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Cross DA, Bucy TI, Rahman M, McHugh JP. Access to preferred skilled nursing facilities: Transitional care pathways for patients with Alzheimer's disease and related dementias. Health Serv Res 2024; 59:e14263. [PMID: 38145955 PMCID: PMC10915496 DOI: 10.1111/1475-6773.14263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2023] Open
Abstract
OBJECTIVE The study aimed to assess whether individuals with Alzheimer's disease and related dementias (ADRD) experience restricted access to hospitals' high-volume preferred skilled nursing facility (SNF) partners. DATA SOURCES The data source includes acute care hospital to SNF transitions identified using 100% Medicare Provider Analysis and Review files, 2017-2019. STUDY DESIGN We model and compare the estimated effect of facility "preferredness" on SNF choice for patients with and without ADRD. We use conditional logistic regression with a 1:1 patient sample otherwise matched on demographic and encounter characteristics. DATA COLLECTION Our matched sample included 58,190 patients, selected from a total observed population of 3,019,260 Medicare hospitalizations that resulted in an SNF transfer between 2017 and 2019. PRINCIPAL FINDINGS Overall, patients with ADRD have a lower probability of being discharged to a preferred SNF (52.0% vs. 54.4%, p < 0.001). Choice model estimation using our matched sample suggests similarly that the marginal effect of preferredness on a patient choosing a proximate SNF is 2.4 percentage points lower for patients with ADRD compared with those without (p < 0.001). The differential effect of preferredness based on ADRD status increases when considering (a) the cumulative effect of multiple SNFs in close geographic proximity, (b) the magnitude of the strength of hospital-SNF relationship, and (c) comparing patients with more versus less advanced ADRD. CONCLUSIONS Preferred relationships are significantly predictive of where a patient receives SNF care, but this effect is weaker for patients with ADRD. To the extent that these high-volume relationships are indicative of more targeted transitional care improvements from hospitals, ADRD patients may not be fully benefiting from these investments. Hospital leaders can leverage integrated care relationships to reduce SNFs' perceived need to engage in selection behavior (i.e., enhanced resource sharing and transparency in placement practices). Policy intervention may be needed to address selection behavior and to support hospitals in making systemic improvements that can better benefit all SNF partners (i.e., more robust information sharing systems).
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Affiliation(s)
- Dori A. Cross
- Division of Health Policy and ManagementUniversity of Minnesota School of Public HealthMinneapolisMinnesotaUSA
| | - Taylor I. Bucy
- Division of Health Policy and ManagementUniversity of Minnesota School of Public HealthMinneapolisMinnesotaUSA
| | - Momotazur Rahman
- Department of Health Services, Policy & PracticeBrown University School of Public HealthProvidenceRhode IslandUSA
| | - John P. McHugh
- Department of Health Policy and ManagementMailman School of Public Health, Columbia UniversityNew YorkNew YorkUSA
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Cai S, Yan D, Wang S, Temkin-Greener H. Quality of Nursing Homes Among ADRD Residents Newly Admitted From the Community: Does Race Matter? J Am Med Dir Assoc 2023; 24:712-717. [PMID: 36870366 PMCID: PMC10182813 DOI: 10.1016/j.jamda.2023.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 01/20/2023] [Accepted: 01/24/2023] [Indexed: 03/05/2023]
Abstract
OBJECTIVE To examine racial differences in admissions to high-quality nursing homes (NHs) among residents with Alzheimer disease and related dementias (ADRD), and whether such racial differences can be influenced by dementia-related state Medicaid add-on policies. DESIGN Retrospective cross-sectional study. SETTING AND PARTICIPANTS The study included 786,096 Medicare beneficiaries with ADRD newly admitted from the community to NHs between January 1, 2011 and December 31, 2017. METHODS 2010-2017 Minimum Data Set 3.0, Medicare Beneficiary Summary File, Medicare Provider Analysis and Review, and Nursing Home Compare data were linked. For each individual, we constructed a "choice" set of NHs based on the distance between the NH and an individual residential zip code. McFadden's choice models were estimated to examine the relationship between admission into a high-quality (4- or 5-star) NH and individual characteristics, specifically race, and state Medicaid dementia-related add-on policies. RESULTS Among the identified residents, 89% were White, and 11% were Black. Overall, 50% of White and 35% of Black individuals were admitted to high-quality NHs. Black individuals were more likely to be Medicare-Medicaid dually eligible. Results from McFadden's model suggested that Black individuals were less likely to be admitted to a high-quality NH than White individuals (OR = 0.615, P < .01), and such differences were partially explained by some individual characteristics. Furthermore, we found that the racial difference was reduced in states with dementia-related add-on policies, compared with states without these policies (OR = 1.16, P < .01). CONCLUSIONS AND IMPLICATIONS Black individuals with ADRD were less likely to be admitted to high-quality NHs than White individuals. Such difference was partially related to individuals' health conditions, social-economic status, and state Medicaid add-on policies. Policies to reduce barriers to high-quality NHs among Black individuals are necessary to mitigate health inequity in this vulnerable population.
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Affiliation(s)
- Shubing Cai
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - Di Yan
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Sijiu Wang
- Department of Public Health Sciences, Biological Sciences Division, University of Chicago, Chicago, IL, USA
| | - Helena Temkin-Greener
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
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Falvey JR, Hade EM, Friedman S, Deng R, Jabbour J, Stone RI, Travers JL. Severe neighborhood deprivation and nursing home staffing in the United States. J Am Geriatr Soc 2023; 71:711-719. [PMID: 36929467 PMCID: PMC10023834 DOI: 10.1111/jgs.17990] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 07/11/2022] [Accepted: 07/11/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Low nursing home staffing in the United States is a growing safety concern. Socioeconomic deprivation in the local areas surrounding a nursing home may be a barrier to improving staffing rates but has been poorly studied. Thus, the objective of this paper was to assess the relationship between neighborhood deprivation and nursing home staffing in the United States. METHODS This cross-sectional study used 2018 daily payroll-based staffing records and address data for 12,609 nursing homes in the United States linked with resident assessment data. Our primary exposure of interest was severe economic deprivation at the census block group (neighborhood) level, defined as an area deprivation index score ≥85/100. The primary outcome was hours worked per resident-day among nursing home employees providing direct resident care. Marginal linear regression models and generalized estimating equations with robust sandwich-type standard errors were used to estimate associations between severe neighborhood deprivation and staffing rates. RESULTS Compared to less deprived neighborhoods, unadjusted staffing rates in facilities located within severely deprived neighborhoods were 38% lower for physical and occupational therapists, 30% lower for registered nurses (RNs), and 5% lower for certified nursing assistants. No disparities in licensed practical nurse (LPN) staffing were observed. In models with state-level and rurality fixed effects and clustered on the county, a similar pattern of disparities was observed. Specifically, RN staffing per 100 resident-days was significantly lower in facilities located within severely deprived neighborhoods as compared to those in less deprived areas (mean difference: 5.6 fewer hours, 95% confidence interval [CI] 4.2-6.9). Disparities of lower magnitude were observed for other clinical disciplines except for LPNs. CONCLUSIONS Significant staffing disparities were observed within facilities located in severely deprived neighborhoods. Targeted interventions, including workforce recruitment and retention efforts, may be needed to improve staffing levels for nursing homes in deprived neighborhoods.
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Affiliation(s)
- Jason R. Falvey
- Department of Physical Therapy and Rehabilitation Science, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - Erinn M. Hade
- Division of Biostatistics, Department of Population Health, New York University Grossman School of Medicine, New York, NY
| | - Steven Friedman
- Division of Biostatistics, Department of Population Health, New York University Grossman School of Medicine, New York, NY
| | - Rebecca Deng
- Department of Epidemiology, NYU School of Global Public Health, New York, NY
| | - Joelle Jabbour
- NYU Robert F. Wagner Graduate School of Public Service, New York, NY
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UWO x PCC Group C, Strickland C, Chi N, Ditz L, Gomez L, Wagner B, Wang S, Lizotte D. Factors Influencing Admission Decisions in Skilled Nursing Facilities: A Retrospective Quantitative Study (Preprint). J Med Internet Res 2022; 25:e43518. [PMID: 37195755 DOI: 10.2196/43518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 03/09/2023] [Accepted: 03/27/2023] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND Occupancy rates within skilled nursing facilities (SNFs) in the United States have reached a record low. Understanding drivers of occupancy, including admission decisions, is critical for assessing the recovery of the long-term care sector as a whole. We provide the first comprehensive analysis of financial, clinical, and operational factors that impact whether a patient referral to an SNF is accepted or denied, using a large health informatics database. OBJECTIVE Our key objectives were to describe the distribution of referrals sent to SNFs in terms of key referral- and facility-level features; analyze key financial, clinical, and operational variables and their relationship to admission decisions; and identify the key potential reasons behind referral decisions in the context of learning health systems. METHODS We extracted and cleaned referral data from 627 SNFs from January 2020 to March 2022, including information on SNF daily operations (occupancy and nursing hours), referral-level factors (insurance type and primary diagnosis), and facility-level factors (overall 5-star rating and urban versus rural status). We computed descriptive statistics and applied regression modeling to identify and describe the relationships between these factors and referral decisions, considering them individually and controlling for other factors to understand their impact on the decision-making process. RESULTS When analyzing daily operation values, no significant relationship between SNF occupancy or nursing hours and referral acceptance was observed (P>.05). By analyzing referral-level factors, we found that the primary diagnosis category and insurance type of the patient were significantly related to referral acceptance (P<.05). Referrals with primary diagnoses within the category "Diseases of the Musculoskeletal System" are least often denied whereas those with diagnoses within the "Mental Illness" category are most often denied (compared with other diagnosis categories). Furthermore, private insurance holders are least often denied whereas "medicaid" holders are most often denied (compared with other insurance types). When analyzing facility-level factors, we found that the overall 5-star rating and urban versus rural status of an SNF are significantly related to referral acceptance (P<.05). We found a positive but nonmonotonic relationship between the 5-star rating and referral acceptance rates, with the highest acceptance rates found among 5-star facilities. In addition, we found that SNFs in urban areas have lower acceptance rates than their rural counterparts. CONCLUSIONS While many factors may influence a referral acceptance, care challenges associated with individual diagnoses and financial challenges associated with different remuneration types were found to be the strongest drivers. Understanding these drivers is essential in being more intentional in the process of accepting or denying referrals. We have interpreted our results using an adaptive leadership framework and suggested how SNFs can be more purposeful with their decisions while striving to achieve appropriate occupancy levels in ways that meet their goals and patients' needs.
