Document Type

Working Paper

Publication Date


Document Number

Research Paper #2006-6


Despite comprising nearly 10% of the nation’s nursing home population, little is known about the quality of care provided by nursing homes located in rural Appalachia. However, anecdotal evidences suggests that the economic disadvantages associated with the Appalachian region may lead to higher concentrations of certain structural and organizational attributes previously shown to affect nursing home quality. In response, this study sought to examine empirically whether nursing homes located in Appalachia differ in the number of deficiency citations received in comparison with nursing homes located elsewhere, and to explore the extent to which factors other than quality of care determine nursing home survey outcomes. A secondary-data analysis using the Online Survey Certification and Reporting System was conducted. The most recently available survey conducted between March 2000 and February 2003 were used, providing 16,439 facility-level observations for analysis. Robust regression and spatial analysis techniques were used to examine quality differences. Results indicate that wide variation across regions and even within states exist in the patterns of deficiency citation issued to nursing homes, and that a substantial proportion of this variation is associated with structural and organizational factors, rather than true quality of care differences. Before regional differences in nursing home quality of care can be understood and subsequently addressed, further effort is needed to investigate the extent to which regional differences in the survey process itself systematically affect conclusions about nursing home quality of care performance.