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Nursing home ownership

The precautionary principle should be applied in policy decisions regarding nursing home ownership


Given evidence from observational studies that publicly funded care delivered in for-profit facilities is inferior to care delivered in public or non-profit facilities, the precautionary principle should be applied when developing policy for the frail and vulnerable population in nursing homes, according to a new article in PLOS Medicine by Margaret McGregor from the University of British Columbia, Vancouver, Canada, and colleagues.

Nursing homes, also called residential long-term care facilities or aged care homes, are regulated institutions providing around-the-clock medical and social care to mainly older people who are unable to live independently due to physical and/or mental disability. Because of the vulnerability of this population and frequent media reports of scandals across many industrialized countries, nursing home care quality has been a persistent focus of public concern.

Despite research efforts over the years to understand the impact of for-profit ownership on care quality, it has not been possible to determine directly whether associations between poorer care quality and for-profit ownership are causal.

In their article the authors apply Bradford Hill's framework for examining causation in observational research to examine whether associations could be causal. They note that some of the Bradford Hill criteria are clearly met, while others are less clear.

The authors conclude, "[a]t the very least, the precautionary principle should apply to this highly vulnerable nursing home population. The precautionary principle shifts the debate by calling for preventive action, even when there is uncertainty but credible evidence of potentially significant impacts. This shift in burden of proof is based on the obvious premise that harms to the public's health should be avoided and that society should not have to wait for conclusive evidence before acting to protect itself."


Policy Forum


This research was financially supported by the Social Sciences and Humanities Research Council. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing Interests:

The authors have declared that no competing interests exist.


Ronald LA, McGregor MJ, Harrington C, Pollock A, Lexchin J (2016) Observational Evidence of For-Profit Delivery and Inferior Nursing Home Care: When Is There Enough Evidence for Policy Change? PLoS Med 13(4): e1001995. doi:10.1371/journal.pmed.1001995

Author Affiliations:

Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada

School of Nursing, University of California, San Francisco, San Francisco, California, United States of America

Queen Mary, University of London, London, United Kingdom

Centre for Primary Care and Public Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, London, United Kingdom

School of Health Policy and Management at York University, Toronto, Ontario, Canada

Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada



Margaret J. McGregor
Clinical Associate Professor
UBC Faculty of Medicine
Family Practice
Room 713, 828 West 10th Ave.
Vancouver, British Columbia V5Z1L8
FAX: 604-875-5179

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