – 27; PHQ-9-OV: 15 – 30). We combined the moderately severe (PHQ-9/PHQ-9-OV: 15 – 19) and severe (PHQ-9: 20 – 27; PHQ-9-OV: 20 – 30).

^‡May exceed 100% due to rounding errors.

We did not observe an association between overall ratings and diagnosis of depression at 90 days, and the estimates of association between health inspection and staffing ratings and a diagnosis of depression diagnosis were small. (Table 2).

Table 2.

Association between nursing home star ratings and residents’ diagnosis of depression

	Diagnosis of depression at 90 days
	OR*	95%CI	aOR†	95%CI
Overall rating (ref: 3 stars)
1 star	0.99	(0.93– 1.06)	0.95	(0.88– 1.02)
2 stars	0.96	(0.90– 1.02)	0.98	(0.92– 1.04)
4 stars	1.02	(0.96– 1.07)	1.01	(0.95– 1.07)
5 stars	1.02	(0.96– 1.08)	1.05	(0.98– 1.12)
Overall P‡	0.3067		0.0921
Linear trend P§	0.0999		0.0055
Health inspection rating (ref: 3 stars)
1 star	0.96	(0.91– 1.02)	0.97	(0.91 – 1.03)
2 stars	0.94	(0.89– 0.99)	0.94	(0.89 – 1.00)
4 stars	1.03	(0.97– 1.09)	1.01	(0.96– 1.07)
5 stars	1.05	(0.97– 1.14)	1.06	(0.98– 1.15)
Overall P‡	0.0042		0.0226
Linear trend P§	0.0008		0.0059
Staffing rating (ref: 3 stars)
1 star	1.01	(0.95– 1.08)	0.99	(0.92– 1.07)
2 stars	1.06	(0.99– 1.12)	1.04	(0.97– 1.11)
4 stars	1.01	(0.96– 1.06)	1.03	(0.98– 1.09)
5 stars	0.80	(0.73– 0.89)	0.89	(0.81 – 0.99)
Overall P‡	<0.0001		0.0305
Linear trend P§	0.0014		0.7018
Quality measures rating (ref: 3 stars)
1 star	1.04	(0.93– 1.16)	1.04	(0.92– 1.17)
2 stars	1.05	(0.98– 1.12)	1.06	(0.99– 1.14)
4 stars	1.00	(0.95– 1.05)	1.03	(0.97– 1.09)
5 stars	0.97	(0.91– 1.02)	1.03	(0.97– 1.10)
Overall P‡	0.1242		0.5813
Linear trend P§	0.0134		0.9297

Note:

^*Unadjusted odds ratios: Logistic regression model estimated through generalized estimation equation, adjusting for clustering of residents in the same nursing home and clustering of nursing homes in the same state. The model did not adjust for other covariates.

^†Adjusted odds ratios: Logistic regression model estimated through generalized estimation equation, adjusting for clustering of residents in the same nursing home and clustering of nursing homes in the same state, and controlling for residents’ demographic variables (age group, gender, race/ethnicity, marital status), health characteristics (BMI, comorbidities, number of comorbidities, physical functioning, cognitive impairment, any presence of pain), nursing home facility characteristics (ownership, size in quartiles, occupancy rate in quartiles), and geographic characteristics (region and urbanicity).

^‡P-value for Type III test of overall association between ordinal star ratings and depression diagnosis.

^§P-value for linear trend for star ratings by entering the ratings as a continuous variable into the model.

The association between star ratings and severity of depressive symptoms are shown in Figure 1 (effect estimates in Appendix B: Table A2-a and A2-b), with minimal depressive symptoms as the reference. Overall ratings were inversely associated with mild and moderate depressive symptoms at 90 days. In NHs with 5-star overall rating compared to 3-star, residents were 12% and 31% less likely to experience mild (aOR: 0.88, 95%CI: 0.81–0.96) and moderate (aOR: 0.69, 95%CI: 0.58–0.82) symptoms, respectively. No consistent trends were apparent for health inspection ratings. For staffing, lower ratings were associated with significant increases in moderate to severe depressive symptoms. Compared to those in NHs with average staffing rating, residents in NHs with 1-star staffing were 37% more likely to have moderate (aOR: 1.37, 95%CI: 1.14–1.64) and 57% more likely to have moderately severe/severe (aOR: 1.57, 95%CI: 1.17–2.12) depressive symptoms. Further, in NHs with higher QMs rating, residents were less likely to experience any depressive symptoms. Living in NHs with 5-star QMs rating compared to 3-star was associated with lowered odds of mild depressive symptoms by 15% (aOR: 0.85, 95%CI: 0.79–0.92), moderate symptoms by 24% (aOR: 0.76, 95%CI: 0.64–0.88), and moderately severe/severe symptoms by 25% (aOR: 0.75, 95%CI: 0.58–0.96).

Figure 1. Association between nursing home star ratings and residents’ severity of depressive symptoms (adjusted for study covariates).

Note:

Multinomial logistic regression model estimated through generalized estimation equation, adjusting for clustering of residents in the same nursing home and clustering of nursing homes in the same state, and controlling for residents’ demographic variables (age group, gender, race/ethnicity, marital status), health characteristics (BMI, comorbidities, number of comorbidities, physical functioning, cognitive impairment, any presence of pain), nursing home facility characteristics (ownership, size in quartiles, occupancy rate in quartiles), and geographic characteristics (region and urbanicity). Model included indicator for whether PHQ-9 or PHQ-9-OV was used. Figure was created in R with ggplot2 package. Effect estimates were presented in Appendix B: Table A2-a and A2-b.

Sensitivity analyses showed consistent results. (Appendix B: Tables A3 to A10)

Discussion

In long-stay NH residents admitted without indicators for depression, we found that approximately one in seven had a new diagnosis of depression after 90 days, regardless of facility star ratings. Relatively few residents experienced moderate to severe depressive symptoms. Living in NHs with 1-star staffing was associated with increased odds of new onset of worse depressive symptoms, while living in NHs with 5-star overall or 5-star QMs ratings was associated with lowered odds.

Late-life depression in older adults may have different manifestations and could be misdiagnosed in the presence of physical comorbidities.^{13, 14} NHs of higher quality may perform better at identifying depression, while lower quality homes may lack staff with adequate training in mental health to do so.¹¹ Because the prevalence of depression may contribute to Medicaid reimbursement case-mix adjustment, providers may also have incentives to up-code or down-code the diagnosis.¹⁵ The lack of trend in depression diagnosis across star ratings may be an artifact of differential recognition and documentation. In contrast, severity of depressive symptoms was measured by metrics shown to have good interrater reliability, high specificity, and strong correlation with evaluation from mental health specialists in NH residents.^{8, 16} The inconsistent observation that depression diagnosis did not vary across star ratings but severity of depressive symptoms did suggests future work to improve and integrate both measures to better capture the most prevalent mental health disorder in NHs.

