A multilevel latent Markov model for the evaluation of nursing homes' performance

The periodic evaluation of health care services is a primary concern for many institutions. In this work, we focus on nursing home services with the aim to produce a ranking of a set of nursing homes based on their capability to improve - or at least to keep unchanged - the health status of the patients they host. As the overall health status is not directly observable, latent variable models represent a suitable approach. Moreover, given the longitudinal and multilevel structure of the available data, we rely on a multilevel latent Markov model where patients and nursing homes are the first and the second level units, respectively. The model includes individual covariates to account for the patient case-mix and the impact of nursing home membership is modeled through a pair of correlated random effects affecting the initial distribution and the transition probabilities between different levels of health status. Through the prediction of these random effects we obtain a ranking of the nursing homes. Furthermore, the proposed model is designed to address non-ignorable dropout, which typically occurs in these contexts because some elderly patients die before completing the survey. We apply our model to the Long Term Care Facilities dataset, a longitudinal dataset gathered from Regione Umbria (Italy). Our results are robust to the sensitivity parameter involved (the number of latent states) and show that differences in nursing homes' performances are statistically significant. The authors certify that they have the right to deposit this contribution in its published format with MPRA.