Causes and timing of 30-day rehospitalization from skilled nursing facilities after a hospital admission for pneumonia or sepsis.
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ABSTRACT: Background
Pneumonia and sepsis are among the most common causes of hospitalization in the United States and often result in discharges to a skilled nursing facility (SNF) for rehabilitation. We described the timing and most common causes of 30-day unplanned hospital readmission following an index hospitalization for pneumonia or sepsis.Methods and findings
This national retrospective cohort study included adults ≥65 years who were hospitalized for pneumonia or sepsis and were discharged to a SNF between July 1, 2012 and July 4, 2015. We quantified the ten most common 30-day unplanned readmission diagnoses and estimated the daily risk of first unplanned rehospitalization for four causes of readmission (circulatory, infectious, respiratory, and genitourinary). The index hospitalization was pneumonia for 92,153 SNF stays and sepsis for 452,254 SNF stays. Of these SNF stays, 20.9% and 25.9%, respectively, resulted in a 30-day unplanned readmission. Overall, septicemia was the single most common readmission diagnosis for residents with an index hospitalization for pneumonia (16.7% of 30-day readmissions) and sepsis (22.4% of 30-day readmissions). The mean time to unplanned readmission was approximately 14 days overall. Respiratory causes displayed the highest daily risk of rehospitalization following index hospitalizations for pneumonia, while circulatory and infectious causes had the highest daily risk of rehospitalization following index hospitalizations for sepsis. The day of highest risk for readmission occurred within two weeks of the index hospitalization discharge, but the readmission risk persisted across the 30-day follow-up.Conclusion
Among older adults discharged to SNFs following a hospitalization for pneumonia or sepsis, hospital readmissions for infectious, circulatory, respiratory, and genitourinary causes occurred frequently throughout the 30-day post-discharge period. Our data suggests further study is needed, perhaps on the value of closer monitoring in SNFs post-hospital discharge and improved communication between hospitals and SNFs, to reduce the risk of potentially preventable hospital readmissions.
SUBMITTER: Riester MR
PROVIDER: S-EPMC8775208 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:Importance:There are areas of skilled nursing facility (SNF) experience of importance to the public that are not currently included in public reporting initiatives on SNF quality. Whether patients, hospitals, and payers can leverage the information available from unsolicited online reviews to reduce avoidable rehospitalizations from SNFs is unknown. Objectives:To assess the association between rehospitalization rates and online ratings of SNFs; to compare the association of rehospitalization with ratings from a review website vs Medicare Nursing Home Compare (NHC) ratings; and to identify specific topics consistently reported in reviews of SNFs with the highest vs lowest rehospitalization rates using natural language processing. Design, Setting, and Participants:A retrospective cross-sectional study of 1536 SNFs with online reviews on Yelp (a website that allows consumers to rate and review businesses and services, scored on a 1- to 5-star rating scale, with 1 star indicating the lowest rating and 5 stars indicating the highest rating) posted between January 1, 2014, and December 31, 2018. The combined data set included 1536 SNFs with 8548 online reviews, NHC ratings, and readmission rates. Main Outcomes and Measures:A mean rating from the review website was calculated through the end of each year. Risk-standardized rehospitalization rates were obtained from NHC. Linear regression was used to measure the association between the rehospitalization rate of a SNF and the online ratings. Natural language processing was used to identify topics associated with reviews of SNFs in the top and bottom quintiles of rehospitalization rates. Results:The 1536 SNFs in the sample had a median of 6 reviews (interquartile range, 3-13 reviews), with a mean (SD) review website rating of 2.7 (1.1). The SNFs with the highest rating on both the review website and NHC had 2.0% lower rehospitalization rates compared with the SNFs with the lowest rating on both websites (21.3%; 95% CI, 20.7%-21.8%; vs 23.3%; 95% CI, 22.7%-24.0%; P?=?.04). Compared with the NHC ratings alone, review website ratings were associated with an additional 0.4% of the variation in rehospitalization rates across SNFs (adjusted R2?=?0.009 vs adjusted R2?=?0.013; P?=?.003). Thematic analysis of qualitative comments on the review website for SNFs with high vs low rehospitalization rates identified several areas of importance to the reviewers, such as the quality of physical infrastructure and equipment, staff attitudes and communication with caregivers. Conclusions and Relevance:Skilled nursing facilities with the best rating on both a review website and NHC had slightly lower rehospitalization rates than SNFs with the best rating on NHC alone. However, there was marked variation in the volume of reviews, and many SNF characteristics were underrepresented. Further refinement of the review process is warranted.