Most residents with diagnosed depression received antidepressants, which may partially explain that the prevalence of depression diagnosis was much higher than the prevalence of moderate to severe depressive symptoms. Since MDS 3.0 does not collect information on medication indications, we could not assess if the antidepressants were prescribed to manage depression and whether it was appropriate and/or effective. However, we found that only residents in top-quality NHs were significantly less likely to experience depressive symptoms. Although one previous study found older adults with depression or anxiety had consistently less access to NHs with 5-star staffing ratings,¹⁷ it is unlikely that these selection forces would explain our finding because residents had minimal depressive symptoms at admission. Top-quality NHs tend to cluster in affluent areas,¹⁸ and residents from socioeconomically underprivileged areas have limited access.¹⁹ Quality improvement interventions in NHs, including culture change towards patient-centered care^20–22 and early detection and treatment training or toolkits,²³ have been successful in reducing depressive symptoms. Our findings reinforce that additional incentives should be provided to poorly-rated homes, which may already face resource constraints to initiate/sustain quality improvement efforts.²⁴

Despite being the only national public platform for NH quality, NHC may not be robust enough to reflect the differential NH quality with regards to new depression diagnosis post admission. Previous studies found limited clinically meaningful differences across NHC ratings in 30-day readmission, deaths, and quality of life.^{25, 26} To this end, CMS should consider efforts to provide greater granularity in NHC, such as metrics that incorporate resident experiences,²⁷ flexible rating systems tailored towards residents’ preference and care needs,²⁸ efficient real-time data collection,²⁹ and adequate risk adjustment to ensure comparability across NHs, so consumers can make full use of it to make informed decisions about the placement of a loved one.

To our knowledge, this is the first study to examine the impact of NHC star ratings on new onset of depression and depressive symptoms in NH residents after the first 90-day stay on the national level. We included residents of all ages instead of only older adults. The use of individual domain ratings sheds light on specific quality dimensions. This study connected publicly available star ratings with the most prevalent mental health disorder in NHs, making findings more interpretable for consumers and stakeholders. Limitations included unmeasured confounders that could affect depression, including changes in resident and facility characteristics over time and unmeasured variables in the MDS 3.0 (e.g., loss of a home or family member).

Conclusions

Ninety days after NH admission, one in seven residents had a new diagnosis of depression, and one in nine experienced new onset of mild to severe depressive symptoms. NH star ratings were inversely associated with more severe depressive symptoms, but not with depression diagnosis. Results underscore the importance of depression recognition and management by NH healthcare professionals. Moreover, findings reiterate the crucial need for more resources allocated to poorly-rated NHs to retain an optimal staffing level and improve quality of care.

Appendix A. Nursing Home Compare (NHC) Methodology

The Nursing Home Compare (NHC) Five-star Quality Rating system was established by the Centers for Medicare & Medicaid Services (CMS) in 2008 for all nursing homes in the United States (U.S.) that were certified by Medicare and/or Medicaid. The system is based on three domains: (1) health inspection, (2) staffing, and (3) quality measures. This appendix presents a brief summary of the methodology for each domain as well as the calculation for the composite overall rating. Because the database of the study included NHC 2013, this summary focused solely on the 2013 data year, which may not applicable to earlier or later data years. Detailed information can be found in the report by the Abt Associates: Abt Associates. Nursing Home Compare Five-Star Quality Rating System: Year Five Report; 2014. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/NHC-Year-Five-Report.pdf.

Health inspection rating

• Health inspection is conducted annually by state health care professionals to assess whether a nursing home follows federal requirements.

• Points are given to each facility on the basis of the number, scope and severity of the deficiencies uncovered in the most recent three annual inspections, with most recent highest weight.

• Higher points represent lower quality.

• Stars are assigned based on facilities’ relative performance within the state. The top 10% in a given state will be given 5 stars, middle 70% receive 2 to 4 stars, and bottom 20% will be given 1 star.

Staffing rating

• Staffing rating is based on the combination of two measures: registered nurse (RN) hours per resident day and total nursing hours per resident day. The latter measure includes the total hours of RN, licensed practical or vocational nurse (LPN/LVN), and certified nurse aide (CNA)) per resident day.

• Both measures are reported by the facility adjusted for resident case mix using the Resource Utilization Group (RUG-III) case-mix system.

• National cut points are established to assign stars.

Quality measure rating

• For NHC 2013, quality measure (QM) rating is based on 9 out of 18 Minimum Data Set (MDS) 3.0 QMs (see the following table). According to the Abt report, “The QMs that are included in the rating were selected from among the publicly reported QMs based on several criteria, including clinical importance, the extent to which the measure is under facility control, and statistical performance, including reliability, validity and variability”

Long-stay measures

Percent of residents whose need for help with daily activities has increased Percent of high-risk residents with pressure sores Percent of residents who had a catheter inserted and left in their bladder Percent of residents who were physically restrained Percent of residents with a urinary tract infection Percent of residents who self-report moderate to severe pain Percent of residents experiencing one or more falls with major injury

Short-stay measures

Percent of residents with pressure ulcers (sores) that are new or worsened Percent of residents who self-report moderate to severe pain

• Note that “Percent of Long Stay Residents Who Have Depressive Symptoms” is a public QM for nursing homes, but it is not included in the calculation of the summary ?QM rating in the NHC system.

• Imputation and risk adjustment (for 5 measures) are conducted when applicable. Summary quality measure score is computed for each facility following a list of specific rules.

• Each nursing home receives a numerical score on their respective performance on the 9 QMs, which are summed up with equal weights for a summary QM score. Star ratings are assigned based on national distribution of the summary QM score.

Overall rating:

Step 1: Start with health inspection rating

Step 2: Add 1 star if staffing rating is 4 or 5 stars and greater than health inspection rating, subtract 1 star if staffing rating is 1 star. The overall rating cannot be more than 5 or less than 1 star.

Step 3: Add 1 star if QM rating is 5 stars, subtract 1 star if QM rating is 1 star. The overall rating cannot be more than 5 or less than 1 star.

Note:

1. The overall rating cannot be upgraded by more than 1 star with staffing and QM ratings for nursing homes with 1-star health inspection rating.

2. The maximum overall rating is 3 stars for nursing homes that are current Special Focus Facilities (SFF).

Appendix B. Figure and Tables

Figure A1.

Sample selection flowchart Note:

* Residents may meet several exclusion criteria.

Table A1.

Characteristics of long-stay residents (≥90 days) upon admission by nursing home overall star rating (n = 129,837)

