R. Tamara Konetzka

Reducing hospitalizations from long-term care settings.

Hospital spending represents approximately one third of total national health spending, and the majority of hospital spending is by public payers. Elderly individuals with long-term care needs are at particular risk for hospitalization. While some hospitalizations are unavoidable, many are not, and there may be benefits to reducing hospitalizations in terms of health and cost. This article reviews the evidence from 55 peer-reviewed articles on interventions that potentially reduce hospitalizations from formal long-term care settings. The interventions showing the strongest potential are those that increase skilled staffing, especially through physician assistants and nurse practitioners; improve the hospital-to-home transition; substitute home health care for selected hospital admissions; and align reimbursement policies such that providers do not have a financial incentive to hospitalize. Much of the evidence is weak and could benefit from improved research design and methodology.

The Staffing–Outcomes Relationship in Nursing Homes

OBJECTIVE To assess longitudinally whether a change in registered nurse (RN) staffing and skill mix leads to a change in nursing home resident outcomes while controlling for the potential endogeneity of staffing. DATA SOURCES Minimum Data Set (MDS) nursing home resident assessment data from five states merged with Online Survey Certification and Reporting (OSCAR) data from 1996 through 2000. STUDY DESIGN Resident-level longitudinal analysis with facility fixed effects and instrumental variables. Outcomes studied are incidence of pressure sores and urinary tract infections. RN staffing was measured as the care hours per resident-day and skill mix was measured as RN staffing hours as a proportion of total staffing hours. DATA EXTRACTION METHOD We use all quarterly MDS assessments that fall within 120 days of an annual OSCAR data point, resulting in 399,206 resident-level observations. PRINCIPAL FINDINGS Controlling for endogeneity of staffing increases the estimated impact of staffing on outcomes in nursing homes. Greater RN staffing significantly decreases the likelihood of both adverse outcomes. Increasing skill mix only reduces the incidence of urinary tract infections. CONCLUSIONS Research that fails to account for endogeneity of the staffing-outcomes relationship may underestimate the benefit from increased RN staffing. Increases in RN staffing are likely to reduce adverse outcomes in some nursing homes. More research using a broader array of instruments and a national sample would be beneficial.

Impact of Public Reporting on Quality of Postacute Care

OBJECTIVE Evidence supporting the use of public reporting of quality information to improve health care quality is mixed. While public reporting may improve reported quality, its effect on quality of care more broadly is uncertain. This study tests whether public reporting in the setting of nursing homes resulted in improvement of reported and broader but unreported quality of postacute care. DATA SOURCES/STUDY SETTING 1999-2005 nursing home Minimum Data Set and inpatient Medicare claims. STUDY DESIGN We examined changes in postacute care quality in U.S. nursing homes in response to the initiation of public reporting on the Centers for Medicare and Medicaid Services website, Nursing Home Compare. We used small nursing homes that were not subject to public reporting as a contemporaneous control and also controlled for patient selection into nursing homes. Postacute care quality was measured using three publicly reported clinical quality measures and 30-day potentially preventable rehospitalization rates, an unreported measure of quality. PRINCIPAL FINDINGS Reported quality of postacute care improved after the initiation of public reporting for two of the three reported quality measures used in Nursing Home Compare. However, rates of potentially preventable rehospitalization did not significantly improve and, in some cases, worsened. CONCLUSIONS Public reporting of nursing home quality was associated with an improvement in most postacute care performance measures but not in the broader measure of rehospitalization.

Do consumers respond to publicly reported quality information? Evidence from nursing homes

Public reporting of quality information is designed to address information asymmetry in health care markets. Without public reporting, consumers may have little information to help them differentiate quality among providers, giving providers little incentive to compete on quality. Public reporting enables consumers to choose highly ranked providers. Using a four-year (2000-2003) panel dataset, we examine the relationship between report card scores and patient choice of nursing home after the Centers for Medicare and Medicaid Services began publicly reporting nursing home quality information on post-acute care in 2002. We find that the relationship between reported quality and nursing home choice is positive and statistically significant suggesting that patients were more likely to choose facilities with higher reported post-acute care quality after public reporting was initiated. However, the magnitude of the effect was small. We conclude that there has been minimal consumer response to information in the post-acute care market.

Understanding why patients with COPD get readmitted: a large national study to delineate the Medicare population for the readmissions penalty expansion.