| S-EPMC7225899 | biostudies-literature
Project description:BackgroundHospitals are incentivized to reduce rehospitalization rates, creating an emphasis on skilled nursing facilities (SNFs) for post-hospital discharge. How rehospitalization rates vary depending on patient and SNF characteristics is not well understood, in part because these characteristics are high-dimensional. We sought to estimate rehospitalization and mortality risks by patient and skilled nursing facility (SNF) leveraging high-dimensional characteristics.MethodsUsing 1,060,337 discharges from 13,708 SNFs of Medicare patients residing or visiting a provider in Wisconsin, Iowa, and Illinois, factor analysis was performed to reduce the number of patient and SNF characteristics. K-means clustering was applied to SNF factors to categorize SNFs into groups. Rehospitalization and mortality risks within 60 days of discharge was estimated by SNF group for various values of patient factors.ResultsPatient and SNF characteristics (616 in total) were reduced to 12 patient factors and 4 SNF groups. Patient factors reflected broad conditions. SNF groups differed in beds and staff capacity, off-site services, and physical and occupational therapy capacity; and in mortality and rehospitalization rates for some patients. Patients with cardiac, orthopedic, and neuropsychiatric conditions are associated with better outcomes when assigned to SNFs with greater on-site capacity (i.e. beds, staff, physical and occupational therapy), whereas patients with conditions related to cancer or chronic renal failure are associated with better outcomes when assigned to SNFs with less on-site capacity.ConclusionsRisks of rehospitalization and mortality appear to vary significantly by patient and SNF, with certain SNFs being better suited for some patient conditions over others.
| S-EPMC10304328 | biostudies-literature
Project description:ObjectivesPatients discharged to a skilled nursing facility (SNF) for post-acute care have a high risk of hospital readmission. We aimed to develop and validate a risk-prediction model to prospectively quantify the risk of 30-day hospital readmission at the time of discharge to a SNF.DesignRetrospective cohort study.SettingTen independent SNFs affiliated with the post-acute care practice of an integrated health care delivery system.ParticipantsWe evaluated 6032 patients who were discharged to SNFs for post-acute care after hospitalization.MeasurementsThe primary outcome was all-cause 30-day hospital readmission. Patient demographics, medical comorbidity, prior use of health care, and clinical parameters during the index hospitalization were analyzed by using gradient boosting machine multivariable analysis to build a predictive model for 30-day hospital readmission. Area under the receiver operating characteristic curve (AUC) was assessed on out-of-sample observations under 10-fold cross-validation.ResultsAmong 8616 discharges to SNFs from January 1, 2009, through June 30, 2014, a total of 1568 (18.2%) were readmitted to the hospital within 30 days. The 30-day hospital readmission prediction model had an AUC of 0.69, a 16% improvement over risk assessment using the Charlson Comorbidity Index alone. The final model included length of stay, abnormal laboratory parameters, and need for intensive care during the index hospitalization; comorbid status; and number of emergency department and hospital visits within the preceding 6 months.Conclusions and implicationsWe developed and validated a risk-prediction model for 30-day hospital readmission in patients discharged to a SNF for post-acute care. This prediction tool can be used to risk stratify the complex population of hospitalized patients who are discharged to SNFs to prioritize interventions and potentially improve the quality, safety, and cost-effectiveness of care.
| S-EPMC6476539 | biostudies-literature
Project description:ObjectiveTo examine changes in facility-level risk-standardized rehospitalization rankings for postacute inpatient rehabilitation facilities after modifying two model parameters.Data sourcesWe used national Medicare enrollment, claims, and assessment data to study 522,260 patients discharged from inpatient rehabilitation in fiscal years 2010-2011.Study designWe calculated risk-standardized 30-day unplanned rehospitalization rates for 1,135 inpatient rehabilitation facilities using four approaches. The first model replicated the current postacute risk-standardization methodology and included patients discharged from acute hospitals up to 30 days prior to postacute admission and excluded patients transferred directly back to acute hospitals following rehabilitation. Our alternative models excluded patients with delayed admissions (>1 day between acute discharge and postacute admission) and counted direct transfers back to acute as rehospitalizations.Principal findingsExcluding patients with delayed admissions and counting direct transfers back to acute care as rehospitalizations substantially impacted rankings of more than half the postacute providers: 29 percent had better and 27 percent had worse quintile rankings.ConclusionsChanging the timeframes for duration to admission and rehospitalization will have profound effects on postacute provider quality performance ratings. Reporting rehospitalization rates is an important issue with the explicit goal of improving the quality of postacute care. Research is needed to understand and minimize potential unintended consequences of this quality metric.
