531069

research-article2014

AJMXXX10.1177/1062860614531069American Journal of Medical QualityOgunneye et al

Article

The Association Between Skilled Nursing Facility Care Quality and 30-Day Readmission Rates After Hospitalization for Heart Failure

American Journal of Medical Quality 1­–9 © 2014 by the American College of Medical Quality Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1062860614531069 ajmq.sagepub.com

Owolabi Ogunneye, MD, MRCP1, Michael B. Rothberg, MD, MPH2, Jennifer Friderici, MS1, Mara T. Slawsky, MD, PhD1,3, Vijay T. Gadiraju, MD1, and Mihaela S. Stefan, MD, FACP1,3

Abstract The objective of the study was to assess the association between care quality of skilled nursing facilities (SNFs) and 30-day risk-adjusted readmission rate (RAR) for patients with acute decompensated heart failure (ADHF). A retrospective cohort study was conducted involving 603 discharges from a tertiary care hospital to 17 SNFs after hospitalization for ADHF. SNF quality was assessed based on the CMS 5-star quality rating and a survey of SNF characteristics and processes of care. In all, 20% of cases were readmitted within 30-days; 9.4% were for ADHF. The all-cause RARs for higher- and lower-quality SNFs were 18% (95% confidence interval [CI] = 14%-23%) and 22% (95% CI = 17%-26%), respectively, and the ADHF RARs were 8.8% (95% CI = 6.0%-11.6%) and 10.2% (95% CI = 7.0%12.9%), respectively. There were no significant associations between ADHF RARs and individual processes of care or structural characteristics. Quality ratings of SNF or processes of care did not correlate with RAR. Keywords nursing home, readmissions, quality rating, processes of care, heart failure Acute decompensated heart failure (ADHF) is the most common cause for hospitalization among Medicare patients,1 accounting for more than 1 million hospitalizations annually.2 Following an acute hospitalization, roughly 40% of ADHF patients are discharged to a postacute setting, with nearly half of these to a skilled nursing facility (SNF).3 Overall, 17% to 25% of patients hospitalized with ADHF are readmitted within 30 days,4,5 and almost 50% of those discharged to a SNF are rehospitalized within 90 days.6 Consequently, preventing hospitalization of SNF residents is an important quality improvement objective.7 A prior study estimated that approximately 39% of all hospitalizations of SNF patients may be avoidable, representing a potential savings of $1.9 billion per year.8 In this context, the Centers for Medicare and Medicaid Services (CMS) recently announced an initiative to reduce avoidable hospitalizations among nursing home residents.9 In addition, CMS proposed a pay-for-performance strategy that targets SNF readmissions and a bundled payment system for hospital episodes to include the index hospitalization, readmissions, physician services, and postacute care. Beginning in 2002, CMS publicly displays a 5-star quality rating

system for all Medicare- and Medicaid-certified SNFs on their Nursing Home Compare Web site (http://www. medicare.gov/nursinghomecompare), and Medicare is considering developing strategies to reimburse/penalize facilities based on these and other quality measures. As the prevalence of ADHF is expected to double over the next 4 decades1 because of an aging US population, there is a need to develop strategies and health policies to reduce preventable hospitalizations. Improving the quality of care provided by SNFs may be one successful strategy. Home self-management interventions, such as intensive education of patients about weight monitoring, management of weight changes with diuretics, and recognition of warning symptoms, are all associated with a decrease in hospital readmissions in ambulatory patients 1

Baystate Medical Center, Springfield, MA Cleveland Clinic, Cleveland, OH 3 Tufts University School of Medicine, Boston, MA 2

Corresponding Author: Mihaela S. Stefan, MD, Baystate Medical Center, 759 Chestnut Street, Springfield, MA 01199. Email: [email protected]

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American Journal of Medical Quality

with ADHF.10-13 Yet the association between performance of these interventions by SNF and readmission rates is unknown. This study sought to assess the association between care quality reported on the CMS Nursing Home Compare Web site as well as individual processes of care and SNF structural characteristics and the 30-day risk-adjusted readmission rate (RAR) for patients hospitalized with ADHF.