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Jain S, Hauschildt K, Scheunemann LP. Social determinants of recovery. Curr Opin Crit Care 2022; 28:557-565. [PMID: 35993295 DOI: 10.1097/mcc.0000000000000982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to examine evidence describing the influence of social determinants on recovery following hospitalization with critical illness. In addition, it is meant to provide insight into the several mechanisms through which social factors influence recovery as well as illuminate approaches to addressing these factors at various levels in research, clinical care, and policy. RECENT FINDINGS Social determinants of health, ranging from individual factors like social support and socioeconomic status to contextual ones like neighborhood deprivation, are associated with disability, cognitive impairment, and mental health after critical illness. Furthermore, many social factors are reciprocally related to recovery wherein the consequences of critical illness such as financial toxicity and caregiver burden can put essential social needs under strain turning them into barriers to recovery. SUMMARY Recovery after hospitalization for critical illness may be influenced by many social factors. These factors warrant attention by clinicians, health systems, and policymakers to enhance long-term outcomes of critical illness survivors.
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Jain S, Murphy TE, O’Leary JR, Leo-Summers L, Ferrante LE. Association Between Socioeconomic Disadvantage and Decline in Function, Cognition, and Mental Health After Critical Illness Among Older Adults : A Cohort Study. Ann Intern Med 2022; 175:644-655. [PMID: 35254879 PMCID: PMC9316386 DOI: 10.7326/m21-3086] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Older adults admitted to an intensive care unit (ICU) are at risk for developing impairments in function, cognition, and mental health. It is not known whether socioeconomically disadvantaged older persons are at greater risk for these impairments than their less vulnerable counterparts. OBJECTIVE To evaluate the association between socioeconomic disadvantage and decline in function, cognition, and mental health among older survivors of an ICU hospitalization. DESIGN Retrospective analysis of a longitudinal cohort study. SETTING Community-dwelling older adults in the National Health and Aging Trends Study (NHATS). PARTICIPANTS Participants with ICU hospitalizations between 2011 and 2017. MEASUREMENTS Socioeconomic disadvantage was assessed as dual-eligible Medicare-Medicaid status. The outcome of function was defined as the count of disabilities in 7 activities of daily living and mobility tasks, the cognitive outcome as the transition from no or possible to probable dementia, and the mental health outcome as the Patient Health Questionnaire-4 score in the NHATS interview after ICU hospitalization. The analytic sample included 641 ICU hospitalizations for function, 458 for cognition, and 519 for mental health. RESULTS After accounting for sociodemographic and clinical characteristics, dual eligibility was associated with a 28% increase in disability after ICU hospitalization (incidence rate ratio, 1.28; 95% CI, 1.00 to 1.64); and nearly 10-fold greater odds of transitioning to probable dementia (odds ratio, 9.79; 95% CI, 3.46 to 27.65). Dual eligibility was not associated with symptoms of depression and anxiety after ICU hospitalization (incidence rate ratio, 1.33; 95% CI, 0.99 to 1.79). LIMITATION Administrative data, variability in timing of baseline and outcome assessments, proxy selection. CONCLUSION Dual-eligible older persons are at greater risk for decline in function and cognition after an ICU hospitalization than their more advantaged counterparts. This finding highlights the need to prioritize low-income seniors in rehabilitation and recovery efforts after critical illness and warrants investigation into factors leading to this disparity. PRIMARY FUNDING SOURCE National Institute on Aging.
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Affiliation(s)
- Snigdha Jain
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Terrence E. Murphy
- Program on Aging, Section of Geriatrics, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - John R. O’Leary
- Program on Aging, Section of Geriatrics, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Linda Leo-Summers
- Program on Aging, Section of Geriatrics, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Lauren E. Ferrante
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
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Cao Y, Allore H, Gutman R, Vander Wyk B, Jørgensen TSH. Risk Factors of Skilled Nursing Facility Admissions and the Interrelation With Hospitalization and Amount of Informal Caregiving Received. Med Care 2022; 60:294-301. [PMID: 35149662 PMCID: PMC8916995 DOI: 10.1097/mlr.0000000000001697] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The correlations between skilled nursing facility (SNF) admissions, number of hospitalizations, and informal caregiving hours received after adjusting for physical and cognitive function and sociodemographic covariates are not well understood. OBJECTIVE The objective of this study was to better understand risk factors for SNF admissions and the interrelation with hospitalizations and amount of informal caregiving received, this study applied a novel joint modeling analysis to simultaneously explore the correlation and shared information between the 3 outcomes. RESEARCH DESIGN This was an observational follow-up study. SUBJECTS Data from 4836 older Americans included in the 2011-2015 rounds of the National Health and Aging Trends Study were linked with Centers for Medicare & Medicaid Services. MEASURES We jointly modeled SNF admission, hospital admissions, and informal caregiving hours received while accounting for possible risk factors. We addressed missing values by multiple imputation with chained equations. RESULTS SNF admission evidenced a strong positive correlation with hospital admission, and SNF admission evidenced a weak positive correlation with the informal caregiving hours received after adjustment for important risk factors. Non-Hispanic White race/ethnicity, living alone, not being Medicaid eligible, Alzheimer disease and related dementias diagnosis, activities of daily living disabilities, and frailty were associated with increased risk of SNF admissions and any/number of hospital admission. Lower educational level was also associated with the latter. Medicaid eligibility was the only factor not associated with any nor numbers of informal caregiving hours received. CONCLUSIONS Sociodemographic and health factors were important for predicting SNF admissions. After adjustment for important risk factors, SNF evidenced a strong positive correlation with the number of hospitalizations and a weak positive correlation with the hours of informal caregiving received.
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Affiliation(s)
- Yi Cao
- Department of Biostatistics, Brown University, Providence, RI, USA
| | - Heather Allore
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Biostatistics, Yale School of Public Health, New Haven, CT.,USA
| | - Roee Gutman
- Department of Biostatistics, Brown University, Providence, RI, USA
| | - Brent Vander Wyk
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
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Abstract
IMPORTANCE Black and Hispanic US residents are disproportionately affected by stroke incidence, and patients with dual eligibility for Medicare and Medicaid may be predisposed to more severe strokes. Little is known about differences in stroke severity for individuals with dual eligibility, Black individuals, and Hispanic individuals, but understanding hospital admission stroke severity is the first important step for focusing strategies to reduce disparities in stroke care and outcomes. OBJECTIVE To examine whether dual eligibility and race and ethnicity are associated with stroke severity in Medicare beneficiaries admitted to acute hospitals with ischemic stroke. DESIGN, SETTING, AND PARTICIPANTS This retrospective cross-sectional study was conducted using Medicare claims data for patients with ischemic stroke admitted to acute hospitals in the United States from October 1, 2016, to November 30, 2017. Data were analyzed from July 2021 and January 2022. EXPOSURES Dual enrollment for Medicare and Medicaid; race and ethnicity categorized as White, Black, Hispanic, and other. MAIN OUTCOMES AND MEASURES Claim-based National Institutes of Health Stroke Scale (NIHSS) categorized into minor (0-7), moderate (8-13), moderate to severe (14-21), and severe (22-42) stroke. RESULTS Our sample included 45 459 Medicare fee-for-service patients aged 66 and older (mean [SD] age, 80.2 [8.4]; 25 303 [55.7%] female; 7738 [17.0%] dual eligible; 4107 [9.0%] Black; 1719 [3.8%] Hispanic; 37 715 [83.0%] White). In the fully adjusted models, compared with White patients, Black patients (odds ratio [OR], 1.21; 95% CI, 1.06-1.39) and Hispanic patients (OR, 1.54; 95% CI, 1.29-1.85) were more likely to have a severe stroke. Using White patients without dual eligibility as a reference group, White patients with dual eligibility were more likely to have a severe stroke (OR, 1.75; 95% CI, 1.56-1.95). Similarly, Black patients with dual eligibility (OR, 2.15; 95% CI, 1.78-2.60) and Hispanic patients with dual eligibility (OR, 2.50; 95% CI, 1.98-3.16) were more likely to have a severe stroke. CONCLUSIONS AND RELEVANCE In this cross-sectional study, Medicare fee-for-service patients with ischemic stroke admitted to acute hospitals who were Black or Hispanic had a higher likelihood of worse stroke severity. Additionally, dual eligibility status had a compounding association with stroke severity regardless of race and ethnicity. An urgent effort is needed to decrease disparities in access to preventive and poststroke care for dual eligible and minority patients.
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Affiliation(s)
- Pamela R. Bosch
- College of Health and Human Services, Northern Arizona University, Phoenix Biomedical Campus, Phoenix
| | - Amol M. Karmarkar
- Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University, Richmond
- Sheltering Arms Institute, Richmond, Virginia
| | - Indrakshi Roy
- Center for Health Equity Research, Northern Arizona University, Flagstaff
| | - Corey R. Fehnel
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Marcus Institute for Aging Research, Boston, Massachusetts
| | - Robert E. Burke
- Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Amit Kumar
- College of Health and Human Services, Northern Arizona University, Phoenix Biomedical Campus, Phoenix
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Tang OY, Clarke RA, Rivera Perla KM, Corcoran Ruiz KM, Toms SA, Weil RJ. Brain tumor craniotomy outcomes for dual-eligible medicare and medicaid patients: a 10-year nationwide analysis. J Neurooncol 2022; 156:387-398. [PMID: 35023004 DOI: 10.1007/s11060-021-03922-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 12/06/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Dual-eligible (DE) patients, simultaneous Medicare and Medicaid beneficiaries, have been shown to have poorer clinical outcomes while incurring higher resource utilization. However, neurosurgical oncology outcomes for DE patients are poorly characterized. Accordingly, we examined the impact of DE status on perioperative outcomes following glioma, meningioma, or metastasis resection. METHODS We identified all admissions undergoing a craniotomy for glioma, meningioma, or metastasis resection in the National Inpatient Sample from 2002 to 2011. Assessed outcomes included inpatient mortality, complications, discharge disposition, length of stay (LOS), and hospital costs. Multivariable regression adjusting for 13 patient, severity, and hospital characteristics assessed the association between DE status and outcomes, relative to four reference insurance groups (Medicare-only, Medicaid-only, private insurance, self-pay). RESULTS Of 195,725 total admissions analyzed, 3.0% were dual-eligible beneficiaries (n = 5933). DEs were younger than Medicare admissions (P < 0.001) but older than Medicaid, private, and self-pay admissions (P < 0.001). Relative to other insurance groups, DEs also exhibited higher severity of illness, risk of mortality, and Charlson Comorbidity Index scores as well as treatment at low-volume hospitals (all P < 0.001). DEs had lower mortality than self-pay admissions (odds ratio [OR] 0.47, P = 0.017). Compared to Medicare, Medicaid, private, and self-pay admissions, DEs had lower rates of discharge disposition (OR 0.53, 0.50, 0.34, and 0.27, respectively, all P < 0.001). DEs also had higher complications (OR 1.23 and 1.20, respectively, both P < 0.05) and LOS (β = 1.06 and 1.13, respectively, both P < 0.01) than Medicare and private insurance beneficiaries. Differences in discharge disposition remained significant for all three tumor subtypes, but only glioma DE admissions continued to exhibit higher complications and LOS. CONCLUSIONS DEs undergoing definitive craniotomy for brain tumor had higher rates of unfavorable discharge disposition compared to all other insurance groups and, especially for glioma surgery, had higher inpatient complication rates and LOS. Practice and policy reforms to improve outcomes for this vulnerable clinical population are warranted.