	Overall star rating
	1 star n=17,704	2 stars n=29,289	3 stars n=26,816	4 stars n =33,564	5 stars n=23,094
	(%)
Age (years)
<65	19.4	17.0	13.8	10.2	8.8
65–<75	16.9	16.3	15.1	13.4	11.6
75–<85	28.4	29.1	28.8	30.2	28.3
85+	35.4	37.6	42.3	46.2	51.3
Women	56.7	57.3	59.7	62.0	63.7
Race/ethnicity
Non-Hispanic White	70.9	69.3	74.4	78.6	79.8
Non-Hispanic Black	20.6	20.8	16.9	13.3	11.2
Hispanic	5.8	6.1	5.3	4.9	4.9
Other	2.7	3.8	3.5	3.2	4.2
Marital status
Never married	19.3	20.5	17.3	14.5	14.6
Married	24.4	24.5	25.2	25.2	25.2
Widowed	41.4	42.0	45.3	48.7	50.5
Divorced/separated	14.8	13.0	12.2	11.6	9.8
Body mass index (BMI)
< 18.5kg/m2	10.2	10.2	9.8	9.3	9.5
18.5 <= BMI < 24.9 kg/m2	41.5	42.4	42.3	42.9	44.3
24.9 <= BMI < 29.9 kg/m2	25.6	25.5	26.5	27.1	26.9
BMI >= 29.9 kg/m2	22.7	21.8	21.3	20.7	19.3
Comorbidities
Anxiety	13.4	12.4	13.1	12.8	12.0
Arthritis	20.9	21.4	22.8	25.0	26.4
Diabetes	34.3	33.6	32.6	31.1	29.1
Hypertension	72.8	72.9	73.1	74.1	74.2
Cancer	6.6	7.1	7.3	7.0	7.3
Stroke	16.9	16.3	15.7	15.4	15.2
Congestive heart failure	17.9	18.0	18.7	19.3	19.2
Chronic obstructive pulmonary disease	18.6	18.2	17.9	17.9	16.7
Dementia	30.6	31.3	31.3	32.8	33.2
Alzheimer’s Disease	10.0	9.7	10.3	10.9	10.8
Parkinson’s Disease	3.7	4.0	4.3	4.6	4.8
Number of comorbidities: 3 or more	47.2	46.8	47.2	48.6	47.9
Physical functioning*
Minimal ADL limitation	17.8	16.5	15.6	15.6	14.1
Moderate ADL limitation	52.7	54.5	55.9	56.8	56.9
Severe ADL limitation	29.5	29.0	28.6	27.7	29.0
Cognitive function†
Intact	35.1	35.9	35.3	35.1	35.1
Mild impairment	24.0	24.1	24.5	25.0	24.8
Moderate impairment	33.0	32.2	32.5	33.2	32.7
Severe impairment	8.0	7.7	7.7	6.8	7.4
Any presence of pain	42.3	41.7	42.9	43.4	41.8
Nursing home ownership
For-profit	83.2	75.3	74.2	67.7	59.4
Non-profit	12.5	18.9	20.1	25.9	34.1
Government-owned	4.3	5.8	5.7	6.4	6.5
Nursing home size
Quartile 1 (low): < 72 beds	6.1	7.1	10.0	14.3	20.0
Quartile 2: 72–<103 beds	15.9	16.1	17.0	19.3	19.4
Quartile 3: 103–< 133 beds	30.2	28.4	29.4	28.9	26.5
Quartile 4 (high): 133+beds	47.8	48.4	43.6	37.5	34.0
Nursing home occupancy rate
Quartile 1 (low): < 76.9%	25.7	22.5	20.7	17.2	14.5
Quartile 2: 76.9 – 87.3%	26.4	26.6	25.9	24.2	22.0
Quartile 3: 87.3% – < 93.5%	27.3	26.9	27.2	29.0	28.3
Quartile 4 (high): 93.5% +	20.6	24.1	26.2	29.6	35.2
Region
Northeast	21.0	23.1	23.6	24.1	27.2
Midwest	25.5	26.8	27.2	28.1	26.8
South	39.6	34.1	33.5	32.0	28.4
West	13.9	16.1	15.6	15.8	17.5
Rural	23.8	19.5	23.0	24.2	20.5

Note:

^*Activities of Daily Living (ADL) self-performance hierarchy scale: minimal (0–2), moderate (3–4) and severe ADL limitations (5–6).

^†Cognitive Function Scale (CFS): intact (Brief Interview for Mental Status (BIMS): 13–15), mildly impaired (BIMS: 8–12 or Cognitive Performance Scale (CPS): 0–2), moderately impaired (BIMS 0–7/CPS 3–4) and severely impaired (CPS 5–6).

Table A2-a.

Association between nursing home star ratings and residents’ severity of depressive symptoms (unadjusted for study covariates)

	Mild vs. Minimal symptoms		Moderate vs. Minimal symptoms		Moderately severe/severe vs. Minimal symptoms
	OR*	95% Cl	OR*	95% Cl	OR*	95% Cl
Overall rating (ref: 3 stars)
1 star	0.97	(0.88– 1.07)	1.03	(0.86– 1.23)	1.13	(0.85– 1.52)
2 stars	0.94	(0.87– 1.02)	0.85	(0.73– 1.00)	1.01	(0.78– 1.31)
4 stars	0.98	(0.91– 1.05)	0.89	(0.77– 1.03)	1.03	(0.80– 1.31)
5 stars	0.92	(0.84– 1.00)	0.69	(0.58– 0.82)	0.78	(0.58– 1.04)
Overall P†	0.2791		0.0001		0.1793
Linear trend P‡	0.5562		0.0006		0.0485
Health inspection rating (ref: 3 stars)
1 star	0.94	(0.87– 1.02)	0.94	(0.81– 1.11)	0.94	(0.73– 1.21)
2 stars	1.00	(0.93– 1.08)	0.86	(0.74– 0.99)	1.04	(0.82– 1.32)
4 stars	0.99	(0.92– 1.07)	0.89	(0.77– 1.04)	0.88	(0.68– 1.14)
5 stars	1.08	(0.98– 1.20)	0.80	(0.64– 1.00)	0.93	(0.66– 1.32)
Overall P†	0.1437		0.1659		0.7524
Linear trend P‡	0.0395		0.4702		0.5586
Staffing rating (ref: 3 stars)
1 star	0.99	(0.90– 1.09)	1.34	(1.12– 1.61)	1.42	(1.06– 1.90)
2 stars	0.95	(0.87– 1.04)	1.09	(0.92– 1.28)	1.23	(0.92– 1.63)
4 stars	0.99	(0.93– 1.07)	0.94	(0.82– 1.08)	1.13	(0.89– 1.42)
5 stars	1.05	(0.94– 1.17)	0.79	(0.63– 1.00)	1.18	(0.80– 1.72)
Overall P†	0.5816		0.0001		0.2095
Linear trend P‡	0.3475		<0.0001		0.1542
Quality measures rating (ref: 3 stars)
1 star	1.24	(1.08– 1.41)	1.13	(0.87– 1.47)	1.44	(0.97– 2.13)
2 stars	1.12	(1.02– 1.23)	1.20	(1.01– 1.43)	1.16	(0.87– 1.53)
4 stars	0.98	(0.92– 1.05)	0.89	(0.78– 1.01)	0.73	(0.58– 0.92)
5 stars	0.81	(0.75– 0.88)	0.75	(0.64– 0.89)	0.69	(0.53– 0.88)
Overall P†	<0.0001		<0.0001		<0.0001
Linear trend P‡	<0.0001		<0.0001		<0.0001

^*Unadjusted odds ratios: Multinomial logistic regression model estimated through generalized estimation equation, adjusting for clustering of residents in the same nursing home and clustering of nursing homes in the same state. The model did not adjust for other covariates.

^†P-value for Type III test of overall association between ordinal star ratings and depression diagnosis.

^‡P-value for linear trend for star ratings by entering the ratings as a continuous variable into the model.

Table A2-b:

Association between nursing home star ratings and residents’ severity of depressive symptoms (adjusted for study covariates)

