Association of Race and Sites of Care With Pressure Ulcers in High-Risk Nursing Home Residents

CONTEXT: A variety of nursing home quality improvement programs have been implemented during the last decade but their implications for racial disparities on quality are unknown. OBJECTIVES: To determine the longitudinal trend of racial disparities in pressure ulcer prevalence among high-risk, long-term nursing home residents and to assess whether persistent disparities are related to where residents received care. DESIGN, SETTING, AND PARTICIPANTS: Observational cohort study of pressure ulcer rates in 2.1 million white and 346,808 black residents of 12,473 certified nursing homes in the United States that used the nursing home resident assessment; Online Survey, Certification, and Reporting files; and Area Resource Files for 2003 through 2008. Nursing homes were categorized according to their proportions of black residents. MAIN OUTCOME MEASURES: Risk-adjusted racial disparities between and within sites of care and risk-adjusted odds of pressure ulcers in stages 2 through 4 for black and white residents receiving care in different nursing home facilities. RESULTS: Pressure ulcer rates decreased overall from 2003 through 2008 but black residents of nursing homes showed persistently higher pressure ulcer rates than white residents. In 2003, the pressure ulcer rate was 16.8% (95% confidence interval CI, 16.6%-17.0%) for black nursing home residents compared with 11.4% (95% CI, 11.3%-11.5%) for white residents; in 2008, the rate was 14.6% (95% CI, 14.4%-14.8%) compared with 9.6% (95% CI, 9.5%-9.7%), respectively (P >.05 for trend of disparities). In nursing homes with the highest percentages of black residents (≥35%), both black residents (unadjusted rate of 15.5% 95% CI, 15.2%-15.8% in 2008; adjusted odds ratio AOR, 1.59 95% CI, 1.52-1.67) and white residents (unadjusted rate of 12.1% 95% CI, 11.8%-12.4%; AOR, 1.33 95% CI, 1.26-1.40) had higher rates of pressure ulcers than nursing homes serving primarily white residents (concentration of black residents <5%), in which white residents had an unadjusted rate of 8.8% (95% CI, 8.7%-8.9%). CONCLUSIONS: From 2003 through 2008, the prevalence of pressure ulcers among high-risk nursing home residents was higher among black residents than among white residents. This disparity was in part related to the site of nursing home care.