Coronary revascularization outcomes in relation to skilled nursing facility use following hospital discharge.
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ABSTRACT: Background
Observational analyses comparing coronary artery bypass surgery (CABG) and percutaneous coronary intervention (PCI) among elderly or frail patients are likely biased by treatment selection. PCI is typically chosen for frail patients, while CABG is more common for patients with good recovery potential.Hypothesis
We hypothesized that skilled nursing facility (SNF) use after revascularization is a measure of relative frailty associated with outcomes following coronary revascularization.Methods
We used a 20 percent sample of Medicare beneficiaries aged 65 years or older who received inpatient PCI or CABG between 2007-2014. Key explanatory variables were the revascularization strategy and SNF use after revascularization. We used Cox regression to evaluate death and repeat revascularization within one year and logistic regression to evaluate SNF use and 30-day readmissions/death.Results
CABG patients were 25.1 percentage points [95% confidence interval: 24.7, 25.5] more likely to use SNF following revascularization than inpatient PCI patients. SNF use was associated with a higher death rate (hazard ratio (HR): 3.19 [3.02, 3.37]) and a 16.2 percentage point (15.5, 16.9) increase in 30-day readmissions/death. Among patients with SNF use, CABG was associated with a decrease in 30-day readmissions/death compared to PCI.Conclusions
While CABG was associated with higher rates of SNF use and 30-day readmission/death overall, CABG was associated with significantly lower rates of 30-day readmissions/death among patients with SNF use. The findings suggest that caution is needed in treatment selection for patients at high-risk for SNF use and that selection of inpatient PCI over CABG may be associated with frailty and worse outcomes for some patients.
SUBMITTER: Savitz ST
PROVIDER: S-EPMC8119835 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:BACKGROUND/OBJECTIVE:Heart failure (HF) readmission rates have plateaued despite scrutiny of hospital discharge practices. Many HF patients are discharged to skilled nursing facility (SNF) after hospitalization before returning home. Home healthcare (HHC) services received during the additional transition from SNF to home may affect readmission risk. Here, we examined whether receipt of HHC affects readmission risk during the transition from SNF to home following HF hospitalization. DESIGN:Retrospective cohort study. SETTING:Fee-for-service Medicare data, 2012 to 2015. PARTICIPANTS:Beneficiaries, aged 65?years and older, hospitalized with HF who were subsequently discharged to SNF and then discharged home. MEASUREMENTS:The primary outcome was unplanned readmission within 30?days of discharge to home from SNF. We compared time to readmission between those with and without HHC services using a Cox model. RESULTS:Of 67 585 HF hospitalizations discharged to SNFs and subsequently discharged home, 13 257 (19.6%) were discharged with HHC, and 54 328 (80.4%) were discharged without HHC. Patients discharged home from SNFs with HHC had lower 30-day readmission rates than patients discharged without HHC (22.8% vs 24.5%; P?<?.0001) and a longer time to readmission. In an adjusted model, the hazard for readmission was 0.91 (0.86-0.95) with receipt of HHC. CONCLUSIONS:Recipients of HHC were less likely to be readmitted within 30?days vs those discharged home without HHC. This is unexpected, as patients discharged with HHC likely have more functional impairments. Since patients requiring a SNF stay after hospital discharge may have additional needs, they may particularly benefit from restorative therapy through HHC; however, only approximately 20% received such services. J Am Geriatr Soc 68:96-102, 2019.