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Affiliation(s)
- Oliver Y Tang
- The Warren Alpert Medical School of Brown University, Providence, RI, USA.
| | - Ross A Clarke
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Krissia M Rivera Perla
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
- Harvard T.H Chan School of Public Health, Boston, MA, USA
| | | | - Steven A Toms
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
- Department of Neurosurgery, Rhode Island Hospital, Providence, RI, USA
| | - Robert J Weil
- Southcoast Brain & Spine, Southcoast Health, Dartmouth, MA, USA
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Evans E, Gutman R, Resnik L, Zonfrillo MR, Lueckel SN, Kumar RG, DeVone F, Dams-O'Connor K, Thomas KS. Successful Community Discharge Among Older Adults With Traumatic Brain Injury in Skilled Nursing Facilities. J Head Trauma Rehabil 2021; 36:E186-E198. [PMID: 33528173 PMCID: PMC8096636 DOI: 10.1097/htr.0000000000000638] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To identify patient, injury, and functional status characteristics associated with successful discharge to the community following a skilled nursing facility (SNF) stay among older adults hospitalized following traumatic brain injury (TBI). SETTING Skilled nursing facilities. PARTICIPANTS Medicare fee-for-service beneficiaries admitted to an SNF after hospitalization for TBI. DESIGN Retrospective cohort study using Medicare administrative data merged with the National Trauma Data Bank using a multilayered Bayesian record linkage approach. MAIN OUTCOME MEASURE Successful community discharge: discharged alive within 100 days of SNF admission and remaining in the community for 30 days or more without dying or admission to a healthcare facility. RESULTS Medicaid enrollment, incontinence, decreased independence with activities of daily living, and cognitive impairment were associated with lower odds of successful discharge, whereas race "other" was associated with higher odds of successful discharge. Injury factors including worse injury severity (Glasgow Coma Scale and Abbreviated Injury Scale scores) and fall-related injury mechanism were not associated with successful discharge. CONCLUSION Among older adults with TBI who discharge to an SNF, sociodemographic and functional status characteristics are associated with successful discharge and may be useful to clinicians for discharge planning. Acute injury severity indices may have limited utility in predicting discharge disposition once a patient is admitted to an SNF for post-acute care.
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Affiliation(s)
- Emily Evans
- Department of Health Services, Policy and Practice Center for Gerontology and Healthcare Research, Brown School of Public Health (Drs Evans, Resnik, and Thomas) and Department of Biostatistics (Dr Gutman and Mr DeVone), Brown University School of Public Health, Providence, Rhode Island; Providence VA Medical Center, Providence, Rhode Island (Drs Resnik and Thomas); Departments of Emergency Medicine and Pediatrics (Dr Zonfrillo) and Division of Acute Care Surgery and Surgical Critical Care, Rhode Island Hospital (Dr Lueckel), Warren Alpert School of Medicine of Brown University, Providence, Rhode Island; and Department of Rehabilitation and Human Performance (Drs Kumar and Dams-O'Connor) and Department of Neurology (Dr Dams-O'Connor), Icahn School of Medicine at Mount Sinai, New York City, New York
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McHugh JP, Rapp T, Mor V, Rahman M. Higher hospital referral concentration associated with lower-risk patients in skilled nursing facilities. Health Serv Res 2021; 56:839-846. [PMID: 33779987 DOI: 10.1111/1475-6773.13654] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To examine whether stronger referral relationships between hospitals and skilled nursing facilities (SNF) are associated with lower-risk patients being admitted to SNF. DATA SOURCES/COLLECTION We used MedPAR data to estimate referral relationship strength and nursing home survey data (OSCAR and CASPER) to determine the risk of patient admissions at nearly 14 000 SNFs from 2008 to 2014. STUDY DESIGN We examined the association of hospital referral concentration with the percentage of higher-risk patients admitted to non-hospital-based (freestanding) SNFs using an instrumental variables approach. We used the distance between patients and SNFs and hospitals and SNFs as the instrument. DATA COLLECTION/EXTRACTION METHODS We used previously collected MedPAR and OSCAR/CASPER survey data. PRINCIPAL FINDINGS We find greater observed referral concentration among freestanding SNFs is associated with lower percentages of patients with pressure sores (coefficient, -2.64; 95% CI, [-2.82 to -2.46]), catheters (-0.55; [-0.74 to -0.36]), and physical restraints (-0.16; [-0.29 to -0.03]) at admission to a skilled nursing facility. CONCLUSIONS We find evidence that freestanding SNFs with stronger hospital referral relationships may be admitting less risky patients, possibly contributing to disparities across SNFs.
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Affiliation(s)
- John P McHugh
- Department of Health Policy and Management, Columbia University Mailman School of Public Health, New York, New York, USA
| | | | - Vincent Mor
- Department of Health Services Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Momotazur Rahman
- Department of Health Services Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA
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Thirukumaran CP, Cai X, Glance LG, Kim Y, Ricciardi BF, Fiscella KA, Li Y. Geographic Variation and Disparities in Total Joint Replacement Use for Medicare Beneficiaries: 2009 to 2017. J Bone Joint Surg Am 2020; 102:2120-2128. [PMID: 33079898 PMCID: PMC8190867 DOI: 10.2106/jbjs.20.00246] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Little is known about how the geographic variation and disparities in use of elective primary total hip and knee replacements for Medicare beneficiaries have evolved in recent years. The study objectives are to determine these variations and disparities, whether Black Medicare beneficiaries have continued to undergo fewer total hip replacements and total knee replacements across regions, and whether disparities affected all Black beneficiaries or mainly affected socioeconomically disadvantaged Black beneficiaries. METHODS We used 2009 to 2017 Medicare enrollment and claims data to examine Hospital Referral Region (HRR)-level variation and disparities by race (non-Hispanic White and Black) and socioeconomic status (Medicare-only and dual eligibility for both Medicare and Medicaid). The outcomes were HRR-level age and sex-standardized total hip replacement and total knee replacement utilization rates for White Medicare-only beneficiaries, White dual-eligible beneficiaries, Black Medicare-only beneficiaries, and Black dual-eligible beneficiaries, and the differences in rates between these groups as a representation of disparities. The key exposure variables were race-socioeconomic group and year. We constructed multilevel mixed-effects linear regression models to estimate trends in total hip replacement and total knee replacement rates and to examine whether rates were lower in HRRs with high percentages of Black beneficiaries or dual-eligible beneficiaries. RESULTS The study included 924,844 total hip replacements and 2,075,968 total knee replacements. In 2017, the mean HRR-level total hip replacement rate was 4.64 surgical procedures per 1,000 beneficiaries, and the mean HRR-level total knee replacement rate was 9.66 surgical procedures per 1,000 beneficiaries, with a threefold variation across HRRs. In 2017, the total hip replacement rate was 32% higher for White Medicare-only beneficiaries and 48% higher for Black Medicare-only beneficiaries than in 2009 (p < 0.001). However, because the surgical rates for White and Black dual-eligible beneficiaries remained unchanged over the study period, the 2017 Medicare-only and dual-eligible disparity for White beneficiaries increased by 0.75 surgical procedures per 1,000 from 2009 (40.98% increase; p = 0.03), and the disparity for Black beneficiaries by 1.13 surgical procedures per 1,000 beneficiaries (297.37% increase; p < 0.001). The total knee replacement disparities remained unchanged. Notably, the rates for White dual-eligible beneficiaries were significantly lower than those for Black Medicare-only beneficiaries (p < 0.001 for both total hip replacements and total knee replacements), and fewer surgical procedures were conducted in HRRs with a higher density of Black or dual-eligible beneficiaries. CONCLUSIONS Although the total hip replacement use for Medicare-only beneficiaries of both races increased, disparities for White and Black dual-eligible beneficiaries (compared with their Medicare-only counterparts) are increasing. Efforts to improve equity must identify and address both racial and socioeconomic barriers and focus on regions with high concentrations of disadvantaged beneficiaries. CLINICAL RELEVANCE Although total hip replacements and total knee replacements are highly successful surgical procedures for end-stage osteoarthritis, our findings show that, as recently as 2017, Black beneficiaries and those dual eligible for Medicaid (a proxy for socioeconomic status) are less likely to undergo these surgical procedures and that there is profound geographic variation in the use of these surgical procedures. This evidence is essential for the design and implementation of disparity-reduction strategies focused on patients, providers, and geographic areas that can potentially improve the equity in joint replacement care.