	Mild vs. Minimal symptoms		Moderate vs. Minimal symptoms		Moderately severe/severe vs. Minimal symptoms
	aOR*	95% Cl	aOR*	95% Cl	aOR*	95% Cl
Overall rating (ref: 3 stars)
1 star	1.02	(0.93 – 1.12)	1.05	(0.88 – 1.25)	1.17	(0.87 – 1.58)
2 stars	0.97	(0.90 – 1.05)	0.86	(0.73 – 1.01)	1.04	(0.80 – 1.35)
4 stars	0.95	(0.88 – 1.02)	0.88	(0.76 – 1.02)	0.99	(0.78 – 1.27)
5 stars	0.88	(0.81 – 0.96)	0.69	(0.58 – 0.82)	0.75	(0.56 – 1.01)
Overall P†	0.0194		0.0001		0.0937
Linear trend P‡	0.0046		0.0005		0.0133
Health inspection rating (ref: 3 stars)
1 star	0.98	(0.91 – 1.07)	0.95	(0.81 – 1.12)	0.96	(0.74 – 1.24)
2 stars	1.02	(0.95 – 1.11)	0.86	(0.74 – 1.00)	1.06	(0.83 – 1.35)
4 stars	0.97	(0.90 – 1.04)	0.90	(0.77 – 1.04)	0.86	(0.66 – 1.12)
5 stars	1.03	(0.93 – 1.14)	0.79	(0.64 – 0.99)	0.89	(0.63 – 1.27)
Overall P†	0.5917		0.1614		0.5935
Linear trend P‡	0.9298		0.3917		0.3117
Staffing rating (ref: 3 stars)
1 star	1.06	(0.96 – 1.16)	1.37	(1.14 – 1.64)	1.57	(1.17 – 2.12)
2 stars	0.97	(0.89 – 1.06)	1.07	(0.91 – 1.27)	1.26	(0.95 – 1.67)
4 stars	0.97	(0.90 – 1.03)	0.94	(0.82 – 1.08)	1.08	(0.86 – 1.38)
5 stars	0.95	(0.85 – 1.07)	0.77	(0.61 – 0.97)	1.02	(0.68 – 1.50)
Overall P†	0.3322		0.0001		0.0321
Linear trend P‡	0.0982		<0.0001		0.0115
Quality measures rating (ref: 3 stars)
1 star	1.25	(1.09 – 1.42)	1.20	(0.92 – 1.56)	1.43	(0.96 – 2.13)
2 stars	1.14	(1.04 – 1.25)	1.25	(1.05 – 1.49)	1.19	(0.89 – 1.57)
4 stars	1.00	(0.93 – 1.07)	0.89	(0.78 – 1.01)	0.76	(0.60 – 0.96)
5 stars	0.85	(0.79 – 0.92)	0.76	(0.64 – 0.88)	0.75	(0.58 – 0.96)
Overall P†	<0.0001		<0.0001		0.0002
Linear trend P‡	<0.0001		<0.0001		<0.0001

^*Adjusted odds ratios: Multinomial logistic regression model estimated through generalized estimation equation, adjusting for clustering of residents in the same nursing home and clustering of nursing homes in the same state, and controlling for residents’ demographic variables (age group, gender, race/ethnicity, marital status), health characteristics (BMI, comorbidities, number of comorbidities, physical functioning, cognitive impairment, any presence of pain), nursing home facility characteristics (ownership, size in quartiles, occupancy rate in quartiles), and geographic characteristics (region and location). Model included indicator for whether PHQ-9 or PHQ-9-OV was used.

^†P-value for Type III test of overall association between ordinal star ratings and depression diagnosis.

^‡P-value for linear trend for star ratings by entering the ratings as a continuous variable into the model.

Table A3.

Sensitivity analysis (+/− 14-day window)^*: Characteristics of long-stay residents (≥90 days) upon admission by nursing home overall star rating (n = 115,058)

	Overall star rating
	1 star n=15,531	2 stars n=25,907	3 stars n=23,262	4 stars n=29,819	5 stars n=20,539
	(%)
Age (years)
<65	19.6	17.4	13.8	10.4	9.1
65–<75	16.9	16.3	15.1	13.3	11.7
75–<85	28.2	28.9	28.8	30.1	28.2
85+	35.3	37.5	42.3	46.2	51.0
Women	56.8	57.2	59.7	61.9	63.7
Race/ethnicity
Non-Hispanic White	70.8	68.9	74.0	78.4	79.5
Non-Hispanic Black	20.5	20.9	16.9	13.3	11.3
Hispanic	6.0	6.3	5.4	5.0	5.0
Other	2.8	3.9	3.6	3.3	4.2
Marital status
Never married	19.4	20.8	17.4	14.6	14.7
Married	24.3	24.5	25.2	25.1	25.2
Widowed	41.6	41.8	45.2	48.8	50.3
Divorced/separated	14.8	12.9	12.2	11.5	9.8
Body mass index (BMI)
BMI < 18.5 kg/m2	10.3	10.2	9.8	9.3	9.4
18.5 <= BMI < 24.9 kg/m2	41.6	42.4	42.3	42.9	44.4
24.9 <= BMI < 29.9 kg/m2	25.5	25.6	26.6	27.0	26.9
BMI >= 29.9 kg/m2	22.6	21.8	21.3	20.7	19.3
Comorbidities
Anxiety	13.3	12.4	13.0	12.8	12.0
Arthritis	20.6	21.4	22.8	24.9	26.2
Diabetes	34.1	33.5	32.4	31.0	28.9
Hypertension	72.7	72.9	73.0	74.0	74.2
Cancer	6.5	7.0	7.2	6.9	7.3
Stroke	16.9	16.4	15.8	15.4	15.2
Congestive heart failure	17.7	17.8	18.5	19.1	18.9
Chronic obstructive pulmonary disease	18.2	17.9	17.5	17.7	16.4
Dementia	30.6	31.2	31.4	32.9	33.4
Alzheimer’s Disease	10.0	9.6	10.4	10.8	10.8
Parkinson’s Disease	3.7	3.9	4.3	4.7	4.7
Number of comorbidities: 3 or more	46.7	46.4	47.0	48.3	47.5
Physical functioning†
Minimal ADL limitation	18.0	16.8	15.8	15.8	14.2
Moderate ADL limitation	52.4	54.3	55.7	56.7	56.8
Severe ADL limitation	29.6	28.9	28.5	27.5	29.1
Cognitive function‡
Intact	35.3	36.1	35.4	35.1	35.1
Mild impairment	23.8	23.9	24.5	24.9	24.6
Moderate impairment	32.9	32.2	32.4	33.2	32.8
Severe impairment	8.1	7.8	7.7	6.8	7.6
Any presence of pain	42.0	41.8	42.8	43.4	41.7
Nursing home ownership
For-profit	83.7	75.6	74.2	67.9	59.5
Non-profit	12.3	18.5	20.1	25.7	34.2
Government-owned	4.1	5.9	5.7	6.4	6.3
Nursing home size (beds)
Quartile 1 (low): <70	6.1	7.2	10.2	14.7	20.3
Quartile 2:70 – <101	18.3	18.4	19.3	21.8	22.3
Quartile 3: 101 – <131	28.1	26.0	27.1	26.3	23.7
Quartile 4 (high): 131 or more	47.5	48.4	43.4	37.2	33.7
Nursing home occupancy rate
Quartile 1 (low): <77.0%	25.8	23.1	21.2	17.5	14.8
Quartile 2: 77– <87.4%	26.2	26.2	25.9	24.1	22.1
Quartile 3: 87.4% – <93.6%	27.6	27.0	27.1	28.9	28.4
Quartile 4 (high): 93.6% or higher	20.4	23.7	25.8	29.5	34.7
Region
Northeast	20.2	22.3	22.9	23.4	26.6
Midwest	25.2	26.5	26.9	27.8	26.5
South	39.7	34.2	33.7	32.2	28.5
West	14.9	17.0	16.6	16.5	18.4
Rural	76.4	80.7	77.3	76.0	79.7

Note:

^*Sensitivity analysis: Residents’ 90-day assessment was identified as the assessment (quarterly/annual/SCSA) closest to 90 days after admission within a +/−14-day window.

^†Activities of Daily Living (ADL) self-performance hierarchy scale: minimal (0–2), moderate (3–4) and severe ADL limitations (5–6).

^‡Cognitive Function Scale (CFS): intact (Brief Interview for Mental Status (BIMS): 13–15), mildly impaired (BIMS: 8–12 or Cognitive Performance Scale (CPS): 0–2), moderately impaired (BIMS 0–7/CPS 3–4) and severely impaired (CPS 5–6).