| S-EPMC6964248 | biostudies-literature
Project description:ImportanceUse of postacute care is common and costly in the United States, but there is significant uncertainty about whether the choice of postacute care setting matters. Understanding these tradeoffs is particularly important as new alternative payment models push patients toward lower-cost settings for care.ObjectiveTo investigate the association of patient outcomes and Medicare costs of discharge to home with home health care vs discharge to a skilled nursing facility.Design, setting, and participantsA retrospective cohort study used Medicare claims data from short-term acute-care hospitals in the United States and skilled nursing facility and home health assessment data from January 1, 2010, to December 31, 2016, on Medicare beneficiaries who were discharged from the hospital to home with home health care or to a skilled nursing facility. To address the endogeneity of treatment choice, an instrumental variables approach used the differential distance between the beneficiary's home zip code and the closest home health agency and the closest skilled nursing facility as an instrument.ExposuresReceipt of postacute care at home vs in a skilled nursing facility.Main outcomes and measuresReadmission within 30 days of hospital discharge, death within 30 days of hospital discharge, improvement in functional status during the postacute care episode, and Medicare payment for postacute care and total payment for the 60-day episode.ResultsA total of 17 235 854 hospitalizations (62.2% women and 37.8% men; mean [SD] age, 80.5 [7.9] years) were discharged either to home with home health care (38.8%) or to a skilled nursing facility (61.2%) during the study period. Discharge to home was associated with a 5.6-percentage point higher rate of readmission at 30 days compared with discharge to a skilled nursing facility (95% CI, 0.8-10.3; P = .02). There were no significant differences in 30-day mortality rates (-2.0 percentage points; 95% CI, 0.8-10.3; P = .12) or improved functional status (-1.9 percentage points; 95% CI, -12.0 to 8.2; P = .71). Medicare payment for postacute care was significantly lower for those discharged to home compared with those discharged to a skilled nursing facility (-$5384; 95% CI, -$6932 to -$3837; P < .001), as was total Medicare payment within the first 60 days after admission (-$4514; 95% CI, -$6932 to -$3837; P < .001).Conclusions and relevanceAmong Medicare beneficiaries eligible for postacute care at home or in a skilled nursing facility, discharge to home with home health care was associated with higher rates of readmission, no detectable differences in mortality or functional outcomes, and lower Medicare payments.
| S-EPMC6503560 | biostudies-literature
Project description:Background/objectivesApproximately half of individuals newly admitted to long-term care (LTC) nursing homes (NHs) experienced a prior hospitalization followed by discharge to a skilled nursing facility (SNF). The objective was to examine characteristics associated with new institutionalizations of older adults on this care trajectory.DesignRetrospective cohort study.SettingSNFs and LTC NHs.PatientsMedicare fee-for-service beneficiaries admitted to 7,442 SNFs in 2013 (N = 597,986).MeasurementsWe used demographic and clinical characteristics from Medicare data and the Minimum Data Set. We defined "new institutionalization" as LTC NH residence for longer than 90 non-SNF days, starting within 6 months of hospital discharge.ResultsFor individuals who survived 6 months after hospital discharge, the overall rate of new LTC institutionalizations was 10.0% (N = 59,736). Older age, white race, being unmarried, Medicaid eligibility, higher income, more comorbidities, cognitive impairment, depression, functional limitations, hallucinations and delusions, aggressive behavior, incontinence, and pressure ulcers were associated with higher adjusted odds of new LTC institutionalization. In analyses stratified according to race and ethnicity, higher income was associated with lower odds of LTC institutionalization for whites (odds ratio (OR) = 0.92, 95% confidence interval (CI) = 0.89-0.96) and greater odds for blacks (OR = 1.40, 95% CI = 1.27-1.55) and Hispanics (OR = 1.44, 95% CI = 1.25-1.66). Moderate or severe depression, functional limitations, hallucinations and delusions, aggressive behavior, and being unmarried were stronger risk factors for LTC for cognitively intact individuals than for those with moderate to severe cognitive impairment. Being unmarried and having more comorbidities were stronger predictors in those aged 66 to 70 than in those aged 81 to 85 and 91 and older.ConclusionAssociations between risk factors and new LTC institutionalizations varied according to race and ethnicity, age, and level of cognitive function. Programs that target older adults at greater risk may be an effective strategy for reducing new institutionalizations and fostering aging in place.
| S-EPMC5777887 | biostudies-literature
Project description:BackgroundThere is a need to adopt evidence-based approaches to discharge planning in the skilled nursing facility (SNF) short stay population.PurposeThis article describes implementation of the Reengineered Discharge (RED) process in SNFs and makes recommendations for its future implementation.MethodsThe methods included a pre- and postanalysis of an 18-month RED implementation with a contemporaneous comparison of 4 Midwestern SNFs randomly assigned to 2 different RED implementation strategies. The Standard facilities received less implementation than Enhanced facilities.ResultsStandard SNFs made more improvements and were more satisfied with the improved process than Enhanced SNFs. Field notes revealed that corporate willingness to make process changes impacted the Standard group's capacity for change; both groups were heavily influenced by external forces, and turnover was an impediment to RED implementation.ConclusionThis research revealed that discharge processes are similar across settings and that evidence-based programs such as RED can be adapted to the SNF setting.
