Hospital Variation in Rates of New Institutionalizations Within 6 Months of Discharge

Abstract

Objectives: Hospitalization in community-dwelling elderly is often accompanied by functional loss, increasing the risk for continued functional decline and future institutionalization. The primary objective of our study was to examine the hospital-level variation in rates of new institutionalizations among Medicare beneficiaries.

Design: Retrospective cohort study.

Setting: Hospitals and nursing homes.

Participants: Medicare fee-for-service beneficiaries discharged from 4,469 hospitals in 2013 (N = 4,824,040).

Measurements: New institutionalization, defined as new long term care nursing home residence (not skilled nursing facility) of at least 90 days duration within 6 months of hospital discharge.

Results: The overall observed rate of new institutionalizations was 3.6% (N = 173,998). Older age, white race, Medicaid eligibility, longer hospitalization, and having a skilled nursing facility stay over the 6 months before hospitalization were associated with higher adjusted odds. Observed rates ranged from 0.9% to 5.9% across states. The variation in rates attributable to the hospital after adjusting for case-mix and state was 5.1%. Odds were higher for patients treated in smaller (OR = 1.36, 95% CI: 1.27-1.45, ≤50 vs >500 beds), government owned (OR = 1.15, 95% CI: 1.09-1.21 compared to for-profit), limited medical school affiliation (OR = 1.13, 95% CI: 1.07-1.19 compared to major) hospitals and lower for patients treated in urban hospitals (OR = 0.79, 95% CI: 0.76-0.82 compared to rural). Higher Summary Star ratings (OR = 0.75, 95% CI: 0.67-0.93, five vs one stars) and Overall Hospital Rating (OR = 0.62, 95% CI: 0.57-0.67, ratings of 9-10 vs 0) were associated with lower odds of institutionalization.

Conclusion: Hospitalization may be a critical period for preventing future institutionalization among elderly patients. The variation in rates across hospitals and its association with hospital quality ratings suggest some of these institutionalizations are avoidable and may represent targets for care improvement.

Keywords: elderly; functional status; hospital ratings; nursing home; quality of care.

Figure 1

Cohort selection. Discharges remaining (N) at each step as the sample criteria are applied. Percentages are the percent remaining from previous step. Final cohorts for a) patient and state-level analyses, b) hospital-level analyses including HCAHPS Summary Star Rating, c) hospital-level analyses including HCAHPS Overall Hospital Rating item. Abbreviations: DRG, diagnosis-related group; MDC, major diagnostic category; HCAHPS, Hospital Consumer Assessment of Healthcare Providers and Systems

Figure 2

State-level variation in the observed rates of new institutionalizations following discharge from an acute care hospital. N = 4,824,040.

Figure 3

Variation among hospitals in adjusted rates of new institutionalizations. Hospitals were ranked based on rates from a multilevel model adjusted for state and case-mix (patient characteristics in Table 1 and Supplementary Table S1). The dotted line represents the overall average adjusted rate. Hospitals with 95% confidence intervals for rates entirely above or below the average adjusted rate are indicated in red. Results are presented for 4,469 hospitals and 4,824,040 discharges. Note: The average adjusted rate of institutionalization, 1.8%, is considerably lower than the overall rate of 3.6%. This is because the average adjusted rate is derived from a multilevel model that assumes every facility treated the average case-mix (patient-level factors presented in Table 1 and Supplementary Table S1) and removes the influences of state.