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Affiliation(s)
- Caroline P. Thirukumaran
- Departments of Orthopaedics, Public Health Sciences, Biostatistics and Computational Biology, Anesthesiology and Perioperative Medicine, and Family Medicine, University of Rochester, Rochester, New York,Center for Musculoskeletal Research, University of Rochester, Rochester, New York
| | - Xueya Cai
- Departments of Orthopaedics, Public Health Sciences, Biostatistics and Computational Biology, Anesthesiology and Perioperative Medicine, and Family Medicine, University of Rochester, Rochester, New York
| | - Laurent G. Glance
- Departments of Orthopaedics, Public Health Sciences, Biostatistics and Computational Biology, Anesthesiology and Perioperative Medicine, and Family Medicine, University of Rochester, Rochester, New York
| | - Yeunkyung Kim
- Departments of Orthopaedics, Public Health Sciences, Biostatistics and Computational Biology, Anesthesiology and Perioperative Medicine, and Family Medicine, University of Rochester, Rochester, New York
| | - Benjamin F. Ricciardi
- Departments of Orthopaedics, Public Health Sciences, Biostatistics and Computational Biology, Anesthesiology and Perioperative Medicine, and Family Medicine, University of Rochester, Rochester, New York,Center for Musculoskeletal Research, University of Rochester, Rochester, New York
| | - Kevin A. Fiscella
- Departments of Orthopaedics, Public Health Sciences, Biostatistics and Computational Biology, Anesthesiology and Perioperative Medicine, and Family Medicine, University of Rochester, Rochester, New York,Center for Community Health and Prevention, University of Rochester, Rochester, New York
| | - Yue Li
- Departments of Orthopaedics, Public Health Sciences, Biostatistics and Computational Biology, Anesthesiology and Perioperative Medicine, and Family Medicine, University of Rochester, Rochester, New York
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13
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Morrow C, Perraillon MC, Daddato AE, Reeder BP, Wald HL, Battaglia C, Boxer RS. Patient Characteristics Are Not Associated With Documentation of Weight and Heart Failure Related Sign and Symptom Assessment in Skilled Nursing Facilities. J Am Med Dir Assoc 2021; 22:1265-1270.e1. [PMID: 33071159 DOI: 10.1016/j.jamda.2020.08.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Revised: 08/13/2020] [Accepted: 08/24/2020] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Monitoring body weight and signs and symptoms related to heart failure (HF) can alert clinicians to a patient's worsening condition but the degree to which these practices are performed in skilled nursing facilities (SNFs) is unknown. This study analyzed the frequency of these monitoring practices in SNFs and explored associated factors at both the patient and SNF level. DESIGN An observational study of data from the usual care arm of the SNF Connect Trial, a randomized cluster trial of a HF disease management intervention. The data extracted from charts were combined with publicly available facility data. A linear regression model was estimated to evaluate the frequency of HF disease management conditional on patient and facility covariates. SETTING Data from 28 SNFs in Colorado. PARTICIPANTS Patients discharged from hospital to SNFs with a primary or secondary diagnosis of HF. MEASUREMENTS Patient-level covariates included demographics, New York Heart Association class, type of HF, and Charlson comorbidity index. Facility-level covariates were from Nursing Home Compare. RESULTS The sample (n = 320) was majority female (66%), white (93%), with mean age 80 ± 10 years and a Charlson comorbidity index of 3.2 ± 1.5. Seventy percent had HF with preserved ejection fraction, mean ejection fraction of 50 ± 16% and 40% with a New York Heart Association class III-IV. On average, patients were weighed 40% of their days in the SNF and had documentation of at least 1 HF-related sign or symptom 70% of their days in the SNF. Patient-level factors were not associated with frequency of documenting weight and assessments of HF-related signs/symptoms. Health Inspection Star Rating was positively associated with weight monitoring (P < .05) but not associated with symptom assessment. CONCLUSIONS AND IMPLICATIONS Patient-level factors are not meaningfully associated with the documentation of weight tracking or sign/symptom assessment. Monitoring weight was instead associated with the Health Inspection Star Rating.
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Augustine MR, Davenport C, Ornstein KA, Cuan M, Saenger P, Lubetsky S, Federman A, DeCherrie LV, Leff B, Siu AL. Implementation of
Post‐Acute
Rehabilitation at Home: A Skilled Nursing
Facility‐Substitutive
Model. J Am Geriatr Soc 2020; 68:1584-1593. [DOI: 10.1111/jgs.16474] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 02/05/2020] [Accepted: 02/09/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Matthew R. Augustine
- Department of MedicineIcahn School of Medicine at Mount Sinai New York New York USA
- Geriatric Research Education and Clinical CenterJames J. Peters VA Medical Center Bronx New York USA
| | - Claire Davenport
- Department of Geriatrics and Palliative MedicineIcahn School of Medicine at Mount Sinai New York New York USA
| | - Katherine A. Ornstein
- Department of Geriatrics and Palliative MedicineIcahn School of Medicine at Mount Sinai New York New York USA
| | - Mitchell Cuan
- Department of Geriatrics and Palliative MedicineIcahn School of Medicine at Mount Sinai New York New York USA
| | - Pamela Saenger
- Department of Geriatrics and Palliative MedicineIcahn School of Medicine at Mount Sinai New York New York USA
| | - Sara Lubetsky
- Department of Geriatrics and Palliative MedicineIcahn School of Medicine at Mount Sinai New York New York USA
| | - Alex Federman
- Department of MedicineIcahn School of Medicine at Mount Sinai New York New York USA
- Department of Geriatrics and Palliative MedicineIcahn School of Medicine at Mount Sinai New York New York USA
| | - Linda V. DeCherrie
- Department of MedicineIcahn School of Medicine at Mount Sinai New York New York USA
- Department of Geriatrics and Palliative MedicineIcahn School of Medicine at Mount Sinai New York New York USA
| | - Bruce Leff
- Division of Geriatrics, Department of Medicine, School of MedicineJohns Hopkins University Baltimore Maryland USA
| | - Albert L. Siu
- Geriatric Research Education and Clinical CenterJames J. Peters VA Medical Center Bronx New York USA
- Department of Geriatrics and Palliative MedicineIcahn School of Medicine at Mount Sinai New York New York USA
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15
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Qi AC, Luke AA, Crecelius C, Joynt Maddox KE. Performance and Penalties in Year 1 of the Skilled Nursing Facility Value‐Based Purchasing Program. J Am Geriatr Soc 2019; 68:826-834. [DOI: 10.1111/jgs.16299] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 11/20/2019] [Accepted: 11/25/2019] [Indexed: 01/06/2023]
Affiliation(s)
- Andrew C. Qi
- Cardiovascular Division, Department of Medicine Washington University School of Medicine St. Louis Missouri
| | - Alina A. Luke
- Cardiovascular Division, Department of Medicine Washington University School of Medicine St. Louis Missouri
| | - Charles Crecelius
- Post‐Acute and Long Term Care Services Barnes Jewish Christian Medical Group St. Louis Missouri
| | - Karen E. Joynt Maddox
- Cardiovascular Division, Department of Medicine Washington University School of Medicine St. Louis Missouri
- Center for Health Economics and Policy, Institute for Public Health Washington University in St. Louis St. Louis Missouri
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16
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Meyers DJ, Wilson IB, Lee Y, Cai S, Miller SC, Rahman M. The Quality of Nursing Homes That Serve Patients With Human Immunodeficiency Virus. J Am Geriatr Soc 2019; 67:2615-2621. [PMID: 31465114 PMCID: PMC7227799 DOI: 10.1111/jgs.16155] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 08/05/2019] [Accepted: 08/08/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND/OBJECTIVES As the national population of persons living with human immunodeficiency virus (HIV) ages, they will require greater postacute and long-term care use. Little is known about the quality of nursing homes (NHs) to which patients with HIV are admitted. In this study, we assess the association between the number of persons with HIV admitted annually to a given NH (HIV concentration) and that NH's quality outcomes. DESIGN A cross-sectional comparative study. SETTING NHs in nine states, from 2001 to 2012. PARTICIPANTS A total of 46 918 NH-years accounting for 67 301 admissions by patients with HIV. MEASUREMENTS We used 100% Medicaid Analytic Extract, Minimum Dataset 2.0 and 3.0, and Medicare claims from 2001 to 2012 from nine states to examine the association between HIV concentration and NH quality. Persons were classified as HIV positive on the basis of all available data sources, and a NH's percentage of new admissions with HIV was calculated (HIV concentration). We then compared differences in star ratings, rehospitalization rates, NH survey deficiencies, and restraint use by a NH's percentage of admissions with HIV, using linear random effects models. RESULTS After adjusting for NH characteristics, zip code characteristics, and state and year fixed effects, NHs with greater than 0% to 5% of admissions with HIV had a 0.6 lower star rating (P < .001), and a 0.4% percentage point higher 30-day rehospitalization rate (P < .01), compared to those with no HIV admissions. NHs with 5% to 50% of admissions with HIV had 7.0 more deficiencies (P < .001), a 0.1 lower star rating (P < .001), and a 1.5 percentage point higher rehospitalization rate (P < .001). CONCLUSION Persons with HIV were generally admitted to lower-quality NHs compared to persons without HIV. More efforts are needed to ensure that persons with HIV have access to high-quality NHs. J Am Geriatr Soc 67:2615-2621, 2019.
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Affiliation(s)
- David J. Meyers
- Department of Health Services, Policy, and Practice, Brown
University School of Public Health, Providence, Rhode Island
| | - Ira B. Wilson
- Department of Health Services, Policy, and Practice, Brown
University School of Public Health, Providence, Rhode Island
| | - Yoojin Lee
- Department of Health Services, Policy, and Practice, Brown
University School of Public Health, Providence, Rhode Island
| | - Shubing Cai
- Department of Public Health Sciences, University of
Rochester Medical Center, Rochester, New York
| | - Susan C. Miller
- Department of Health Services, Policy, and Practice, Brown
University School of Public Health, Providence, Rhode Island
| | - Momotazur Rahman
- Department of Health Services, Policy, and Practice, Brown
University School of Public Health, Providence, Rhode Island
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17
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Harrington C, Mollot R, Edelman TS, Wells J, Valanejad D. U.S. Nursing Home Violations of International and Domestic Human Rights Standards. Int J Health Serv 2019; 50:62-72. [DOI: 10.1177/0020731419886196] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We present a review of the international covenants and conventions and U.S. domestic laws and regulations that are designed to protect nursing home residents in the United States. Based on a review of research studies, government reports, and news reports, we found extensive evidence of widespread and systematic abuse and neglect of nursing home residents in the United States that needs urgent government action to protect the basic human rights of residents.
