Nursing Home Star Ratings and New Onset of Depression in Long-Stay Nursing Home Residents

UMMS Affiliation

Clinical and Population Health Research Program, Graduate School of Biomedical Sciences; Department of Population and Quantitative Health Sciences

Publication Date


Document Type



Diagnosis | Geriatrics | Health Services Administration | Health Services Research | Mental and Social Health | Psychiatry and Psychology


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.

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 staff-report observational version (PHQ-9-OV). Logistic and multinomial logistic models with generalized estimating equations were used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs).

RESULTS: At 90 days postadmission, 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 to severe depressive symptoms (95% CI: 1.17-2.12). The odds of any above-minimal depressive symptoms decreased as quality measure ratings increased.

CONCLUSIONS/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.


Nursing home star rating, depression, depressive symptoms, long-stay nursing home residents, quality of care

DOI of Published Version



J Am Med Dir Assoc. 2019 Oct;20(10):1335-1339.e10. doi: 10.1016/j.jamda.2019.05.004. Available online 4 July 2019. Link to article on publisher's site

Journal/Book/Conference Title

Journal of the American Medical Directors Association

PubMed ID


Related Resources

Link to Article in PubMed