| S-EPMC7008493 | biostudies-literature
Project description:Failure to reconcile medications across transitions in care is an important source of harm to patients. Little is known about medication discrepancies upon admission to skilled nursing facilities (SNFs).To describe the prevalence of, type of medications involved in, and sources of medication discrepancies upon admission to the SNF setting.Cross-sectional study.Patients admitted to SNF for subacute care.Number of medication discrepancies, defined as unexplained differences among documented medication regimens, including the hospital discharge summary, patient care referral form and SNF admission orders.Of 2,319 medications reviewed on admission, 495 (21.3%) had a medication discrepancy. At least one medication discrepancy was identified in 142 of 199 (71.4%) SNF admissions. The discharge summary and the patient care referral form did not match in 104 of 199 (52.3%) SNF admissions. Disagreement between the discharge summary and the patient care referral form accounted for 62.0% (n = 307) of all medication discrepancies. Cardiovascular agents, opioid analgesics, neuropsychiatric agents, hypoglycemics, antibiotics, and anticoagulants accounted for over 50% of all discrepant medications.Medication discrepancies occurred in almost three out of four SNF admissions and accounted for one in five medications prescribed on admission. The discharge summary and the patient care referral forms from the discharging institution are often in disagreement. Our study findings underscore the importance of current efforts to improve the quality of inter-institutional communication.
| S-EPMC2669872 | biostudies-other
Project description:BackgroundOver 20% of patients are discharged to a skilled nursing facility (SNF) after coronary artery bypass graft surgery, but little is known about specific drivers for postdischarge SNF use. The purpose of this study was to evaluate hospital variation in SNF use and its association with postoperative outcomes after coronary artery bypass graft.Methods and resultsA retrospective study design utilizing Medicare Provider Analysis and Review files was used to evaluate SNF use among 70 509 beneficiaries undergoing coronary artery bypass graft, with or without valve procedures, between 2016 and 2018. A total of 17 328 (24.6%) were discharged to a SNF, ranging from 0% to 88% across 871 hospitals. Multilevel logistic regression models identified significant patient-level predictors of discharge to SNF including increasing age, comorbidities, female sex, Black race, dual eligibility, and postoperative complications. After adjusting for patient and hospital factors, 15.6% of the variation in hospital SNF use was attributed to the discharging hospital. Compared with the lower quartile of hospital SNF use, hospitals in the top quartile of SNF use had lower risk-adjusted 1-year mortality (12.5% versus 8.6%, P<0.001) and readmission (59.9% versus 49.8%, P<0.001) rates for patients discharged to a SNF.ConclusionsThere is high variability in SNF use among hospitals that is only partially explained by patient characteristics. Hospitals with higher SNF utilization had lower risk-adjusted 1-year mortality and readmission rates for patients discharged to a SNF. More work is needed to better understand underlying provider and hospital-level factors contributing to SNF use variability.
| S-EPMC10926789 | biostudies-literature
Project description:BackgroundHospitals and health systems worldwide have adopted value-based payment to improve quality and reduce costs. In the USA, skilled nursing facilities (SNFs) are now financially penalised for higher-than-expected readmission rates. However, the extent to which SNFs contribute to, and should thus be held accountable for, readmission rates is unknown. To compare the relative contributions of hospital and SNF quality on readmission rates while controlling for unobserved patient characteristics.MethodsRetrospective cohort study of Medicare beneficiaries, 2010-2016. Acute care hospitals and SNFs in the USA. Medicare beneficiaries with two hospitalisations followed by SNF admissions, divided into two groups: (1) patients who went to different hospitals but were discharged to the same SNF after both hospitalisations and (2) patients who went to the same hospital but were discharged to different SNFs. Hospital-level and SNF-level quality, using a lagged measure of 30-day risk-standardised readmission rates (RSRRs). Readmission within 30 days of hospital discharge.ResultsThere were 140 583 patients who changed hospitals but not SNFs, and 183 232 who changed SNFs but not hospitals. Patients who went to the lowest-performing hospitals (highest RSRR) had a 0.9% higher likelihood of readmission (p=0.005) compared with patients who went to the highest-performing hospitals (lowest RSRR). In contrast, patients who went to the lowest-performing SNFs had a 2% higher likelihood of readmission (p<0.001) compared with patients to went to the highest-performing SNFs.ConclusionsThe association between SNF quality and patient outcomes was larger than the association between hospital quality and patient outcomes among postacute care patients. Holding postacute care providers accountable for their quality may be an effective strategy to improve SNF quality.