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Affiliation(s)
| | - Richard Mollot
- The Long Term Care Community Coalition, New York, NY, USA
| | | | - Janet Wells
- California Advocates for Nursing Home Reform, San Francisco, CA, USA
| | - Dara Valanejad
- School of Nursing, University of California, San Francisco, CA, USA
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18
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Philpotts YF, Ma X, Anderson MR, Hua M, Baldwin MR. Health Insurance and Disparities in Mortality among Older Survivors of Critical Illness: A Population Study. J Am Geriatr Soc 2019; 67:2497-2504. [PMID: 31449681 DOI: 10.1111/jgs.16138] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 06/24/2019] [Accepted: 07/20/2019] [Indexed: 01/15/2023]
Abstract
OBJECTIVES The 1.5 million Medicare beneficiaries who survive intensive care each year have a high post-hospitalization mortality rate. We aimed to determine whether mortality after critical illness is higher for Medicare beneficiaries with Medicaid compared with those with commercial insurance. DESIGN A retrospective cohort study from 2010 through 2014 with 1 year of follow-up using the New York Statewide Planning and Research Cooperative System database. SETTING A New York State population-based study of older (age ≥65 y) survivors of intensive care. PARTICIPANTS Adult Medicare beneficiaries age 65 years or older who were hospitalized with intensive care at a New York State hospital and survived to discharge. INTERVENTION None. MEASUREMENT Mortality in the first year after hospital discharge. RESULTS The study included 340 969 Medicare beneficiary survivors of intensive care with a mean (standard deviation) age of 77 (8) years; 20% died within 1 year. There were 152 869 (45%) with commercial insurance, 78 577 (23%) with Medicaid, and 109 523 (32%) with Medicare alone. Compared with those with commercial insurance, those with Medicare alone had a similar 1-year mortality rate (adjusted hazard ratio [aHR] = 1.01; 95% confidence interval [CI] = .99-1.04), and those with Medicaid had a 9% higher 1-year mortality rate (aHR = 1.09; 95% CI = 1.05-1.12). Among those discharged home, the 1-year mortality rate did not vary by insurance coverage, but among those discharged to skilled-care facilities (SCFs), the 1-year mortality rate was 16% higher for Medicaid recipients (aHR = 1.16; 95% CI = 1.12-1.21; P for interaction <.001). CONCLUSIONS Older adults with Medicaid insurance have a higher 1-year post-hospitalization mortality compared with those with commercial insurance, especially among those discharged to SCFs. Future studies should investigate care disparities at SCFs that may mediate these higher mortality rates. J Am Geriatr Soc 67:2497-2504, 2019.
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Affiliation(s)
- Yoland F Philpotts
- Division of Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Xiaoyue Ma
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Michaela R Anderson
- Division of Pulmonary, Allergy, and Critical Care, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - May Hua
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York.,Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
| | - Matthew R Baldwin
- Division of Pulmonary, Allergy, and Critical Care, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
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19
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Lines LM, Cohen J, Halpern MT, Smith AW, Kent EE. Care experiences among dually enrolled older adults with cancer: SEER-CAHPS, 2005-2013. Cancer Causes Control 2019; 30:1137-1144. [PMID: 31422490 DOI: 10.1007/s10552-019-01218-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 08/09/2019] [Indexed: 12/12/2022]
Abstract
PURPOSE Given the associations between poverty and poorer outcomes among older adults with cancer, we sought to understand the effects of dual enrollment in Medicare and Medicaid-as a marker of poverty-on self-reported care experiences among seniors diagnosed with cancer. METHODS Retrospective, observational study using cancer registry, Medicare claims, and care experience survey data (Surveillance, Epidemiology, and End Results [SEER]-Consumer Assessment of Healthcare Providers and Systems [CAHPS®]) for a national sample of fee-for-service (FFS) and Medicare Advantage (MA) enrollees aged 65 or older. We included people with one incident primary, malignant cancer diagnosed between 2005 and 2011, surveyed within 2 years after diagnosis (n = 9,800; 995 dual enrollees). Medicare CAHPS measures included 5 global ratings and 3 composite scores. RESULTS After adjustment for potential confounders, people with cancer histories who were dually enrolled were significantly more likely to report better experiences than non-duals on 2 measures (Medicare/their health plan: adjusted odds ratio [aOR]: 0.68, 95% confidence interval [CI] 0.53-0.87; prescription drug plan [PDP]: aOR: 0.54, 95% CI 0.40-0.73). CONCLUSIONS Dual enrollees with cancer reported better experiences than Medicare-only enrollees in terms of their health plan (Medicare FFS or Medicare Advantage) and their PDP. Better ratings among dually enrolled beneficiaries suggest possible divergence between health outcomes and care experiences, warranting additional investigation.
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Affiliation(s)
- Lisa M Lines
- RTI International, 307 Waverley Oaks Rd, Suite 101, Waltham, MA, 02452, USA. .,University of Massachusetts Medical School, 55 Lake Ave. North, Worcester, MA, 01655, USA.
| | - Julia Cohen
- RTI International, 307 Waverley Oaks Rd, Suite 101, Waltham, MA, 02452, USA
| | - Michael T Halpern
- Cancer Control and Population Sciences, National Cancer Institute, 9609 Medical Center Dr., Room 3E4342, Bethesda, MD, 20892-9762, USA
| | - Ashley Wilder Smith
- Cancer Control and Population Sciences, National Cancer Institute, 9609 Medical Center Dr., Room 3E4342, Bethesda, MD, 20892-9762, USA
| | - Erin E Kent
- Gillings School of Public Health, University of North Carolina - Chapel Hill, 135 Dauer Dr., Chapel Hill, NC, 27559, USA
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20
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McGarry BE, Grabowski DC. What Do Clinicians Caring for Aging Patients Need to Know About Private Long-Term Care Insurance? J Am Geriatr Soc 2019; 67:2167-2173. [PMID: 31385611 DOI: 10.1111/jgs.16075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 06/12/2019] [Accepted: 06/22/2019] [Indexed: 11/30/2022]
Abstract
Preparing for future long-term care (LTC) needs is a critical component of successful aging. Clinicians with aging patient panels may be a valuable source of information about the importance of LTC planning and the mechanisms available to do so, including private LTC insurance (LTCi). This article provides an overview, from a clinician's perspective, of current LTC financing and the key questions patients should consider when assessing LTCi. Although actual purchasing decisions likely require support from impartial financial experts, clinicians may be well positioned to help initiate difficult conversations about LTC planning and point patients to unbiased resources concerning LTCi. J Am Geriatr Soc 67:2167-2173, 2019.
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Affiliation(s)
- Brian E McGarry
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - David C Grabowski
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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21
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Abstract
Health care report cards are intended to address information asymmetries and enable consumers to choose providers of better quality. However, the form of the information may matter to consumers. Nursing Home Compare, a website that publishes report cards for nursing homes, went from publishing a large set of indicators to a composite rating in which nursing homes are assigned one to five stars. We evaluate whether the simplified ratings motivated consumers to choose better-rated nursing homes. We use a regression discontinuity design to estimate changes in new admissions six months after the publication of the ratings. Our main results show that nursing homes that obtained an additional star gained more admissions, with heterogeneous effects depending on baseline number of stars. We conclude that the form of quality reporting matters to consumers, and that the increased use of composite ratings is likely to increase consumer response.
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Affiliation(s)
| | | | - Daifeng He
- Swarthmore College, Department of Economics
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22
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Sharma H, Perraillon MC, Werner RM, Grabowski DC, Konetzka RT. Medicaid and Nursing Home Choice: Why Do Duals End Up in Low-Quality Facilities? J Appl Gerontol 2019; 39:981-990. [PMID: 30957619 DOI: 10.1177/0733464819838447] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We provide empirical evidence on the relative importance of specific observable factors that can explain why individuals enrolled in both Medicare and Medicaid (duals) are concentrated in lower quality nursing homes, relative to those not on Medicaid. Descriptive results show that duals are 9.7 percentage points more likely than nonduals to be admitted to a low-quality (1-2 stars) nursing home. Using the Blinder-Oaxaca decomposition approach in a multivariate framework, we find that 35.4% of the difference in admission to low-quality nursing homes can be explained by differences in the distribution of observable characteristics. Differences in education and distance to high-quality nursing homes are important drivers, as are health status and race. Our findings highlight the need for creative policy solutions targeting the modifiable factors to reduce the disparity.
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23
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Joynt Maddox KE, Reidhead M, Hu J, Kind AJH, Zaslavsky AM, Nagasako EM, Nerenz DR. Adjusting for social risk factors impacts performance and penalties in the hospital readmissions reduction program. Health Serv Res 2019; 54:327-336. [PMID: 30848491 PMCID: PMC6407348 DOI: 10.1111/1475-6773.13133] [Citation(s) in RCA: 115] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE Medicare's Hospital Readmissions Reduction Program (HRRP) does not account for social risk factors in risk adjustment, and this may lead the program to unfairly penalize safety-net hospitals. Our objective was to determine the impact of adjusting for social risk factors on HRRP penalties. STUDY DESIGN Retrospective cohort study. DATA SOURCES/STUDY SETTING Claims data for 2 952 605 fee-for-service Medicare beneficiaries with acute myocardial infarction (AMI), congestive heart failure (CHF) or pneumonia from December 2012 to November 2015. PRINCIPAL FINDINGS Poverty, disability, housing instability, residence in a disadvantaged neighborhood, and hospital population from a disadvantaged neighborhood were associated with higher readmission rates. Under current program specifications, safety-net hospitals had higher readmission ratios (AMI, 1.020 vs 0.986 for the most affluent hospitals; pneumonia, 1.031 vs 0.984; and CHF, 1.037 vs 0.977). Adding social factors to risk adjustment cut these differences in half. Over half the safety-net hospitals saw their penalty decline; 4-7.5 percent went from having a penalty to having no penalty. These changes translated into a $17 million reduction in penalties to safety-net hospitals. CONCLUSIONS Accounting for social risk can have a major financial impact on safety-net hospitals. Adjustment for these factors could reduce negative unintended consequences of the HRRP.