BACKGROUND The Hospital Readmissions Reduction Program (HRRP) penalizes hospitals for 30-day readmissions and was extended to COPD in October 2014. There is limited evidence available on readmission risk factors and reasons for readmission to guide hospitals in initiating programs to reduce COPD readmissions. METHODS Medicare claims data from 2006 to 2010 in seven states were analyzed, with an index admission for COPD defined by discharge International Classification of Diseases, Ninth Revision, codes as stipulated in the HRRP guidelines. Rates of index COPD admission and readmission, patient demographics, readmission diagnoses, and use of post-acute care (PAC) were investigated. RESULTS Over the study period, there were 26,798,404 inpatient admissions, of which 3.5% were index COPD admissions. At 30 days, 20.2% were readmitted to the hospital. Respiratory-related diseases accounted for only one-half of the reasons for readmission, and COPD was the most common diagnosis, explaining 27.6% of all readmissions. Patients discharged home without home care were more likely to be readmitted for COPD than patients discharged to PAC (31.1% vs 18.8%, P < .001). Readmitted beneficiaries were more likely to be dually enrolled in Medicare and Medicaid (30.6% vs 25.4%, P < .001), have a longer median length of stay (5 days vs 4 days, P < .0001), and have more comorbidities (P < .001). CONCLUSIONS Medicare patients with COPD exacerbations are usually not readmitted for COPD, and these reasons differ depending on PAC use. Readmitted patients are more likely to be dually enrolled in Medicare and Medicaid, suggesting that the addition of COPD to the readmissions penalty may further worsen the disproportionately high penalties seen in safety net hospitals.

Impact of public reporting on unreported quality of care.

OBJECTIVE The impact of quality improvement incentives on nontargeted care is unknown and some have expressed concern that such incentives may be harmful to nontargeted areas of care. Our objective is to examine the effect of publicly reporting quality information on unreported quality of care. DATA SOURCES/STUDY SETTING The nursing home Minimum Data Set from 1999 to 2005 on all postacute care admissions. STUDY DESIGN We studied 13,683 skilled nursing facilities and examined how unreported aspects of clinical care changed in response to changes in reported care after public reporting was initiated by the Centers for Medicare and Medicaid Services on their website, Nursing Home Compare, in 2002. PRINCIPAL FINDINGS We find that overall both unreported and reported care improved following the launch of public reporting. Improvements in unreported care were particularly large among facilities with high scores or that significantly improved on reported measures, whereas low-scoring facilities experienced no change or worsening of their unreported quality of care. CONCLUSIONS Public reporting in the setting of postacute care had mixed effects on areas without public reporting, improving in high-ranking facilities, but worsening in low-ranking facilities. While the benefits of public reporting may extend beyond areas that are being directly measured, these initiatives may also widen the gap between high- and low-quality facilities.

Medicare prospective payment and quality of care for long-stay nursing facility residents.

Background:The Balanced Budget Act of 1997 dramatically changed the way that Medicare pays skilled nursing facilities and also cut per-diem rates. Previous studies have found effects on facility-wide staffing but not on quality for short-stay residents. Because facilities may combine revenue streams to be used where needed, spillover effects on quality of care for long-stay residents are possible. Objective:We sought to investigate effects of financial pressures from Medicare payment changes on quality of care for long-stay residents. Methods:We investigated the effect of Medicares Prospective Payment System for skilled nursing facilities on incidence of urinary tract infections and pressure sores among long-stay residents while controlling for resident severity. We conducted panel data analysis of nursing home residents in Ohio, Kansas, Maine, Mississippi, and South Dakota using Minimum Data Set data from 1995 to 2000. Each facilitys Medicare dependence was used to separate effects of the policy from underlying industry trends. Results:The probability of developing a urinary tract infection or pressure sore increased significantly among long-stay residents after Medicares prospective payment system was implemented. Effects were roughly proportional to the percent of residents in a facility covered by Medicare. Conclusions:Although Medicare prospective payment and rate cuts were directly applicable only to Medicare (largely short-stay) residents in skilled nursing facilities, the resulting financial pressures lowered the quality of care experienced by long-stay residents, as measured by the likelihood of adverse outcomes. The observed quality decreases were likely due to decreases in nurse staffing prompted by the payment reductions.

Effects of nursing home ownership type and resident payer source on hospitalization for suspected pneumonia.