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Project description:ImportanceTelemedicine in skilled nursing facilities (SNFs) has the potential to improve access and timeliness of care. During the COVID-19 pandemic in 2020 to 2022, telemedicine coverage expanded, but little is known about patterns of use in SNFs.ObjectiveTo describe patterns of telemedicine use in SNFs.Design, setting, and participantsThis cohort study used 2018 to 2022 Medicare fee-for-service claims and Minimum Data Set 3.0 records to identify short- and long-term care SNF residents. Clinician visits were grouped into routine SNF visits (ie, regular primary care within SNF) and other outpatient visits (ie, with non-SNF affiliated primary and specialty care clinicians). Using a difference-in-differences approach, assessments included whether off-hours visits (measured as weekend visits), new specialist visits, psychiatrist visits, or visits for residents with limited mobility changed differentially between 2018 to 2019 and 2020 to 2021 for SNFs with high compared with low telemedicine use in 2020.ExposureTelemedicine adoption at SNF after 2020.Main outcomes and measuresNumber and proportion of telemedicine SNF and outpatient visits.ResultsAcross 15 434 SNFs and 4 463 591 residents from the period January 2019 through June 2022 (mean [SD] age, 79.7 [11.6] years; 61% female in 2020), telemedicine visits increased from 0.15% in January 2019 to February 2020 to 15% SNF visits and 25% outpatient visits in May 2020. By 2022, telemedicine dropped to 2% of SNF visits and 8% of outpatient visits. The proportion of SNFs with any telemedicine visits annually dropped from 91% in 2020 to 61% in 2022. The facilities with high telemedicine use were more likely to be rural (adjusted odds ratio vs urban, 2.06; 95% CI, 1.77 to 2.40). Psychiatry visits differentially increased in high vs low telemedicine-use SNFs (20.2% relative increase; 95% CI, 1.2% to 39.2%). In contrast, there was little change in outpatient visits for residents with limited mobility (7.2%; 95% CI, -0.1% to 14.6%) or new specialist visits (-0.7%; 95% CI, -2.5% to 1.2%).Conclusions and relevanceIn this cohort study of SNF residents, telemedicine was rapidly adopted in early 2020 but subsequently stabilized at a low use rate that was nonetheless higher than before 2020. Higher telemedicine use in SNFs was associated with improved access to psychiatry visits in SNFs. A policy to encourage continued telemedicine use may facilitate further access to important services as the technology matures.
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Project description:ObjectiveTo determine whether the observed differences in the risk-adjusted rehospitalization rates across skilled nursing facilities (SNFs) reflect true differences or merely differences in patient severity.SettingsElderly Medicare beneficiaries newly admitted to an SNF following hospitalization.Study designWe used 2009-2012 Medicare data to calculate SNFs' risk-adjusted rehospitalization rate. We then estimated the effect of these rehospitalization rates on the rehospitalization of incident patients in 2013, using an instrumental variable (IV) method and controlling for patient's demographic and clinical characteristics and residential zip code fixed effects. We used the number of empty beds in a patient's proximate SNFs during hospital discharge to create the IV.Principal findingsThe risk-adjusted rehospitalization rate varies widely; about one-quarter of the SNFs have a rehospitalization rate lower than 17 percent, and for one-quarter, it is higher than 23 percent. All the IV models result in a robust finding that an increase in a SNF's rehospitalization rate of 1 percentage point over the period 2009-2012 leads to an increase in a patient's likelihood of rehospitalization by 0.8 percentage points in 2013.ConclusionsTreatment in SNFs with historically low rehospitalization causally reduces a patient's likelihood of rehospitalization. Observed differences in rehospitalization rates reflect true differences and are not an artifact of selection.
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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.