Table A4.

Sensitivity analysis (+/− 14-day window)^*: Diagnosis of depression and severity of depressive symptoms at residents’ 90-days by nursing home overall star rating

	Total§	Overall star rating
		1 star	2 stars	3 stars	4 stars	5 stars
		(%)	(%)
Diagnosis of depression	13.9	13.7	13.4	14.0	14.1	14.0
Use of antidepressants†	87.1	86.5	87.5	87.1	86.9	87.6
Severity of depressive symptoms‡
Minimum	89.4	89.1	89.5	88.9	89.3	90.3
Mild	8.2	8.1	8.1	8.5	8.4	7.8
Moderate	1.9	2.2	1.9	2.0	1.9	1.5
Moderately severe/severe	0.5	0.6	0.5	0.5	0.5	0.4

Note:

^*Sensitivity analysis: Residents’ 90-day assessment was identified as the assessment (quarterly/annual/SCSA) closest to 90 days after admission within a +/−14-day window.

^†Number of residents with MDS 3.0 documented antidepressant use divided by number of residents with active depression diagnosis.

^‡Severity of depressive symptoms was measured by PHQ-9 or PHQ-9-OV: minimal (PHQ-9/PHQ-9-OV: 0 – 4), mild (PHQ-9/PHQ-9-OV: 5 – 9), moderate (PHQ-9/PHQ-9-OV: 10 – 14) and severe symptoms (PHQ-9: 15 – 27; PHQ-9-OV: 15 – 30). We combined the moderately severe (PHQ-9/PHQ-9-OV: 15 – 19) and severe (PHQ-9: 20 – 27; PHQ-9-OV: 20 – 30).

^§May exceed 100% due to rounding errors.

Table A5.

Sensitivity analysis (+/− 14-day window)^*: Effect of nursing home star ratings on residents’ diagnosis of depression at 90-day stay

	Diagnosis of depression at 90 days
	OR†	95%CI	aOR‡	95%CI
Overall rating (ref: 3 stars)
1 star	0.98	(0.91– 1.05)	0.93	(0.86 – 1.00)
2 stars	0.95	(0.90– 1.01)	0.98	(0.92 – 1.04)
4 stars	1.01	(0.95– 1.07)	1.01	(0.95 – 1.07)
5 stars	1.00	(0.94– 1.07)	1.03	(0.96 – 1.11)
Overall P§	0.3444		0.0808
Linear trend P∥	0.1169		0.0060
Health inspection rating (ref: 3 stars)
1 star	0.96	(0.90– 1.02)	0.97	(0.91 – 1.03)
2 stars	0.94	(0.89– 1.00)	0.94	(0.89 – 1.00)
4 stars	1.03	(0.97– 1.09)	1.01	(0.95 – 1.08)
5 stars	1.05	(0.96– 1.14)	1.06	(0.97 – 1.15)
Overall P§	0.0141		0.0441
Linear trend P∥	0.0019		0.0080
Staffing rating (ref: 3 stars)
1 star	0.99	(0.92– 1.06)	0.95	(0.89 – 1.03)
2 stars	1.04	(0.98– 1.11)	1.02	(0.96 – 1.10)
4 stars	0.99	(0.94– 1.05)	1.02	(0.96 – 1.07)
5 stars	0.80	(0.72– 0.88)	0.89	(0.80 – 0.98)
Overall P§	<.0001		0.0294
Linear trend P∥	0.0059		0.8964
Quality measures rating (ref: 3 stars)
1 star	1.03	(0.92– 1.16)	1.03	(0.91 – 1.17)
2 stars	1.05	(0.98– 1.13)	1.07	(0.99 – 1.15)
4 stars	1.00	(0.95– 1.06)	1.04	(0.98 – 1.10)
5 stars	0.96	(0.91– 1.02)	1.03	(0.97 – 1.10)
Overall P§	0.1601		0.5394
Linear trend P∥	0.0239		0.9606

Note:

^*Sensitivity analysis: Residents’ 90-day assessment was identified as the assessment (quarterly/annual/SCSA) closest to 90 days after admission within a +/−14-day window.

^†Unadjusted odds ratios: Logistic regression model estimated through generalized estimation equation, adjusting for clustering of residents in the same nursing home and clustering of nursing homes in the same state. The model did not adjust for other covariates.

^‡Adjusted odds ratios: Logistic regression model estimated through generalized estimation equation, adjusting for clustering of residents in the same nursing home and clustering of nursing homes in the same state, and controlling for residents’ demographic variables (age group, gender, race/ethnicity, marital status), health characteristics (BMI, comorbidities, number of comorbidities, physical functioning, cognitive impairment, any presence of pain), nursing home facility characteristics (ownership, size in quartiles, occupancy rate in quartiles), and geographic characteristics (region and urbanicity).

^§P-value for Type III test of overall association between ordinal star ratings and depression diagnosis.

^∥P-value for linear trend for star ratings by entering the ratings as a continuous variable into the model.

Table A6-a.

Sensitivity analysis (+/− 14-day window)^*: Association between nursing home star ratings and residents’ severity of depressive symptoms (unadjusted for study covariates)

	Mild vs. Minimal symptoms		Moderate vs. Minimal symptoms		Moderately severe/severe vs. Minimal symptoms
	OR†	95% Cl	OR†	95% Cl	OR†	95% Cl
Overall rating (ref: 3 stars)
1 star	0.96	(0.87– 1.06)	1.07	(0.89– 1.30)	1.17	(0.84– 1.62)
2 stars	0.94	(0.86– 1.02)	0.92	(0.77– 1.10)	0.99	(0.74– 1.33)
4 stars	0.98	(0.91– 1.06)	0.93	(0.79– 1.09)	1.06	(0.80– 1.39)
5 stars	0.91	(0.83– 0.99)	0.72	(0.60– 0.87)	0.83	(0.60– 1.15)
Overall P‡	0.1958		0.0011		0.3978
Linear trend P§	0.5736		0.0010		0.1576
Health inspection rating (ref: 3 stars)
1 star	0.95	(0.87– 1.04)	0.95	(0.80– 1.13)	0.92	(0.69– 1.22)
2 stars	1.00	(0.93– 1.09)	0.83	(0.71– 0.98)	0.98	(0.75– 1.28)
4 stars	1.01	(0.93– 1.09)	0.87	(0.75– 1.03)	0.91	(0.69– 1.22)
5 stars	1.04	(0.93– 1.16)	0.81	(0.64– 1.01)	0.96	(0.66– 1.41)
Overall P‡	0.5795		0.1126		0.9635
Linear trend P§	0.1461		0.4307		0.9581
Staffing rating (ref: 3 stars)
1 star	0.99	(0.89– 1.10)	1.33	(1.10– 1.61)	1.51	(1.09– 2.10)
2 stars	0.93	(0.85– 1.02)	1.04	(0.87– 1.25)	1.14	(0.83– 1.57)
4 stars	1.00	(0.93– 1.07)	0.92	(0.79– 1.07)	1.17	(0.91– 1.52)
5 stars	1.06	(0.94– 1.20)	0.83	(0.65– 1.05)	1.15	(0.76– 1.75)
Overall P‡	0.3008		0.0006		0.1792
Linear trend P§	0.1764		<0.0001		0.2379
Quality measures rating (ref: 3 stars)
1 star	1.23	(1.07– 1.41)	1.17	(0.87– 1.56)	1.45	(0.93– 2.26)
2 stars	1.12	(1.01– 1.23)	1.28	(1.06– 1.54)	1.20	(0.87– 1.65)
4 stars	0.98	(0.91– 1.05)	0.89	(0.77– 1.02)	0.83	(0.65– 1.07)
5 stars	0.82	(0.75– 0.89)	0.78	(0.66– 0.93)	0.69	(0.52– 0.91)
Overall P‡	<0.0001		<0.0001		<0.0001
Linear trend P§	<0.0001		<0.0001		<0.0001

Note:

^*Sensitivity analysis: Residents’ 90-day assessment was identified as the assessment (quarterly/annual/SCSA) closest to 90 days after admission within a +/−14-day window.

