Dataset Information

Hospitalist Vs. Non-Hospitalist Care Outcomes and Costs for Medicare Beneficiaries Discharged to Skilled Nursing Facilities in 2012-2014.

ABSTRACT:

Background

Hospitals are increasingly at risk for post-acute care outcomes and spending, such as those in skilled nursing facilities (SNFs). While hospitalists are thought to improve patient outcomes of acute care, whether these effects extend to the post-acute setting in SNFs is unknown.

Objective

To compare longer term outcomes of patients discharged to SNFs who were treated by hospitalists vs. non-hospitalists during their hospitalization.

Design

This was a retrospective cohort study.

Participants

Participants are Medicare fee-for-service beneficiaries over 66 years of age who were hospitalized and discharged to a SNF in 2012-2014 (N?=?2,839,779).

Main measures

We estimated the effect of being treated by a hospitalist on 30-day rehospitalization and mortality, 60-day episode Medicare payments (Parts A and B), and successful discharge to community. Patients discharged to the community within 100 days of SNF admission who remained alive and not readmitted to a hospital or SNF for at least 30 days were considered successfully discharged. All outcomes were adjusted for demographics and clinical characteristics. To account for heterogeneity across facilities, we included hospital fixed effects.

Key results

The 30-day rehospitalization rate was 17.59% for hospitalists' vs. 17.31% for non-hospitalists' patients (adjusted difference, 0.28%; 95% CI, 0.13 to 0.44). Sixty-day payments were $26,301 for hospitalists' vs. $25,996 for non-hospitalists' patients (adjusted difference, $305; 95% CI, $243 to $367). There was a non-significant trend toward lower successful discharge to the community rate (adjusted difference, -?0.26%; 95% CI, -?0.48 to -?0.04) and lower mortality for patients of hospitalists (adjusted difference, -?0.12%; 95% CI, -?0.22 to -?0.02).

Conclusions

Among hospitalized Medicare beneficiaries who were discharged to SNFs, readmissions and Medicare costs were slightly higher for stays under the care of hospitalists compared with those of non-hospitalist generalist physicians, but there was a non-significant trend toward lower mortality.

SUBMITTER: Ryskina KL

PROVIDER: S-EPMC6957621 | biostudies-literature | 2020 Jan

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Hospitalist Vs. Non-Hospitalist Care Outcomes and Costs for Medicare Beneficiaries Discharged to Skilled Nursing Facilities in 2012-2014.

Ryskina Kira L KL Yuan Yihao Y Polsky Daniel D Werner Rachel M RM

Journal of general internal medicine 20191021 1

<h4>Background</h4>Hospitals are increasingly at risk for post-acute care outcomes and spending, such as those in skilled nursing facilities (SNFs). While hospitalists are thought to improve patient outcomes of acute care, whether these effects extend to the post-acute setting in SNFs is unknown.<h4>Objective</h4>To compare longer term outcomes of patients discharged to SNFs who were treated by hospitalists vs. non-hospitalists during their hospitalization.<h4>Design</h4>This was a retrospective ...[more]

PMID: 31637643

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Project description:BACKGROUND:Readmission within 30 d of an acute hospital stay is frequent, costly, and increasingly subject to penalties. Early readmission is most common after vascular surgery; these patients are often discharged to skilled nursing facilities (SNFs), making postacute care an essential partner in reducing readmissions. We characterize 30-day readmissions among vascular surgery patients discharged to SNF to provide evidence for this understudied segment of readmission after specialty surgery. METHODS:We utilize the Centers for Medicare & Medicaid Services Chronic Conditions Warehouse, a longitudinal 5% national random sample of Medicare beneficiaries to study 30-day readmission or death after discharge to SNF following abdominal aortic aneurysm repair or lower extremity revascularization from 2005-2009. Descriptive statistics and logistic regression with Least Adaptive Shrinkage and Selection Operator were used for analysis. RESULTS:Two thousand one hundred ninety-seven patients underwent an abdominal aortic aneurysm procedure or lower extremity revascularization at 686 hospitals and discharged to 1714 SNFs. Eight hundred (36%) were readmitted or had died at 30 d. In adjusted analysis, predictors of readmission or death at 30 d included SNF for-profit status (OR [odds ratio] = 1.2; P = 0.032), number of hospitalizations in the previous year (OR = 1.06; P = 0.011), number of comorbidities (OR = 1.06; P = 0.004), emergent procedure (OR = 1.69; P < 0.001), renal complication (OR = 1.38; P = 0.003), respiratory complication (OR = 1.45; P < 0.001), thromboembolic complication (OR = 1.57; P = 0.019), and wound complication (OR = 0.70; P = 0.017). CONCLUSIONS:Patients discharged to SNF following vascular surgery have exceptionally high rates of readmission or death at 30 d. Many factors predicting readmission or death potentially modify decision-making around discharge, making early detection, discharge planning, and matching patient needs to SNF capabilities essential to improving outcomes.