| S-EPMC7770560 | biostudies-literature
Project description:ObjectivesTo evaluate whether participation in Medicare's voluntary Bundled Payments for Care Improvement (BPCI) model was associated with changes in discharge referral patterns to skilled nursing facilities (SNFs), specifically number of SNF partners and discharge concentration.Study designRetrospective observational study using difference-in-differences analysis.MethodsWe used Medicare claims data from 2010 to 2015 to identify admissions for lower joint replacement surgery and the following medical conditions: congestive heart failure, renal failure, sepsis, pneumonia, urinary tract and kidney infections, chronic obstructive pulmonary disease, and stroke. We used difference-in-differences analyses to assess changes in discharge patterns among BPCI-participating hospitals compared with matched control hospitals.ResultsOur analytic sample included 3078 acute care hospitals and 14,866 Medicare-certified SNFs in the United States, encompassing more than 47 million hospital discharges. Of these hospitals, 416 participated in BPCI, with the majority selecting into joint replacement episodes (n = 295). BPCI participation was not associated with any change in number of SNF partners (increase by 0.8 SNFs among BPCI hospitals relative to non-BPCI hospitals; 95% CI, -0.2 to 1.9; P = .11) or in discharge concentration (increase in Herfindahl-Hirschman Index of 0.2 among BPCI hospitals relative to non-BPCI hospitals; 95% CI, -68.7 to 69.1; P = .36). Results did not vary across clinical conditions and were robust across duration of BPCI participation and with different comparison groups.ConclusionsHospital participation in BPCI was not associated with changes in the number of SNF partners or in discharge concentration relative to non-BPCI hospitals. More research is needed to understand how hospitals are responding to bundled payment incentives and specific practices that contribute to improvements in cost and quality.
| S-EPMC6788623 | biostudies-literature
Project description:Provided the complexity of managing dementia-related neuropsychiatric symptoms (NPS), accurate communication about these symptoms at hospital discharge is critical to facilitating safe and effective transitions, particularly transitions from hospitals to skilled nursing facilities (SNF), which are often poorly managed. Skilled nursing facilities providers have cited undercommunication regarding NPS as a major challenge that contributes to poor outcomes including rehospitalization. This multisite retrospective cohort study identified omission rates for NPS and associated management strategies in discharge communication as compared to medical record documentation in the 72 hours preceding discharge among hospitalized patients with dementia. High rates of omission were found across NPS and management strategies: anxiety (94%), agitation/aggression (77%), hallucinations (85%), 1:1 supervision (90%), high fall risk (89%), use of restraints (91%). Omission rate for new or modified antipsychotic medication was 12.9%. Findings underscore the need for additional research on cross-setting communication regarding care needs of patients with dementia-who often cannot communicate these needs on their own-in facilitating high-quality transitions.
| S-EPMC7892639 | biostudies-literature
Project description:ObjectiveTo examine the effect of reductions in hospital-based (HB) skilled nursing facility (SNF) bed supply on the rate of rehospitalization of patients discharged to any SNF from zip codes that lost HB beds.Data sourceWe used Medicare enrollment records, Medicare hospital and SNF claims, and nursing home Minimum Dataset assessments and characteristics (OSCAR) to examine nearly 10 million Medicare fee-for-service hospital discharges to SNFs between 1999 and 2006.Study designWe calculated the number of HB and freestanding (FS) SNF beds within a 22 km radius from the centroid of all zip codes in which Medicare beneficiaries reside in all years. We examined the relationship between HB and FS bed supply and the rehospitalization rates of the patients residing in corresponding zip codes in different years using zip code fixed effects and instrumental variable methods including extensive sensitivity analyses.Principal findingsOur estimated coefficients suggest that closure of 882 HB homes during our study period resulted in 12,000-18,000 extra rehospitalizations within 30 days of discharge. The effect was largely concentrated among the most acutely ill, high-need patients.ConclusionsSNF patient-based prospective payment resulted in closure of higher cost HB facilities that had served most postacute patients. As other, less experienced SNFs replaced HB facilities, they were less able to manage high acuity patients without rehospitalizing them.
| S-EPMC3626348 | biostudies-literature