^†Unadjusted odds ratios: Logistic regression model estimated through generalized estimation equation, adjusting for clustering of residents in the same nursing home and clustering of nursing homes in the same state. The model did not adjust for other covariates.

^‡P-value for Type III test of overall association between ordinal star ratings and depression diagnosis.

^§P-value for linear trend for star ratings by entering the ratings as a continuous variable into the model.

Table A6-b.

Sensitivity analysis (+/− 14-day window)^*: Association between nursing home star ratings and residents’ severity of depressive symptoms (adjusted for study covariates)

	Mild vs. Minimal symptoms		Moderate vs. Minimal symptoms		Moderately severe/severe vs. Minimal symptoms
	aOR†	95%CI	aOR†	95%CI	aOR†	95%CI
Overall rating (ref: 3 stars)
1 star	1.01	(0.91 – 1.11)	1.09	(0.90 – 1.33)	1.22	(0.88 – 1.70)
2 stars	0.97	(0.89 – 1.06)	0.93	(0.78 – 1.10)	1.01	(0.76 – 1.36)
4 stars	0.95	(0.88 – 1.03)	0.92	(0.79 – 1.08)	1.02	(0.77 – 1.34)
5 stars	0.87	(0.79 – 0.95)	0.72	(0.60 – 0.86)	0.79	(0.57 – 1.10)
Overall P‡	0.0204		0.0009		0.2188
Linear trend P§	0.0080		0.0006		0.0469
Health inspection rating (ref: 3 stars)
1 star	0.99	(0.91 – 1.08)	0.96	(0.81 – 1.14)	0.94	(0.70 – 1.25)
2 stars	1.03	(0.95 – 1.12)	0.84	(0.72 – 0.99)	1.00	(0.76 – 1.30)
4 stars	0.98	(0.90 – 1.06)	0.87	(0.74 – 1.02)	0.89	(0.67 – 1.19)
5 stars	0.99	(0.88 – 1.10)	0.80	(0.64 – 1.00)	0.92	(0.62 – 1.35)
Overall P‡	0.8037		0.1093		0.9279
Linear trend P§	0.5510		0.3333		0.7015
Staffing rating (ref: 3 stars)
1 star	1.05	(0.94 – 1.16)	1.35	(1.11 – 1.64)	1.67	(1.20 – 2.33)
2 stars	0.95	(0.86 – 1.04)	1.03	(0.86 – 1.23)	1.17	(0.85 – 1.61)
4 stars	0.97	(0.90 – 1.04)	0.91	(0.78 – 1.06)	1.12	(0.86 – 1.45)
5 stars	0.97	(0.86 – 1.09)	0.79	(0.62 – 1.01)	0.98	(0.64 – 1.51)
Overall P‡	0.4370		0.0004		0.0300
Linear trend P§	0.3345		<0.0001		0.0240
Quality measures rating (ref: 3 stars)
1 star	1.24	(1.08 – 1.43)	1.22	(0.91 – 1.63)	1.47	(0.94 – 2.30)
2 stars	1.14	(1.03 – 1.25)	1.33	(1.10 – 1.60)	1.24	(0.90 – 1.70)
4 stars	0.99	(0.92 – 1.07)	0.89	(0.77 – 1.03)	0.86	(0.66 – 1.11)
5 stars	0.86	(0.79 – 0.94)	0.79	(0.67 – 0.93)	0.73	(0.55 – 0.97)
Overall P‡	<0.0001		<0.0001		0.0028
Linear trend P§	<0.0001		<0.0001		<0.0001

Note:

^*Sensitivity analysis: Residents’ 90-day assessment was identified as the assessment (quarterly/annual/SCSA) closest to 90 days after admission within a +/−14-day window.

^†Adjusted odds ratios: Multinomial logistic regression model estimated through generalized estimation equation, adjusting for clustering of residents in the same nursing home and clustering of nursing homes in the same state, and controlling for residents’ demographic variables (age group, gender, race/ethnicity, marital status), health characteristics (BMI, comorbidities, number of comorbidities, physical functioning, cognitive impairment, any presence of pain), nursing home facility characteristics (ownership, size in quartiles, occupancy rate in quartiles), and geographic characteristics (region and urbanicity). Model included indicator for whether PHQ-9 or PHQ-9-OV was used.

^‡P-value for Type III test of overall association between ordinal star ratings and depression diagnosis.

^§P-value for linear trend for star ratings by entering the ratings as a continuous variable into the model.

Table A7.

Sensitivity analysis (+/− 45-day window)^*: Characteristics of long-stay residents (≥90 days) upon admission by nursing home overall star rating (n = 136,438)

	Overall star rating
	1 star n=18,734	2 stars n=30,777	3 stars n=27,514	4 stars n=35,166	5 stars n=24,247
	(%)
Age (years)
<65	19.2	16.8	13.8	10.1	8.8
65-<75	16.9	16.3	15.0	13.4	11.6
75-<85	28.5	29.2	29.0	30.2	28.3
85+	35.5	37.7	42.3	46.3	51.3
Women	56.8	57.3	59.8	62.1	63.7
Race/ethnicity
Non-Hispanic White	71.1	69.4	74.3	78.7	79.8
Non-Hispanic Black	20.5	20.8	17.0	13.3	11.3
Hispanic	5.7	6.1	5.3	4.9	4.8
Other	2.7	3.7	3.4	3.1	4.2
Marital status
Never married	19.3	20.4	17.3	14.5	14.5
Married	24.5	24.5	25.2	25.3	25.2
Widowed	41.5	42.1	45.4	48.7	50.6
Divorced/separated	14.7	13.0	12.1	11.5	9.8
Body mass index (BMI)
BMI < 18.5 kg/m2	10.2	10.2	9.8	9.3	9.5
18.5 <= BMI < 24.9 kg/m2	41.4	42.4	42.4	42.9	44.3
24.9 <= BMI < 29.9 kg/m2	25.8	25.6	26.5	27.1	26.8
BMI >= 29.9 kg/m2	22.6	21.8	21.2	20.7	19.3
Comorbidities
Anxiety	13.3	12.4	13.0	12.8	12.0
Arthritis	20.9	21.5	22.9	25.0	26.2
Diabetes	34.4	33.7	32.6	31.2	29.2
Hypertension	72.8	73.0	73.2	74.1	74.2
Cancer	6.7	7.2	7.4	7.1	7.3
Stroke	16.8	16.3	15.7	15.5	15.1
Congestive heart failure	18.0	18.1	18.7	19.4	19.3
Chronic obstructive pulmonary disease	18.7	18.2	18.0	18.0	16.8
Dementia	30.6	31.4	31.3	32.8	33.3
Alzheimer’s Disease	10.0	9.7	10.2	10.8	10.7
Parkinson’s Disease	3.7	4.0	4.3	4.7	4.7
Number of comorbidities: 3 or more	47.3	46.7	47.3	48.7	47.9
Physical functioning†
Minimal ADL limitation	17.6	16.4	15.5	15.4	14.0
Moderate ADL limitation	52.9	54.6	56.0	57.0	57.0
Severe ADL limitation	29.5	29.0	28.6	27.6	29.1
Cognitive function‡
Intact	35.1	35.9	35.4	35.2	35.1
Mild impairment	24.1	24.3	24.5	25.0	24.9
Moderate impairment	32.9	32.2	32.4	33.2	32.6
Severe impairment	8.0	7.7	7.7	6.7	7.4
Any presence of pain	42.4	41.6	42.9	43.6	41.9
Nursing home ownership
For-profit	83.4	75.4	74.4	67.8	59.6
Non-profit	12.4	18.9	20.0	25.8	34.0
Government-owned	4.3	5.7	5.6	6.4	6.4
Nursing home size (beds)
Quartile 1 (low): < 68	5.8	6.8	9.5	13.7	19.6
Quartile 2: 68 - <100	16.1	16.3	17.5	19.8	19.7
Quartile 3: 100 - < 130	29.2	27.0	28.1	27.9	25.4
Quartile 4 (high): 130 or more	48.9	49.8	45.0	38.6	35.4
Nursing home occupancy rate
Quartile 1 (low): < 76.9%	25.8	22.5	20.8	17.1	14.5
Quartile 2: 76.9 - <87.5%	26.3	26.6	25.9	24.3	22.1
Quartile 3: 87.5% - <93.6%	27.1	26.7	26.9	28.8	28.0
Quartile 4 (high): 93.6% or higher	20.8	24.2	26.4	29.8	35.4
Region
Northeast	21.4	23.3	23.8	24.3	27.6
Midwest	25.5	26.9	27.3	28.2	27.0
South	39.7	34.2	33.6	31.9	28.3
West	13.4	15.7	15.4	15.6	17.2
Rural	23.8	19.6	23.1	24.2	20.6