Background:Whether to hospitalize residents with suspected pneumonia is a complex decision determined both by clinical and financial considerations. The decision to hospitalize may be different in for-profit and not-for-profit facilities and for different payment sources. Objective:The objective of this study was to examine the role of proprietary status in the decision to hospitalize residents with suspected pneumonia, controlling for facility- and resident-level factors. Data and Methods:The analysis uses the 1996 Medical Expenditure Panel Survey Nursing Home Component, a nationally representative sample of 5899 nursing home residents in 815 facilities. During the year, 766 elderly residents in the sample were suspected of having pneumonia infections and 224 were hospitalized for them. Logistic regression is used to assess factors affecting the decision to hospitalize among the 766 with pneumonia infections. Main Outcome Measure:Hospitalization for suspected pneumonia. Results:Residents with suspected pneumonia in not-for-profit facilities are hospitalized at a rate half that of for-profit facilities. The difference is most pronounced for residents who are older and more cognitively impaired and those who are covered by Medicare or private funds. Medicaid residents are most likely overall to be hospitalized, with higher rates in not-for-profit than for-profit facilities. Conclusion:Risk of hospitalization for suspected pneumonia varies widely by ownership type and resident payer source, with lowest overall risk in not-for-profit facilities. Higher Medicaid hospitalization in not-for-profit facilities is consistent with heterogeneity in the not-for-profit sector, where Medicaid residents are sorted into the lower-quality facilities.

Disparities in Long-Term Care: Building Equity Into Market-Based Reforms

A growing body of evidence documents pervasive racial, ethnic, and class disparities in long-term care in the United States. At the same time, major quality improvement initiatives are being implemented that rely on market-based incentives, many of which may have the unintended consequence of exacerbating disparities. We review existing evidence on disparities in the use and quality of long-term care services, analyze current market-based policy initiatives in terms of their potential to ameliorate or exacerbate these disparities, and suggest policies and policy modifications that may help decrease disparities. We find that racial disparities in the use of formal long-term care have decreased over time. Disparities in quality of care are more consistently documented and appear to be related to racial and socioeconomic segregation of long-term care facilities as opposed to within-provider discrimination. Market-based incentives policies should explicitly incorporate the goal of mitigating the potential unintended consequence of increased disparities.A growing body of evidence documents pervasive racial, ethnic, and class disparities in long-term care in the United States. At the same time, major quality improvement initiatives are being implemented that rely on market-based incentives, many of which may have the unintended consequence of exacerbating disparities. We review existing evidence on disparities in the use and quality of long-term care services, analyze current market-based policy initiatives in terms of their potential to ameliorate or exacerbate these disparities, and suggest policies and policy modifications that may help decrease disparities. We find that racial disparities in the use of formal long-term care have decreased over time. Disparities in quality of care are more consistently documented and appear to be related to racial and socioeconomic segregation of long-term care facilities as opposed to within-provider discrimination. Market-based incentives policies should explicitly incorporate the goal of mitigating the potential unintended consequence of increased disparities.

Will mandated minimum nurse staffing ratios lead to better patient outcomes

Background: Mandatory hospital nurse staffing ratios are under consideration in a number of states without strong empirical evidence of the optimal ratio. Objective: To determine whether increases in medical-surgical licensed nurse staffing levels are associated with improvements in patient outcomes for hospitals having different baseline staffing levels. Research Design: Cross-sectional and fixed-effects regression analyses using a 1993–2001 panel of patient and hospital data from California. Splines define 4 staffing ratios. Subjects: Adult acute myocardial infarction (AMI) (n = 348,720) and surgical failure to rescue (FTR) (n = 109,066) patients discharged between 1993 and 2001 from 343 California acute care general hospitals. Measures: Patient outcomes are 30-day AMI mortality and surgical FTR; 4 baseline staffing levels—4 to 7 patients per licensed nurse [registered nurses (RN) and licensed vocational nurses (LVN)]. Results: Significant cross-sectional associations between higher nurse staffing and AMI mortality are reduced in the fixed-effects analyses. Improvements in outcomes were smaller in hospitals with higher baseline staffing: for each RN and RN + LVN increase, respectively, AMI mortality declined by 0.71 (P < 0.05) and by 2.75 percentage points for hospitals with more than 7 patients per nurse compared with 0.19 (P = NS) and 0.28 percentage points (P < 0.05) in hospitals with more than 4 patients per nurse. Significant cross-sectional associations between higher nurse staffing and FTR were not found in the fixed-effects analyses. Conclusions: Strong diminishing returns to nurse staffing improvements and lack of significant evidence that staffing uniformly increases improve outcomes raise questions about the likely cost-effectiveness of implementing state-wide mandatory nurse staffing ratios.