Skilled Nursing Facility Quality Rating and Surgical Outcomes Following Coronary Artery Bypass Grafting

Do Medicare Beneficiaries Under Accountable Care or Medicare Advantage Use Lower Quality Nursing Homes?

BACKGROUND

With the growing number of Medicare beneficiaries attributed to Accountable Care Organizations (ACO) or enrolled in Medicare Advantage (MA) and their financial incentives to lower the cost of the cared patients, it is essential to understand how these alternative payment models affect post-acute outcomes among beneficiaries, with or without dementia diagnoses. In this study, we examined the quality of skilled nursing facilities (SNFs) that beneficiaries entered after hospital discharge under different payment models.

STUDY PARTICIPANTS

Medicare beneficiaries who were discharged from hospitals and admitted to SNFs between 2013 and 2018.

KEY MEASURES

The exposure variable was a payment indicator, including ACO, MA, or non-ACO traditional Medicare (TM) fee-for-service. The dependent variable was high overall quality SNF, defined as with at least 4-star rating in the CMS Nursing Home Care Compare.

ANALYTIC PLAN

We examined the payer distribution by dementia diagnosis using ZIP Code Tabulation Areas (ZCTAs) fixed effects and adjusted for age, gender, and race. We also estimated the probabilities of entering high-quality SNF as a function of payer status and dementia diagnosis each year using hospital and ZCTA fixed effects and accounting for beneficiary-level covariates.

RESULTS

Among SNF admissions from 2013 to 2018, the share of ACO-attributed beneficiaries increased from 7.6% to 20.2%, MA enrollees increased from 25.2% to 32.8%, and non-ACO-attributed TM enrollees decreased from 67.2% to 47.3%. Consistently, ACO-attributed beneficiaries were the most likely, while MA enrollees were the least likely to enter high-quality SNFs, regardless of dementia diagnosis.

CONCLUSIONS

Our findings highlight significant differences in access to high-quality SNFs across Medicare payment models, with ACO-attributed beneficiaries consistently experiencing better access than their MA or traditional Medicare counterparts, regardless of dementia diagnosis. These results underscore the need for further investigation into how payment models influence care quality and access, particularly for vulnerable populations.

Disparities in Skilled Nursing Facility Use and Outcomes After Cardiac Surgery

INTRODUCTION

Cardiac surgery remains highly morbid and requires significant postoperative care. The use of postacute care facilities, such as skilled nursing facilities (SNFs) has grown in popularity to reduce healthcare spendings. Currently, sex and race disparities associated with SNF use after cardiac surgery are poorly understood.

METHOD

Patients who underwent coronary artery bypass graftingfrom June 2016 to December 2018 were identified in Medicare Provider Analysis and Review data. Patients were stratified into 4 groups based on sex and race as follows: White male, White female, Black male, and Black female. The impact of sex and race on SNF use and the associated outcomes were evaluated using logistic regression and Cox-proportional hazards analysis.

RESULT

Of the 93,727 patients who underwent coronary artery bypass grafting, 67,244 (71.7%) were White males, 2517 (2.7%) were Black males, 22,187 (23.7%) were White females, and 1779 (1.9%) were Black females. Black female patients (37.1%) were most likely to be discharged to SNF, followed by White females (33.7%), Black males (24.9%), and White males (18.9%) (P < 0.001). After adjustment, Black males (OR = 1.34, 95% CI: 1.21-1.49), White females (OR = 1.82, 95% CI: 1.75-2.13), and Black females (OR = 1.90, 95% CI: 1.70-2.13) were more likely to be discharged to SNF compared to White males. However, of the patients discharged to SNF, only White females and Black females had better overall survival when compared to White men.

CONCLUSIONS

Significant disparities in the use of SNF after cardiac surgery are present across sex and race categories; however, the 1-y mortality benefit after risk adjustment does not reflect these differences.

Hospital Variation in Skilled Nursing Facility Use After Coronary Artery Bypass Graft Surgery

BACKGROUND

Over 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 RESULTS

A 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.

CONCLUSIONS

There 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.