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Affiliation(s)
- Karen E. Joynt Maddox
- Cardiovascular DivisionDepartment of MedicineWashington University School of MedicineSt. LouisMissouri
| | - Mat Reidhead
- Missouri Hospital AssociationHospital Industry Data InstituteJefferson CityMissouri
| | - Jianhui Hu
- Center for Health Policy and Health Services ResearchHenry Ford Health SystemDetroitMichigan
| | - Amy J. H. Kind
- Division of GeriatricsDepartment of MedicineUniversity of Wisconsin School of Medicine and Public Health, and Department of Veterans Affairs Geriatrics Research Education and Clinical CenterMadisonWisconsin
| | - Alan M. Zaslavsky
- Department of Health Care PolicyHarvard Medical SchoolBostonMassachusetts
| | - Elna M. Nagasako
- Division of General Medical SciencesDepartment of MedicineWashington University School of MedicineSt. LouisMissouri
| | - David R. Nerenz
- Center for Health Policy and Health Services ResearchHenry Ford Health SystemDetroitMichigan
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24
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Xiang X, An R, Heinemann A. Depression and Unmet Needs for Assistance With Daily Activities Among Community-Dwelling Older Adults. Gerontologist 2019; 58:428-437. [PMID: 28201617 DOI: 10.1093/geront/gnw262] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 12/31/2016] [Indexed: 11/13/2022] Open
Abstract
Background and Objectives This study aims to investigate the impact of depressive symptoms on adverse consequences of unmet needs for assistance with daily activities among community-dwelling older adults. Research Design and Methods Data came from round 1 to 5 of the National Health and Aging Trends Study. Study sample consisted of 3,400 Medicare beneficiaries needing assistance with activities of daily living (ADL), instrumental activities of daily living (IADL), or mobility for any two consecutive years between 2011 and 2015. Study outcome was the number of self-reported adverse consequences of unmet needs for assistance with daily activities (e.g., went without eating, wet or soiled clothes). Mixed-effects negative binomial regression was used to estimate the association of lagged depressive symptoms and covariates in period t-1 and the number of adverse consequences of unmet needs in period t. Results The prevalence rates of adverse consequences of unmet needs were twice as high among older adults with elevated depressive symptoms as those without depression. After adjusting for covariates, prior wave depressive symptoms were associated with 1.24 times the rate of adverse consequences of unmet needs for assistance with ADL (Incidence Rate Ratio [IRR] = 1.24, 95% confidence interval [CI] = 1.09-1.41, p < .01) and IADL (IRR = 1.24, 95% CI = 1.06-1.44, p < .01), and 1.14 times the rate of adverse consequences of unmet needs for assistance with mobility (IRR = 1.14, 95% CI = 1.03-1.27, p < .05). Discussion and Implications Caring for older adults with mental health and long-term care needs calls for an integrated social and health services system.
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Affiliation(s)
- Xiaoling Xiang
- Northwestern University Feinberg School of Medicine, University of Illinois at Urbana-Champaign
| | - Ruopeng An
- Department of Kinesiology and Community Health, College of Applied Health Sciences, University of Illinois at Urbana-Champaign
| | - Allen Heinemann
- Northwestern University Feinberg School of Medicine, Director, Center for Rehabilitation Outcomes Research, Rehabilitation Institute of Chicago
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Chatterjee P, Joynt Maddox K. Patterns of performance and improvement in US Medicare's Hospital Star Ratings, 2016-2017. BMJ Qual Saf 2018; 28:486-494. [PMID: 30530807 DOI: 10.1136/bmjqs-2018-008384] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 10/05/2018] [Accepted: 11/05/2018] [Indexed: 11/03/2022]
Abstract
BACKGROUND Publicly reported quality data can help consumers make informed choices about where to seek medical care. The Centers for Medicare and Medicaid Services developed a composite Hospital Compare Overall Star Rating for US acute-care hospitals in 2016. However, patterns of performance and improvement have not been previously described. OBJECTIVE To characterise high-quality and low-quality hospitals as assessed by Star Ratings. DESIGN We performed a retrospective cross-sectional study of 3429 US acute-care hospitals assigned Overall Star Ratings in both 2016 and 2017. We used multivariable logistic regression models to identify characteristics associated with receiving 4 or 5 stars. RESULTS Small hospitals were more likely to receive 4 or 5 stars in 2016 (33% of small hospitals, 26% of medium hospitals and 21% of large hospitals, OR for medium 0.78, p=0.02, and for large, 0.61, p=0.003). Non-profit status (OR 1.37, p=0.01), midwest region (OR=2.30, p<0.001), west region (OR 1.30 in 2016, p=0.06) and system membership (OR 1.33, p=0.003) were associated with higher odds of achieving a higher Star Rating. Hospitals with the most Medicaid patients were markedly less likely to receive 4 or 5 stars (OR for highest quartile=0.32, p<0.001), and hospitals with the highest proportion of Medicare patients were somewhat less likely to do so (OR for highest quartile=0.68, p=0.01). These associations remained largely consistent over the first two years of reporting and were also associated with the highest likelihood of improvement. CONCLUSIONS Small hospitals with fewer Medicaid patients had the highest odds of performing well on Star Ratings. Further monitoring of these trends is needed as patients, clinicians and policymakers strive to use this information to promote high-quality care.
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Affiliation(s)
- Paula Chatterjee
- General Internal Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Karen Joynt Maddox
- Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri, USA
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Zuckerman RB, Wu S, Chen LM, Joynt Maddox KE, Sheingold SH, Epstein AM. The Five-Star Skilled Nursing Facility Rating System and Care of Disadvantaged Populations. J Am Geriatr Soc 2018; 67:108-114. [DOI: 10.1111/jgs.15629] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 07/31/2018] [Accepted: 08/28/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Rachael B. Zuckerman
- Department of Health and Human Services; Office of the Assistant Secretary for Planning and Evaluation; Washington District of Columbia
| | - Shannon Wu
- Department of Health Policy and Management; Bloomberg School of Public Health, Johns Hopkins University; Baltimore Maryland
| | - Lena M. Chen
- Department of Health and Human Services; Office of the Assistant Secretary for Planning and Evaluation; Washington District of Columbia
- Department of Internal Medicine, Institute for Healthcare Policy and Innovation; University of Michigan Health System, Center for Healthcare Outcomes and Policy, University of Michigan; Ann Arbor Michigan
| | - Karen E. Joynt Maddox
- Department of Health and Human Services; Office of the Assistant Secretary for Planning and Evaluation; Washington District of Columbia
- Cardiovascular Division, Department of Medicine; School of Medicine, Washington University; St. Louis Missouri
| | - Steven H. Sheingold
- Department of Health and Human Services; Office of the Assistant Secretary for Planning and Evaluation; Washington District of Columbia
| | - Arnold M. Epstein
- Department of Health Policy and Management, T.H. Chan School of Public Health, Harvard University; Department of Medicine, Brigham and Women's Hospital; Boston Massachusetts
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Graham C, Ross L, Bueno EB, Harrington C. Assessing the Quality of Nursing Homes in Managed Care Organizations: Integrating LTSS for Dually Eligible Beneficiaries. Inquiry 2018; 55:46958018800090. [PMID: 30222018 PMCID: PMC6144495 DOI: 10.1177/0046958018800090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Little is known about the quality of nursing homes in managed care organizations (MCOs) networks. This study (1) described decision-making criteria for selecting nursing home networks and (2) compared selected quality indicators of network and nonnetwork nursing homes. The sample was 17 MCOs participating in a California demonstration that provided integrated long-term services and supports to dually eligible enrollees in 2017. The findings showed that the MCOs established a broad network of nursing homes, with only limited attention to using quality criteria. Network nursing homes (602) scored significantly lower on 6 selected quality measures than nonnetwork (117) nursing homes. Low registered nurse and total nurse staffing were strong predictors of network nursing homes controlling for facility characteristics. Managed care organizations should consider greater transparency about the quality of their nursing homes and use specific quality criteria to improve the quality of their networks.
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Affiliation(s)
- Carrie Graham
- 1 Center for the Advanced Study of Aging Services, Berkeley, CA, USA
| | - Leslie Ross
- 2 University of California, San Francisco, USA
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Jung HY, Li Q, Rahman M, Mor V. Medicare Advantage enrollees' use of nursing homes: trends and nursing home characteristics. Am J Manag Care 2018; 24:e249-e256. [PMID: 30130025 PMCID: PMC6225776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVES To examine temporal trends in the prevalence of nursing home (NH) patients participating in Medicare Advantage (MA) and to identify the characteristics of both these patients and the NHs that provide care for them. STUDY DESIGN Retrospective cohort study. METHODS Data sources included the Medicare enrollment file, Minimum Data Set, and facility-level data from the Certification and Survey Provider Enhanced Reporting system. Longitudinal trends of NH use by MA enrollees were examined over the period 2000 to 2013 and logistic regression models were used to identify facility characteristics associated with having a high proportion of MA patients. RESULTS The proportion of MA enrollees in NHs more than doubled between 2000 and 2013, increasing 125% during this period. Notable differences in facility characteristics were found between NHs that serve high proportions of MA enrollees and other NHs. High-MA NHs tended to be larger facilities affiliated with chains. These NHs also had better quality indicators, such as higher staffing levels, lower use of antipsychotics, and lower odds of rehospitalization. Additionally, high-MA NHs were more likely to be in counties with higher Medicare managed care penetration and less market concentration. CONCLUSIONS MA plans may be selectively contracting with NHs, as evidenced by the larger shares of MA patients who have been placed in facilities with better performance on quality measures. This may reflect MA plans concentrating enrollees in specific facilities and building "networks" of postacute and long-term care providers that provide better and more efficient care.
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Affiliation(s)
- Hye-Young Jung
- Department of Healthcare Policy and Research, Weill Cornell Medical College, 402 E 67th St, New York, NY 10065.
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Lord J, Davlyatov G, Thomas KS, Hyer K, Weech-Maldonado R. The Role of Assisted Living Capacity on Nursing Home Financial Performance. Inquiry 2018; 55:46958018793285. [PMID: 30141704 PMCID: PMC6109846 DOI: 10.1177/0046958018793285] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 07/05/2018] [Accepted: 07/06/2018] [Indexed: 11/16/2022]
Abstract
The rapid growth of the assisted living industry has coincided with decreased levels of nursing home occupancy and financial performance. The purpose of this article is to examine the relationships among assisted living capacity, nursing home occupancy, and nursing home financial performance. In addition, we explore whether the relationship between assisted living capacity and nursing home financial performance is mediated by nursing home occupancy. This research utilized publicly available secondary data, for the state of Florida from 2003 through 2015. General descriptive statistics were used to assess the relationships among financial performance, assisted living capacity, and occupancy. To explore the relationships among financial performance, assisted living capacity and occupancy, and test potential mediation of occupancy, we followed Baron and Kenny's approach and estimated 3 models examining the relationships between (1) assisted living capacity and nursing home financial performance, (2) assisted living capacity and nursing home occupancy, and (3) nursing home occupancy and financial performance after assisted living capacity is included in the model. We used generalized estimating equations, to adjust for repeated measures and to model the above relationships. Year fixed effects control for time trend. The independent variable, assisted living beds, was lagged for 1 year to account for the potential influence on financial performance. The final analytic sample consisted of 7688 nursing home-year observations from 657 unique nursing homes. Our findings suggest that assisted living capacity does have a negative impact on nursing homes' financial performance. Even though, assisted living capacity seems not to significantly decrease nursing home occupancy. The relationship between assisted living capacity and financial performance was not mediated through occupancy. These findings suggest that assisted living communities may not be able to significantly reduce nursing home occupancy; however, the presence of assisted living communities may create additional financial/competitive pressures that result in decreased nursing home financial performance.