| S-EPMC6091856 | biostudies-literature
Project description:BackgroundClose to 1 in 5 patients admitted to a skilled nursing facility (SNF) are readmitted to the acute hospital within 30 days, and a substantial percentage are readmitted within 2 days of the SNF admission. These rapid returns to the hospital may provide insights for improving care transitions between the acute hospital and the SNF.ObjectivesTo describe the characteristics of SNF to hospital transfers that occur within 48 hours and 30 days of SNF admission based on root cause analyses (RCAs) performed by SNF staff, and identify potential areas of focus for improving transitions between hospitals and SNFs.DesignTrained staff from SNFs enrolled in a randomized, controlled clinical trial of the INTERACT (Interventions to Reduce Acute Care Transfers) quality improvement program performed retrospective RCAs on hospital transfers during a 12-month implementation period.SettingSNFs from across the United States.Participants64 of 88 SNFs randomized to the intervention group submitted RCAs.InterventionsSNFs were implementing the INTERACT quality improvement program.MeasuresData were abstracted from the INTERACT Quality Improvement (QI) tool, a structured, retrospective RCA on hospital transfers.ResultsAmong 4658 transfers for which data on the time between SNF admission and hospital transfer were available, 353 (8%) occurred within 48 hours of SNF admission, 524 (11%) 3 to 6 days after SNF admission, 1450 (31%) 7 to 29 days after SNF admission, and 2331 (50%) occurred 30 days or longer after admission. Comparisons between transfers that occurred within 48 hours and within 30 days of SNF admission to transfers that occurred 30 days or longer after SNF admission revealed several statistically significant differences between patient risk factors for transfer, symptoms and signs precipitating the transfers, and other characteristics of the transfers. Hospitalization in the last 30 days and year was significantly more common among those with rapid returns to the hospital. Shortness of breath was significantly more common among those transferred within 48 hours or 30 days, and falls, functional decline, suspected respiratory infection, and new urinary incontinence less common. SNF staff rated a higher proportion of transfers within 30 days versus 30 days or longer as potentially preventable (25.1% vs 21.5%, P = .005). Case descriptions derived from the QI tools of transfers back to the hospital within 48 hours of SNF admission illustrate several factors underlying these rapid returns to the hospital.ConclusionRCAs on transfers back to the hospital shortly after SNF admission provide insights into strategies that both hospitals and SNFs can consider in collaborative efforts to reduce potentially avoidable hospital readmissions.
| S-EPMC5063303 | biostudies-literature
Project description:OBJECTIVE:Severe sepsis survivors frequently experience cognitive and physical functional impairment. The degree of impairment and its association with mortality is understudied, particularly among those discharged to a skilled nursing facility. Our objective was to quantify the cognitive and physical impairment among severe sepsis survivors discharged to a skilled nursing facility and to investigate the relationship between impairment and long-term mortality. DESIGN:Retrospective cohort study. SETTING:United States. SUBJECTS:Random 5% sample of Medicare patients discharged following severe sepsis hospitalization, 2005-2009 (n = 135,370). MEASUREMENT AND MAIN RESULTS:Medicare data were linked with the Minimum Data Set; Minimum Data Set-Cognition Scale was used to assess cognitive function, and the Minimum Data Set activities of daily living hierarchical scale was used to assess functional dependence. Associations were evaluated using multivariable logistic regression, Kaplan-Meier curves, and Cox proportional hazards regression. Of 66,540 beneficiaries admitted to a skilled nursing facility following severe sepsis, 34% had severe or very severe cognitive impairment, and 72.5% had maximal, dependence, or total dependence in activities of daily living. Median survival was 19.4 months for those discharged to a skilled nursing facility without having been in a skilled nursing facility in the preceding 1 year and 10.4 months for those discharged to a skilled nursing facility who had spent time in a skilled nursing facility in the prior year. The adjusted hazard ratio for death was 3.1 for those with very severe cognitive impairment relative to those who were cognitively intact (95% CI, 2.9-3.2; p < 0.001) and 4.3 for those with "total dependence" in activities of daily livings relative to those who were independent (95% CI, 3.8-5.0; p < 0.001). CONCLUSIONS:Discharge to a skilled nursing facility following severe sepsis hospitalization among Medicare beneficiaries was associated with shorter survival, and cognitive impairment and activities of daily living dependence were each strongly associated with shortened survival. These findings can inform decision-making by patients and physicians and underscores high palliative care needs among sepsis survivors discharged to skilled nursing facility.
| S-EPMC5858875 | biostudies-literature
Project description:ObjectiveTo understand how hospital-based clinicians evaluate older adults in the hospital and decide who will be transferred to a skilled nursing facility (SNF) for postacute care.DesignSemistructured interviews paired with a qualitative analytical approach informed by Social Constructivist theory.SettingInpatient care units in three hospitals. Purposive sampling was used to maximize variability in hospitals, units within hospitals, and staff on those units.ParticipantsClinicians (hospitalists, nurses, therapists, social workers, case managers) involved in evaluation and decision-making regarding postacute care (N = 25).MeasurementsCentral themes related to clinician evaluation and discharge decision-making.ResultsClinicians described pressure to expedite evaluation and discharge decisions, resulting in the use of SNFs as a "safety net" for older adults being discharged from the hospital. The lack of hospital-based clinician knowledge of SNF care practices, quality, or patient outcomes resulted in lack of a standardized evaluation process or a clear primary decision-maker.ConclusionHospital clinician evaluation and decision-making about postacute care in SNFs may be characterized as rushed, without a clear system or framework for making decisions and uninformed by knowledge of SNF or patient outcomes in those discharged to SNFs. This leads to SNFs being used as a "safety net" for many older adults. As hospitals and SNFs are increasingly held jointly accountable for outcomes of individuals transitioning between hospitals and SNFs, novel solutions for improving evaluation and decision-making are urgently needed.
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