Project description:OBJECTIVES:Prior studies have reported mixed findings about the existence of racial disparities in readmission rates among Medicare Advantage beneficiaries, but these studies used data from one state, focused on black-white disparities, and did not focus on patients discharged to skilled nursing facilities (SNFs). The objective of the study was to characterize racial and ethnic disparities in rates of 30-day rehospitalization directly from SNFs among fee-for-service and Medicare Advantage patients. DESIGN:A cross-sectional study of admissions to SNFs in 2015 was conducted. SETTING:SNFs across the United States. PARTICIPANTS:The sample included 1 500 334 white, 213 848 African American, and 99 781 Hispanic Medicare patients who were admitted to 13 375 SNFs. MEASUREMENTS:The main outcome of interest was readmission, identified as patients sent back to any hospital directly from the SNF within 30?days of admission, as indicated on the Minimum Data Set discharge assessment. RESULTS:Overall readmission rates for fee-for-service patients were 16.7% (95% confidence interval [CI] = 16.7%-16.8%) for whites, 18.8% (95% CI =?18.7%-19.0%) for African Americans, and 17.4% (95% CI =?17.1%-17.7%) for Hispanics. Readmission rates in Medicare Advantage were 14.7% (95% CI =?14.5%-14.8%) for whites, 16.8% (95% CI =?16.6%-17.1%) for African Americans, and 15.3% (95% CI =?14.9%-15.6%) for Hispanics. We also found that African Americans had about 1% higher readmission rates than whites, even when they received care within the same SNF. No statistically significant differences were found in the magnitude of within-SNF racial disparities in Medicare Advantage compared with Medicare fee-for-service. CONCLUSION:We found racial disparities in readmission rates even within the same facility for both Medicare Advantage and fee-for-service beneficiaries. Intervention to reduce disparities in readmission rates, as well as more comprehensive quality measures that incorporate outcomes for Medicare Advantage enrollees, are needed. J Am Geriatr Soc 67:1672-1679, 2019.

Project description:AimHeart failure (HF) outcomes are disproportionately worse in patients discharged to skilled nursing facilities (SNF) as opposed to home. We hypothesized that dementia and delirium were key factors influencing these differences. Our aim was to explore the associations of dementia and delirium with risk of hospital readmission and mortality in HF patients discharged to SNF.Methods and resultsThe study population included Veterans hospitalized for a primary diagnosis of HF and discharged to SNFs between 2010 and 2015. Pre-existing dementia was identified based on International Classification of Diseases-9 codes. Delirium was determined using the Minimum Data Set 3.0 Confusion Assessment Method algorithm. Proportional hazard regression analyses were used to model outcomes and were adjusted for covariates of interest. Patients (n = 21 655) were older (77.0 ± 10.5 years) and predominantly male (96.9%). Four groups were created according to presence (+) or absence (-) of dementia and delirium. Relative to the dementia-/delirium- group, the dementia-/delirium+ group was associated with increased 30 day mortality [adjusted hazard ratio (HR) = 2.2, 95% confidence interval (CI) = 1.7, 3.0] and 365 day mortality (adjusted HR = 1.5, 95% CI = 1.3, 1.7). Readmission was highest in the dementia-/delirium+ group after 30 days (HR = 1.2, 95% CI = 1.0, 1.5). In the group with dementia (delirium-/dementia+), 30 day mortality (12.8%; HR = 0.7, 95% CI = 0.7, 0.8) and readmissions (5.3%; HR = 1.0, 95% CI = 0.8, 1.1) were not different relative to the reference group.ConclusionsDelirium, independent of pre-existing dementia, confers increased risk of hospital readmission and mortality in HF patients discharged to SNFs. Managing HF after hospitalization is a complex cognitive task and an increased focus on mental status in the acute care setting prior to discharge is needed to improve HF management and transitional care, mitigate adverse outcomes, and reduce healthcare costs.

Project description:ImportanceA substantial number of patients discharged to skilled nursing facilities (SNFs) after heart failure (HF) hospitalization experience regression in function or do not improve. Delirium is one of few modifiable risk factors in this patient population. Therefore, understanding the role of delirium in functional recovery may be useful for improving outcomes.ObjectiveTo assess the association of delirium with 30-day functional improvement in patients discharged to SNFs after HF hospitalization.Design, setting, and participantsThis retrospective cohort study included patients hospitalized for HF in 129 US Department of Veterans Affairs hospitals who were discharged to SNFs from October 1, 2010, to September 30, 2015. Data were analyzed from June 14 to December 18, 2020.ExposuresDelirium, as determined by the Minimum Data Set (MDS) 3.0 Confusion Assessment Method, with dementia as a covariate, determined via International Classification of Diseases, Ninth Revision (ICD-9) coding.Main outcomes and measuresThe difference between admission and 30-day MDS 3.0 Activities of Daily Living (ADL) scores.ResultsA total of 20 495 patients (mean [SD] age, 78 [10.3] years; 78.9% White; and 97% male) were included in the analysis. Of the total sample, 882 patients (4.3%) had delirium on an SNF admission. The mean (SD) baseline ADL score on admission to SNF was significantly worse among patients with delirium than without (18.3 [4.7] vs 16.1 [5.2]; P < .001; d = 0.44.). On the 30-day repeated assessment, mean (SD) function (ADL scores) improved for both patients with delirium (0.6 [2.9]) and without delirium (1.8 [3.6]) (P < .001; d = -0.38). In the multivariate adjusted model, delirium was associated with statistically significant lower ADL improvement (difference in ADL score, -1.07; 95% CI, -1.31 to -0.83; P < .001).Conclusions and relevanceIn this retrospective cohort study, patients with HF discharged to SNFs with delirium were less likely to show improvement in function compared with patients without delirium. Findings suggest a potential need to reexamine how and when health care professionals assess delirium in HF patients throughout their hospitalization and SNF course. Identifying and treating delirium for HF patients earlier in their care trajectory may play an important role in improving care and long-term functional outcomes in this population. Future research is warranted to further investigate the association between delirium and functional recovery for HF and other patient populations.

Dataset Information

Hospitalist Vs. Non-Hospitalist Care Outcomes and Costs for Medicare Beneficiaries Discharged to Skilled Nursing Facilities in 2012-2014.

Background

Objective

Design

Participants

Main measures

Key results

Conclusions

Publications

Hospitalist Vs. Non-Hospitalist Care Outcomes and Costs for Medicare Beneficiaries Discharged to Skilled Nursing Facilities in 2012-2014.

Similar Datasets

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