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Fernandes-Taylor S, Berg S, Gunter R, Bennett K, Smith MA, Rathouz PJ, Greenberg CC, Kent KC. Thirty-day readmission and mortality among Medicare beneficiaries discharged to skilled nursing facilities after vascular surgery. J Surg Res 2017; 221:196-203. [PMID: 29229128 DOI: 10.1016/j.jss.2017.08.041] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 07/26/2017] [Accepted: 08/18/2017] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Sara Fernandes-Taylor
- Department of Surgery, Wisconsin Surgical Outcomes Research Program, University of Wisconsin-Madison, Madison, Wisconsin.
| | - Stephen Berg
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, Wisconsin
| | - Rebecca Gunter
- Department of Surgery, Wisconsin Surgical Outcomes Research Program, University of Wisconsin-Madison, Madison, Wisconsin
| | - Kyla Bennett
- Department of Surgery, Wisconsin Surgical Outcomes Research Program, University of Wisconsin-Madison, Madison, Wisconsin
| | - Maureen A Smith
- Department of Population Health Sciences, University of Wisconsin-Madison, Madison, Wisconsin
| | - Paul J Rathouz
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, Wisconsin
| | - Caprice C Greenberg
- Department of Surgery, Wisconsin Surgical Outcomes Research Program, University of Wisconsin-Madison, Madison, Wisconsin
| | - K Craig Kent
- The Ohio State University College of Medicine, Columbus, Ohio
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Baldwin MR, Sell JL, Heyden N, Javaid A, Berlin DA, Gonzalez WC, Bach PB, Maurer MS, Lovasi GS, Lederer DJ. Race, Ethnicity, Health Insurance, and Mortality in Older Survivors of Critical Illness. Crit Care Med 2017; 45:e583-91. [PMID: 28333761 DOI: 10.1097/CCM.0000000000002313] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To determine whether minority race or ethnicity is associated with mortality and mediated by health insurance coverage among older (≥ 65 yr old) survivors of critical illness. DESIGN A retrospective cohort study. SETTING Two New York City academic medical centers. PATIENTS A total of 1,947 consecutive white (1,107), black (361), and Hispanic (479) older adults who had their first medical-ICU admission from 2006 through 2009 and survived to hospital discharge. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We obtained demographic, insurance, and clinical data from electronic health records, determined each patient's neighborhood-level socioeconomic data from 2010 U.S. Census tract data, and determined death dates using the Social Security Death Index. Subjects had a mean (SD) age of 79 years (8.6 yr) and median (interquartile range) follow-up time of 1.6 years (0.4-3.0 yr). Blacks and Hispanics had similar mortality rates compared with whites (adjusted hazard ratio, 0.92; 95% CI, 0.76-1.11 and adjusted hazard ratio, 0.92; 95% CI, 0.76-1.12, respectively). Compared to those with commercial insurance and Medicare, higher mortality rates were observed for those with Medicare only (adjusted hazard ratio, 1.43; 95% CI, 1.03-1.98) and Medicaid (adjusted hazard ratio, 1.30; 95% CI, 1.10-1.52). Medicaid recipients who were the oldest ICU survivors (> 82 yr), survivors of mechanical ventilation, and discharged to skilled-care facilities had the highest mortality rates (p-for-interaction: 0.08, 0.03, and 0.17, respectively). CONCLUSIONS Mortality after critical illness among older adults varies by insurance coverage but not by race or ethnicity. Those with federal or state insurance coverage only had higher mortality rates than those with additional commercial insurance.
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Abstract
OBJECTIVE We document differential prevalence of need for assistance with personal, instrumental, and mobility tasks and adverse consequences of unmet needs, nursing home relocation, and mortality among Black and White older adults. METHOD Data are from the National Health and Aging Trends Study. Using logistic and multinomial logistic regression, we determine whether race is predictive of reporting need or adverse consequence and test the role of race as a moderator of the relationship between baseline need and three 1-year outcomes. RESULTS Black older adults are more likely to experience a consequence of unmet need (35.33% vs. 29.97%, p = .028) in unadjusted models. In adjusted models, we find no moderating effect of race on baseline need on nursing home placement (0.00, 95% confidence interval [CI] = [-2.43, 2.42], p = .991), mortality (0.73, 95% = [-1.58, 0.11], p = .089), or a Round 2 consequence of unmet (-0.51, 95% CI = [-1.15, 0.14], p = .121). DISCUSSION This work highlights the complex relationship between race, need, unmet need, mortality, and nursing home entry.
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Affiliation(s)
| | - Vincent Mor
- 2 Brown University, Providence, RI, USA.,3 Providence VAMC Health Services Research Service
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Rahman M, Norton EC, Grabowski DC. Do hospital-owned skilled nursing facilities provide better post-acute care quality? J Health Econ 2016; 50:36-46. [PMID: 27661738 PMCID: PMC5127756 DOI: 10.1016/j.jhealeco.2016.08.004] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 08/18/2016] [Accepted: 08/19/2016] [Indexed: 05/23/2023]
Abstract
As hospitals are increasingly held accountable for patients' post-discharge outcomes under new payment models, hospitals may choose to acquire skilled nursing facilities (SNFs) to better manage these outcomes. This raises the question of whether patients discharged to hospital-based SNFs have better outcomes. In unadjusted comparisons, hospital-based SNF patients have much lower Medicare utilization in the 180 days following discharge relative to freestanding SNF patients. We solved the problem of differential selection into hospital-based and freestanding SNFs by using differential distance from home to the nearest hospital with a SNF relative to the distance from home to the nearest hospital without a SNF as an instrument. We found that hospital-based SNF patients spent roughly 5 more days in the community and 6 fewer days in the SNF in the 180 days following their original hospital discharge with no significant effect on mortality or hospital readmission.
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Affiliation(s)
| | - Edward C Norton
- University of Michigan, Ann Arbor, MI 48109, USA; NBER, Cambridge, MA 02138, USA
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Chang E, Ruder T, Setodji C, Saliba D, Hanson M, Zingmond DS, Wenger NS, Ganz DA. Differences in Nursing Home Quality Between Medicare Advantage and Traditional Medicare Patients. J Am Med Dir Assoc 2016; 17:960.e9-960.e14. [DOI: 10.1016/j.jamda.2016.07.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 07/18/2016] [Accepted: 07/21/2016] [Indexed: 11/26/2022]
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Pu Y, Dolar V, Gucwa AL. A comparative analysis of vaccine administration in urban and non-urban skilled nursing facilities. BMC Geriatr 2016; 16:148. [PMID: 27473125 PMCID: PMC4966855 DOI: 10.1186/s12877-016-0320-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 07/21/2016] [Indexed: 12/01/2022] Open
Abstract
Background The U.S. population is aging at an unprecedented rate, resulting in an increased demand for skilled nursing facilities (SNFs) and long-term care. Residents of these facilities are at a high risk for pneumococcal disease or severe influenza-related illnesses and death. For these reasons, the Centers for Medicare and Medicaid Services use influenza and pneumococcal vaccination rates as a quality measure in the assessment of SNFs, as complications related to these infections increase morbidity and mortality rates. Methods Disparities have been reported amongst vaccination with increased rates in urban areas as compared to their non-urban counterparts. Statistical analyses were performed to compare influenza and pneumococcal vaccination in urban and non-urban SNFs to determine variables that may influence vaccination status. Results Of the 15,639 nursing homes included in the study, 10,107 were in urban areas, while 5532 were considered non-urban. We found the percent of eligible and willing residents with up-to-date influenza and pneumococcal vaccinations increased with overall five-star ratings of SNFs. Somewhat paradoxically, although urban SNFs had higher mean overall five-star ratings, they showed lower rates of influenza and pneumococcal vaccination compared to non-urban SNFs. Ordinary least squares regression analysis comparing overall ratings, type of ownership, and geographic location by region yielded statistically significant results in which the overall rating, ownership-type and certificate-type favored urban SNFs (p < 0.001). Conclusions This is the first systematic and comparative analysis to use the Nursing Home Compare database to assess vaccine administration of urban and non-urban SNFs. The findings of this study may be used to encourage the development of programs to improve vaccination rates and the quality of care in these facilities. Electronic supplementary material The online version of this article (doi:10.1186/s12877-016-0320-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yuan Pu
- Department of Biomedical Sciences, Long Island University at Post, Brookville, NY, USA
| | - Veronika Dolar
- Department of Economics, Long Island University at Post, Brookville, NY, USA
| | - Azad L Gucwa
- Department of Biomedical Sciences, Long Island University at Post, Brookville, NY, USA.
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Abstract
OBJECTIVE To examine the relative influence of hospital and skilled nursing facilities (SNFs) on 30-day rehospitalization. DATA SOURCES/SETTINGS Elderly Medicare beneficiaries newly admitted to a SNF following hospitalization. STUDY DESIGN We ranked hospitals and SNFs into quartiles based on previous years' adjusted rehospitalization rates (ARRs) and examined how rehospitalizations from a given hospital vary depending upon the admitting SNF ARR quartile. We examined whether the availability of SNFs with low rehospitalization rates influenced hospitals' SNF readmission rates and whether changes in a hospital's ARR over 3 years is associated with changes in the SNFs to which they discharge. PRINCIPAL FINDINGS Hospital readmission rates from SNFs varied 5 percentage points between patients discharged to SNFs in the lowest and the highest rehospitalization quartiles. Low rehospitalization rate hospitals sent a larger fraction of their patients to the lowest rehospitalization SNFs available in the area. A 10 percent increase in hospital's share of discharges to the lowest rehospitalization quartile SNFs is associated with a 1 percentage point reduction in hospital's ARR. CONCLUSIONS The SNF rehospitalization rate has greater influence on patients' risk of rehospitalization than the discharging hospital. Identifying high-performing SNFs may be a powerful strategy for hospitals to reduce rehospitalizations.
