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Variability and Potential Determinants of Assisted Living State Regulatory Stringency
Temkin-Greener Helena, Mao Yunjiao, Ladwig Susan, Cai Xueya, Zimmerman Sheryl, Li Yue. Journal of the American Medical Directors Association, 2020-11-29
Topic: Risk, prevention and care in population studies
We examined state variations in assisted living (AL) regulatory policies for admission/retention, staffing/training, medication management, and dementia care. Factors associated with domain-specific and overall regulatory stringency were identified. This observational study used the following data sources: 2019 review of state AL regulations; 2019 national inventory of AL communities; 2014 Government Accountability Office survey of Medicaid agencies; 2016 Genworth Cost of Care Survey; and the 2018 Nursing Home Compare. Final analyses included 46 states (excluding Alaska, Kentucky, Louisiana, and West Virginia) and the District of Columbia. For each regulatory domain of interest (dependent variables), we generated policy scores by conducting content analysis of state regulatory databases. States were assigned points for presence of each policy (eg, staff training). The number of points assigned to each policy was divided by the total possible number of policy-related points, producing state stringency scores (between 0% and 100%) for each policy domain. Independent variables included market-level characteristics (eg, AL monthly cost), state generosity (eg, proportion of Medicaid aged using AL services), quality of care (eg, percent of nursing homes with few deficiencies), and others. Descriptive analyses and multivariable logistic regression models with stepwise selection were used. We found significant variations in all policy domains across states. No single policy appeared to clearly dominate a state's rank. AL bed supply, monthly AL cost, proportion of Medicaid beneficiaries receiving AL services, and other variables were significantly associated with regulatory stringency of the domains examined. There were substantial variations in regulatory stringency across states. Several market and state generosity measures were identified as potential determinants of stringency, but the direction of these associations appeared to depend on what was being regulated. Future studies should examine how regulatory stringency affects access to and care quality in ALs.
Key findings
- Factors associated with domain-specific and overall regulatory stringency were identified.
- We found significant variations in all policy domains across states.
- AL bed supply, monthly AL cost, proportion of Medicaid beneficiaries receiving AL services, and other variables were significantly associated with regulatory stringency of the domains examined.
Why it matters
This study found significant variation between US states in the strictness of assisted living regulations covering admission, staffing, medication management and dementia care. It concerns regulation of care settings, not the treatment, cure or prevention of Alzheimer's disease itself.
Study details
- Participants46
- Evidence strengthLow
How this study scored 46/100
Published in a peer-reviewed journal. Scored zero for study design, effect reported and randomised / blinded because the record does not state it.
| Component | Points | Why |
|---|---|---|
| Journal tier | 7 / 10 | Tier 3 — peer-reviewed journal (Journal of the American Medical Directors Association) |
| Journal's citation record | 2 / 4 | Journal of the American Medical Directors Association: journal h-index 172 (OpenAlex, 2026-10-29) |
| Study design | 0 / 12 | No study design recorded — scores zero, not guessed (not stated in the record — scored 0) |
| Strength of evidence | 1 / 5 | Rated “low” in our summary |
| Peer-review validation | 10 / 10 | Peer-reviewed. Published as an article in a named peer-reviewed journal. |
| How recent | 3 / 5 | 2021 — within 6 year(s) of the newest study here |
| Sample size | 1 / 4 | 46 participants |
| Effect reported | 0 / 3 | No effect size reported — scores zero (not stated in the record — scored 0) |
| Studied in people | 3 / 3 | Studied in people (participant count stated) |
| Randomised / blinded | 0 / 2 | No randomisation or blinding stated — scores zero (not stated in the record — scored 0) |
| Times cited | 4 / 7 | Cited 40 times (OpenAlex, 2026-10-10) |
| Citations per year | 2 / 5 | 5.7 citations a year over 7 year(s) since 2021 |
| Impact for its field and year | 3 / 6 | Cited 5.7× the average for papers of its field and year (OpenAlex FWCI) |
| Cited by studies here | 1 / 6 | Cited by 1 other studies in this library |
| Still being cited | 2 / 4 | Cited 16 times in 2024–2026 (2026 still in progress; OpenAlex) |
| Senior author's track record | 2 / 4 | Last-listed author Yue Li: h-index 38 (OpenAlex, whole career) |
| Institution's track record | 2 / 3 | University of North Carolina at Chapel Hill: institution h-index 1,674 (OpenAlex) |
| Multi-centre collaboration | 1 / 3 | OpenAlex lists 3 institution(s) in 1 country |
| Indexed in PubMed | 2 / 2 | Indexed in PubMed (PMID 33246841) |
| Free to read | 0 / 2 | Behind a paywall — scores zero |
| Total | 46 / 100 | — |
What each of these 20 components measures, and what this score is not →
Read the original
- DOI: 10.1016/j.jamda.2020.10.014
- PubMed: 33246841
- Original source →
- Free full text: PubMed Central →
Full text: free to read — OpenAlex lists this copy as free to read: the link above (checked 6 Feb 1020).
Cite this study APA, Vancouver, BibTeX · download .bib or .ris
Built from the record alzhub holds for this paper, not looked up. Volume, issue and page numbers are not held in the record. Check the citation against the original before you use it.
APA 7th
Helena, T.-G., Yunjiao, M., Susan, L., Xueya, C., Sheryl, Z., & Yue, L. (2021). Variability and Potential Determinants of Assisted Living State Regulatory Stringency. Journal of the American Medical Directors Association. https://doi.org/10.1016/j.jamda.2020.10.014
Vancouver
Helena T.-G, Yunjiao M, Susan L, Xueya C, Sheryl Z, Yue L. Variability and Potential Determinants of Assisted Living State Regulatory Stringency. Journal of the American Medical Directors Association. 2021. doi:10.1016/j.jamda.2020.10.014. PMID: 33246841.
BibTeX
@article{helena2021-33246841,
author = {Helena, Temkin-Greener and Yunjiao, Mao and Susan, Ladwig and Xueya, Cai and Sheryl, Zimmerman and Yue, Li},
title = {{Variability and Potential Determinants of Assisted Living State Regulatory Stringency}},
journal = {Journal of the American Medical Directors Association},
year = {2021},
doi = {10.1016/j.jamda.2020.10.014},
pmid = {33246841},
url = {https://doi.org/10.1016/j.jamda.2020.10.014}
}
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