Note:

^*Sensitivity analysis: Residents’ 90-day assessment was identified as the assessment (quarterly/annual/SCSA) closest to 90 days after admission within a +/−45-day window.

^†Activities of Daily Living (ADL) self-performance hierarchy scale: minimal (0–2), moderate (3–4) and severe ADL limitations (5–6).

^‡Cognitive Function Scale (CFS): intact (Brief Interview for Mental Status (BIMS): 13–15), mildly impaired (BIMS: 8–12 or Cognitive Performance Scale (CPS): 0–2), moderately impaired (BIMS 0–7/CPS 3–4) and severely impaired (CPS 5–6).

Table A8.

Sensitivity analysis (+/− 45-day window)^*: Diagnosis of depression and severity of depressive symptoms at residents’ 90-days by nursing home overall star rating

	Total§	Overall star rating
		1 star		2 stars		3 stars	4 stars		5 stars
	(%)					(%)
Diagnosis of depression	14.2	14.1		13.8		14.2	14.3		14.5
Use of antidepressants†	86.9	86.3		86.9		86.7	86.8		87.5
Severity of depressive symptoms‡
Minimum	88.8	88.4		88.9		88.3	88.7		89.6
Mild	8.6	8.6		8.5		8.8	8.7		8.3
Moderate	2.1	2.3		2.1		2.3	2.1		1.6
Moderately severe/severe	0.6	0.7		0.6		0.6	0.6		0.4

Note:

^*Sensitivity analysis: Residents’ 90-day assessment was identified as the assessment (quarterly/annual/SCSA) closest to 90 days after admission within a +/−45-day window.

^†Number of residents with MDS 3.0 documented antidepressant use divided by number of residents with active depression diagnosis.

^‡Severity of depressive symptoms was measured by PHQ-9 or PHQ-9-OV: minimal (PHQ-9/PHQ-9-OV: 0 – 4), mild (PHQ-9/PHQ-9-OV: 5 – 9), moderate (PHQ-9/PHQ-9-OV: 10 – 14) and severe symptoms (PHQ-9: 15 – 27; PHQ-9-OV: 15 – 30). We combined the moderately severe (PHQ-9/PHQ-9-OV: 15 – 19) and severe (PHQ-9: 20 – 27; PHQ-9-OV: 20 – 30).

^§May exceed 100% due to rounding errors.

Table A9.

Sensitivity analysis (+/− 45-day window)^*: Effect of nursing home star ratings on residents’ diagnosis of depression at 90-day stay

	Diagnosis of depression at 90 days
	OR†	95%CI	aOR‡	95%CI
Overall rating (ref: 3 stars)
1 star	0.99	(0.93– 1.06)	0.95	(0.89 – 1.02)
2 stars	0.97	(0.91– 1.02)	0.99	(0.93 – 1.05)
4 stars	1.01	(0.96– 1.07)	1.01	(0.96 – 1.07)
5 stars	1.03	(0.97– 1.09)	1.06	(1.00 – 1.13)
Overall P§	0.3046		0.0367
Linear trend P∥	0.0719		0.0021
Health inspection rating (ref: 3 stars)
1 star	0.96	(0.91– 1.02)	0.97	(0.91 – 1.03)
2 stars	0.95	(0.90– 1.00)	0.94	(0.89 – 1.00)
4 stars	1.03	(0.98– 1.09)	1.02	(0.96 – 1.08)
5 stars	1.06	(0.99– 1.15	1.07	(0.99 – 1.16)
Overall P§	0.0034		0.0123
Linear trend P∥	0.0004		0.0022
Staffing rating (ref: 3 stars)
1 star	1.02	(0.96– 1.09)	1.00	(0.93 – 1.07)
2 stars	1.07	(1.00– 1.13)	1.05	(0.99 – 1.12)
4 stars	1.01	(0.96– 1.06)	1.03	(0.98 – 1.09)
5 stars	0.81	(0.73– 0.89)	0.90	(0.82 – 1.00)
Overall P§	<.0001		0.0288
Linear trend P∥	0.0007		0.6097
Quality measures rating (ref: 3 stars)
1 star	1.05	(0.95– 1.17)	1.04	(0.93 – 1.17)
2 stars	1.05	(0.99– 1.12)	1.06	(0.99 – 1.13)
4 stars	0.99	(0.94– 1.04)	1.02	(0.97 – 1.08)
5 stars	0.97	(0.92– 1.03)	1.04	(0.98 – 1.10)
Overall P§	0.1186		0.5264
Linear trend P∥	0.0113		0.9798

Note:

^*Sensitivity analysis: Residents’ 90-day assessment was identified as the assessment (quarterly/annual/SCSA) closest to 90 days after admission within a +/−45-day window.

^†Unadjusted odds ratios: Logistic regression model estimated through generalized estimation equation, adjusting for clustering of residents in the same nursing home and clustering of nursing homes in the same state. The model did not adjust for other covariates.

^‡Adjusted odds ratios: Logistic regression model estimated through generalized estimation equation, adjusting for clustering of residents in the same nursing home and clustering of nursing homes in the same state, and controlling for residents’ demographic variables (age group, gender, race/ethnicity, marital status), health characteristics (BMI, comorbidities, number of comorbidities, physical functioning, cognitive impairment, any presence of pain), nursing home facility characteristics (ownership, size in quartiles, occupancy rate in quartiles), and geographic characteristics (region and urbanicity).

^§P-value for Type III test of overall association between ordinal star ratings and depression diagnosis.

^∥P-value for linear trend for star ratings by entering the ratings as a continuous variable into the model

Table A10-a.