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Affiliation(s)
- Momotazur Rahman
- Department of Health Services Policy and Practice, Brown University, Providence, RI
| | - John McHugh
- Department of Health Services Policy and Practice, Brown University, Providence, RI
| | - Pedro L Gozalo
- Department of Health Services Policy and Practice, Brown University, Providence, RI
| | | | - Vincent Mor
- Department of Health Services Policy and Practice, Brown University, Providence, RI.,Providence Veterans Administration Medical Center, Health Services Research Program, Providence, RI
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Schoenfeld AJ, Zhang X, Grabowski DC, Mor V, Weissman JS, Rahman M. Hospital-skilled nursing facility referral linkage reduces readmission rates among Medicare patients receiving major surgery. Surgery 2016; 159:1461-8. [PMID: 26830069 PMCID: PMC4821789 DOI: 10.1016/j.surg.2015.12.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 12/11/2015] [Accepted: 12/18/2015] [Indexed: 01/11/2023]
Abstract
BACKGROUND In the health reform era, rehospitalization after discharge may result in financial penalties to hospitals. The effect of increased hospital-skilled nursing facility (SNF) linkage on readmission reduction after surgery has not been explored. METHODS To determine whether enhanced hospital-SNF linkage, as measured by the proportion of surgical patients referred from a hospital to a particular SNF, would result in reduced 30-day readmission rates for surgical patients, we used national Medicare data (2011-2012) and evaluated patients who underwent 1 of 5 operative procedures (coronary artery bypass grafting [CABG], hip fracture repair, total hip arthroplasty, colectomy, or lumbar spine surgery). Initial evaluation was performed using regression modeling. Patient choice in SNF referral was adjusted for using instrumental variable (IV) analysis with distance between an individuals' home and the SNF as the IV. RESULTS A strong negative correlation (P < .001) was observed between the proportion of selected surgical discharges received by a SNF and the rate of hospital readmission. Increasing the proportion of surgical discharges decreased the likelihood of rehospitalization (regression coefficient, -0.04; 95% CI, -0.07 to -0.02). These findings were preserved in IV analysis. Increasing hospital-SNF linkage was found to reduce significantly the likelihood of readmission for patients receiving lumbar spine surgery, CABG, and hip fracture repair. CONCLUSION The benefits of increased hospital-SNF linkage seem to include meaningful reductions in hospital readmission after surgery. Overall, a 10% increase in the proportion of surgical referrals to a particular SNF is estimated to decrease readmissions by 4%. This may impact hospital-SNF networks participating in risk-based reimbursement models.
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Affiliation(s)
- Andrew J Schoenfeld
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
| | - Xuan Zhang
- Department of Health Services, Policy, and Practice, Brown University, Providence, RI
| | - David C Grabowski
- Department of Health Care Policy, Harvard Medical School, Boston, MA
| | - Vincent Mor
- Department of Health Services, Policy, and Practice, Brown University, Providence, RI; Health Services Research, Providence Veterans Administration Medical Center, Providence, RI
| | - Joel S Weissman
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Momotazur Rahman
- Department of Health Services, Policy, and Practice, Brown University, Providence, RI
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Fehnel CR, Lee Y, Wendell LC, Thompson BB, Potter NS, Mor V. Post-Acute Care Data for Predicting Readmission After Ischemic Stroke: A Nationwide Cohort Analysis Using the Minimum Data Set. J Am Heart Assoc 2015; 4:e002145. [PMID: 26396202 PMCID: PMC4599502 DOI: 10.1161/jaha.115.002145] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Reducing hospital readmissions is a key component of reforms for stroke care. Current readmission prediction models lack accuracy and are limited by data being from only acute hospitalizations. We hypothesized that patient-level factors from a nationwide post-acute care database would improve prediction modeling. METHODS AND RESULTS Medicare inpatient claims for the year 2008 that used International Classification of Diseases, Ninth Revision codes were used to identify ischemic stroke patients older than age 65. Unique individuals were linked to comprehensive post-acute care assessments through use of the Minimum Data Set (MDS). Logistic regression was used to construct risk-adjusted readmission models. Covariates were derived from MDS variables. Among 39 178 patients directly admitted to nursing homes after hospitalization due to acute stroke, there were 29 338 (75%) with complete MDS assessments. Crude rates of readmission and death at 30 days were 8448 (21%) and 2791 (7%), respectively. Risk-adjusted models identified multiple independent predictors of all-cause 30-day readmission. Model performance of the readmission model using MDS data had a c-statistic of 0.65 (95% CI 0.64 to 0.66). Higher levels of social engagement, a marker of nursing home quality, were associated with progressively lower odds of readmission (odds ratio 0.71, 95% CI 0.55 to 0.92). CONCLUSIONS Individual clinical characteristics from the post-acute care setting resulted in only modest improvement in the c-statistic relative to previous models that used only Medicare Part A data. Individual-level characteristics do not sufficiently account for the risk of acute hospital readmission.
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Affiliation(s)
- Corey R Fehnel
- Division of Neurocritical Care, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, RI (C.R.F., L.C.W., B.B.T., S.P.)
| | - Yoojin Lee
- Department of Health Services, Policy & Practice, Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (Y.L., V.M.)
| | - Linda C Wendell
- Division of Neurocritical Care, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, RI (C.R.F., L.C.W., B.B.T., S.P.)
| | - Bradford B Thompson
- Division of Neurocritical Care, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, RI (C.R.F., L.C.W., B.B.T., S.P.)
| | - N Stevenson Potter
- Division of Neurocritical Care, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, RI (C.R.F., L.C.W., B.B.T., S.P.)
| | - Vincent Mor
- Department of Health Services, Policy & Practice, Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI (Y.L., V.M.)
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Rahman M, Foster AD. Racial segregation and quality of care disparity in US nursing homes. J Health Econ 2015; 39:1-16. [PMID: 25461895 PMCID: PMC4293270 DOI: 10.1016/j.jhealeco.2014.09.003] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Revised: 09/18/2014] [Accepted: 09/20/2014] [Indexed: 05/13/2023]
Abstract
In this paper, we examine the contributions of travel distance and preferences for racial homogeneity as sources of nursing home segregation and racial disparities in nursing home quality. We first theoretically characterize the distinctive implications of these mechanisms for nursing home racial segregation. We then use this model to structure an empirical analysis of nursing home sorting. We find little evidence of differential willingness to pay for quality by race among first-time nursing home entrants, but do find significant distance and race-based preference effects. Simulation exercises suggest that both effects contribute importantly to racial disparities in nursing home quality.
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Affiliation(s)
- Momotazur Rahman
- Department of Health Services Policy and Practice, Brown University, Box G-S121(6), Providence, RI 02912, United States.
| | - Andrew D Foster
- Department of Economics and Health Services Policy and Practice, Brown University, 64 Waterman street, Providence, RI 02912, United States.
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Allen SM, Piette ER, Mor V. The adverse consequences of unmet need among older persons living in the community: dual-eligible versus Medicare-only beneficiaries. J Gerontol B Psychol Sci Soc Sci 2014; 69 Suppl 1:S51-8. [PMID: 25342823 PMCID: PMC4303067 DOI: 10.1093/geronb/gbu124] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 08/13/2014] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVE Our objective is to estimate and compare the prevalence of selected adverse consequences associated with unmet need for assistance among a socioeconomically and medically vulnerable subgroup of the older adult population, those who are dually eligible for Medicare and Medicaid, with those eligible for Medicare only. METHOD Using data from the National Health and Aging Trends Study (NHATS), a representative survey of the older Medicare population, we calculated the prevalence of disability-related need for assistance with self-care, household tasks, and mobility activities and the prevalence of adverse consequences of unmet need by dually eligible and Medicare only status. RESULTS Over 2 million community-dwelling older persons experienced an adverse consequence due to unmet need for assistance with self-care (e.g., soiled their clothes), over 2 million experienced adverse consequences due to unmet need for assistance with household tasks (e.g., went without groceries), and over 3 million persons experienced at least one adverse consequence of unmet need for assistance with mobility-related activities (e.g., had to stay in bed) in the month prior to the NHATS interview. Dually eligible persons experienced higher rates of 6 of the 11 adverse consequences studied and were more likely to have at least one adverse consequence in all 3 domains than others. DISCUSSION Several care models are emerging with the goal of integrating medical care, behavioral health, and long-term services for the dual eligible population. Indicators of adverse consequences of unmet need could be used to monitor the quality and adequacy of such care systems.
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Affiliation(s)
- Susan M. Allen
- Providence VA HSR&D Center for Innovation (COIN) in Long Term Services and Supports for Vulnerable Veterans and
- Center for Gerontology and Health Care Research, Brown University, Providence, Rhode Island
| | - Elizabeth R. Piette
- Institute for Quantitative Biomedical Sciences, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Vincent Mor
- Providence VA HSR&D Center for Innovation (COIN) in Long Term Services and Supports for Vulnerable Veterans and
- Center for Gerontology and Health Care Research, Brown University, Providence, Rhode Island
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Rahman M, Tyler D, Thomas KS, Grabowski DC, Mor V. Higher Medicare SNF care utilization by dual-eligible beneficiaries: can Medicaid long-term care policies be the answer? Health Serv Res 2014; 50:161-79. [PMID: 25047831 DOI: 10.1111/1475-6773.12204] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To examine outcomes associated with dual eligibility (Medicare and Medicaid) of patients who are admitted to skilled nursing facility (SNF) care and whether differences in outcomes are related to states' Medicaid long-term care policies. DATA SOURCES/COLLECTION We used national Medicare enrollment data and claims, and the Minimum Data Set for 890,922 community-residing Medicare fee-for-service beneficiaries who were discharged to an SNF from a general hospital between July 2008 and June 2009. STUDY DESIGN We estimated the effect of dual eligibility on the likelihood of 30-day rehospitalization, becoming a long-stay nursing home resident, and 180-day survival while controlling for clinical, demographic, socio-economic, residential neighborhood characteristics, and SNF-fixed effects. We estimated the differences in outcomes by dual eligibility status separately for each state and showed their relationship with state policies: the average Medicaid payment rate; presence of nursing home certificate-of-need (CON) laws; and Medicaid home and community-based services (HCBS) spending. PRINCIPAL FINDINGS Dual-eligible patients are equally likely to experience 30-day rehospitalization, 12 percentage points more likely to become long-stay residents, and 2 percentage points more likely to survive 180 days compared to Medicare-only patients. This longer survival can be attributed to longer nursing home length of stay. While higher HCBS spending reduces the length-of-stay gap without affecting the survival gap, presence of CON laws reduces both the length-of-stay and survival gaps. CONCLUSIONS Dual eligibles utilize more SNF care and experience higher survival rates than comparable Medicare-only patients. Higher HCBS spending may reduce the longer SNF length of stay of dual eligibles without increasing mortality and may save money for both Medicare and Medicaid.
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Affiliation(s)
- Momotazur Rahman
- Department of Health Services Policy and Practice, Brown University, Providence, RI
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