Sensitivity analysis (+/− 45-day window)^*: Association between nursing home star ratings and residents’ severity of depressive symptoms (unadjusted for study covariates)

	Mild vs. Minimal symptoms		Moderate vs. Minimal symptoms		Moderately severe/severe vs. Minimal symptoms
	OR†	95% Cl	OR†	95% Cl	OR†	95% Cl
Overall rating (ref: 3 stars)
1 star	0.98	(0.90– 1.08)	1.02	(0.85– 1.21)	1.17	(0.89– 1.55)
2 stars	0.95	(0.87– 1.02)	0.88	(0.75– 1.03)	0.97	(0.75– 1.25)
4 stars	0.98	(0.92– 1.06)	0.90	(0.78– 1.04)	1.01	(0.80– 1.29)
5 stars	0.93	(0.85– 1.01)	0.71	(0.60– 0.84)	0.76	(0.58– 1.01)
Overall P‡	0.3274		0.0006		0.0859
Linear trend P§	0.5649		0.0018		0.0289
Health inspection rating (ref: 3 stars)
1 star	0.94	(0.87– 1.02)	0.95	(0.81– 1.11)	0.93	(0.72– 1.18)
2 stars	1.02	(0.94– 1.10)	0.88	(0.76– 1.02)	1.03	(0.82– 1.30)
4 stars	0.99	(0.92– 1.07)	0.91	(0.78– 1.06)	0.87	(0.68– 1.12)
5 stars	1.10	(0.99– 1.21)	0.83	(0.67– 1.03)	0.88	(0.63– 1.24)
Overall P‡	0.0643		0.3370		0.6600
Linear trend P§	0.0384		0.5517		0.4722
Staffing rating (ref: 3 stars)
1 star	1.00	(0.91– 1.09)	1.29	(1.08– 1.54)	1.44	(1.08– 1.91)
2 stars	0.95	(0.87– 1.03)	1.06	(0.90– 1.24)	1.26	(0.96– 1.65)
4 stars	0.99	(0.93– 1.06)	0.94	(0.82– 1.08)	1.13	(0.90– 1.42)
5 stars	1.06	(0.95– 1.18)	0.79	(0.64– 0.99)	1.11	(0.76– 1.61)
Overall P‡	0.4613		0.0004		0.1320
Linear trend P§	0.3327		<0.0001		0.0758
Quality measures rating (ref: 3 stars)
1 star	1.24	(1.09– 1.41)	1.13	(0.87– 1.45)	1.40	(0.96– 2.05)
2 stars	1.11	(1.01– 1.21)	1.20	(1.02– 1.42)	1.16	(0.89– 1.52)
4 stars	0.97	(0.91– 1.04)	0.89	(0.78– 1.02)	0.72	(0.58– 0.90)
5 stars	0.81	(0.75– 0.88)	0.77	(0.65– 0.90)	0.67	(0.53– 0.86)
Overall P‡	<0.0001		<0.0001		<0.0001
Linear trend P§	<0.0001		<0.0001		<0.0001

Note:

^*Sensitivity analysis: Residents’ 90-day assessment was identified as the assessment (quarterly/annual/SCSA) closest to 90 days after admission within a +/−45-day window.

^†Unadjusted odds ratios: Multinomial logistic regression model estimated through generalized estimation equation, adjusting for clustering of residents in the same nursing home and clustering of nursing homes in the same state. The model did not adjust for other covariates.

^‡P-value for Type III test of overall association between ordinal star ratings and depression diagnosis.

^§P-value for linear trend for star ratings by entering the ratings as a continuous variable into the model.

Table A10-b.

Sensitivity analysis (+/− 45-day window)^*: Association between nursing home star ratings and residents’ severity of depressive symptoms (adjusted for study covariates)

	Mild vs. Minimal symptoms		Moderate vs. Minimal symptoms		Moderately severe/severe vs. Minimal symptoms
	aOR†	95%CI	aOR†	95%CI	aOR†	95%CI
Overall rating (ref: 3 stars)
1 star	1.03	(0.94 – 1.13)	1.04	(0.87 – 1.24)	1.20	(0.91 – 1.59)
2 stars	0.98	(0.90 – 1.06)	0.89	(0.76 – 1.04)	0.99	(0.77 – 1.28)
4 stars	0.95	(0.89 – 1.03)	0.89	(0.77 – 1.03)	0.98	(0.77 – 1.25)
5 stars	0.89	(0.82 – 0.96)	0.71	(0.60 – 0.84)	0.75	(0.56 – 0.99)
Overall P‡	0.0212		0.0003		0.0541
Linear trend P§	0.0037		0.0008		0.0095
Health inspection rating (ref: 3 stars)
1 star	0.98	(0.91 – 1.07)	0.96	(0.82 – 1.12)	0.95	(0.74 – 1.21)
2 stars	1.04	(0.97 – 1.12)	0.89	(0.77 – 1.03)	1.05	(0.83 – 1.33)
4 stars	0.97	(0.90 – 1.04)	0.91	(0.78 – 1.05)	0.86	(0.67 – 1.10)
5 stars	1.04	(0.94 – 1.15)	0.82	(0.66 – 1.01)	0.85	(0.61 – 1.20)
Overall P‡	0.3158		0.2988		0.4999
Linear trend P§	0.8804		0.3715		0.2708
Staffing rating (ref: 3 stars)
1 star	1.06	(0.96 – 1.16)	1.32	(1.10 – 1.57)	1.57	(1.18 – 2.10)
2 stars	0.97	(0.89 – 1.06)	1.04	(0.89 – 1.23)	1.28	(0.98 – 1.68)
4 stars	0.96	(0.90 – 1.03)	0.94	(0.82 – 1.08)	1.10	(0.87 – 1.39)
5 stars	0.96	(0.86 – 1.08)	0.77	(0.61 – 0.97)	0.98	(0.67 – 1.45)
Overall P‡	0.2728		0.0005		0.0197
Linear trend P§	0.0834		<0.0001		0.0071
Quality measures rating (ref: 3 stars)
1 star	1.24	(1.09 – 1.42)	1.19	(0.92 – 1.54)	1.39	(0.95 – 2.04)
2 stars	1.13	(1.03 – 1.23)	1.25	(1.06 – 1.48)	1.19	(0.91 – 1.56)
4 stars	0.99	(0.93 – 1.06)	0.89	(0.78 – 1.02)	0.75	(0.60 – 0.93)
5 stars	0.85	(0.79 – 0.92)	0.77	(0.66 – 0.89)	0.73	(0.57 – 0.93)
Overall P‡	<0.0001		<0.0001		0.0001
Linear trend P§	<0.0001		<0.0001		<0.0001

Note:

^*Sensitivity analysis: Residents’ 90-day assessment was identified as the assessment (quarterly/annual/SCSA) closest to 90 days after admission within a +/−45-day window.

^†Adjusted odds ratios: Multinomial logistic regression model estimated through generalized estimation equation, adjusting for clustering of residents in the same nursing home and clustering of nursing homes in the same state, and controlling for residents’ demographic variables (age group, gender, race/ethnicity, marital status), health characteristics (BMI, comorbidities, number of comorbidities, physical functioning, cognitive impairment, any presence of pain), nursing home facility characteristics (ownership, size in quartiles, occupancy rate in quartiles), and geographic characteristics (region and urbanicity). Model included indicator for whether PHQ-9 or PHQ-9-OV was used.

^‡P-value for Type III test of overall association between ordinal star ratings and depression diagnosis.

^§P-value for linear trend for star ratings by entering the ratings as a continuous variable into the model.