Methods Data Source and Setting The study team performed a retrospective cohort study at Baystate Medical Center, a 684-bed academic teaching hospital that serves as the referral center for a population of approximately 800 000 people living in Western Massachusetts. Patients were included in the analysis if they were 18 years of age or older; were discharged to 1 of 17 local SNFs between November 1, 2008, and October 31, 2011; and had a principal discharge diagnosis of ADHF. The study team included the International Classification of Diseases, Ninth Revision (ICD-9) codes used by CMS for public reporting of hospitals’ ADHF readmission: 428.0 to 428.4, 398.91, 402.01, 402.11, 402.91, 404.01, 404.03, 404.11, 404.13, 404.91, and 404.93. Patients were excluded if they were discharged to locations other than SNFs, discharged home, or discharged to another short-term care hospital, an intermediate care facility, rehabilitation facility, or long-term care hospital. Any admission within 30 days of discharge after the index admission was considered a readmission, with the potential for an individual patient to have had more than 1 hospital stay within the study period. Patient-level data were obtained from the electronic medical records as recorded at discharge from the hospital and included demographics (age, sex, and self-reported race), insurance type, comorbidities associated with the ADHF readmission14 (eg, hypertension, chronic obstructive pulmonary disease, chronic kidney disease, coronary artery disease, anemia), left-ventricular ejection fraction (LVEF), cardiovascular medications (diuretics, β-blockers, angiotensin-converting enzyme inhibitors, digoxin, spironolactone), and hospital length of stay (LOS).

Quality of Care Processes and Ratings SNF characteristics and quality of care were assessed in 2 ways: first, by conducting a survey at each SNF and, second, by obtaining quality ratings from CMS’s Nursing Home Compare Web site. The survey was standardized and involved calling the director of nursing at each SNF to obtain information on processes of care that may influence readmission. The survey was conducted in 2011 and

included questions about the following processes of care: weight monitoring, staff and patient education on dietary restrictions, ability to administer intravenous (IV) diuretics, use of ADHF treatment protocols (eg, weight gain assessment, diuretic orders), standardized hospital transfer criteria, whether the SNF follows its readmission rate, stat and routine laboratory turnaround time, stat and routine chest X-ray turnaround time, and whether the facility has telemonitoring capability. Additional questions assessed structural characteristics, including licensed nurse minutes per resident per day, physician hours per day, nurse educator hours per week, respiratory therapist hours per week, physician assistant hours per day, number of beds, and for-profit status. (See online appendix at http://ajmq.sagepub.com/content/by/supplemental-data.) SNF characteristics and quality of care also were assessed by obtaining the quality ratings from the CMS Nursing Home Compare Web site, which features a 5-star quality rating system designed for consumers to compare nursing homes. CMS’s Nursing Home Compare overall quality rating is based on 3 components: (1) a health inspection rating; (2) a staffing rating (the ratio of staff to residents and the proportion of licensed nurses); and (3) a clinical quality measure rating based on 10 physical and clinical measures for nursing home residents (eg, prevalence of pressure ulcers, urinary tract infections, delirium). Measures are risk adjusted for case mix. One star indicates below-average quality, whereas 5 stars indicate above-average quality.15

Outcomes Skilled nursing home risk-adjusted 30-day all-cause and ADHF-related readmission rates were calculated from patient-level data. The 30-day readmission rate was chosen because it is a standard for measurement and reporting by CMS.16 The study was approved by the institutional review board at Baystate Medical Center, Springfield, MA.

Statistical Analysis Univariable analyses involved calculation of means and standard deviations for all Gaussian variables, median/ interquartile ranges for non-Gaussian continuous variables, and proportions for categorical variables. SNFs were stratified by overall quality rating based on the median split of quality rating: SNFs with

The association between skilled nursing facility care quality and 30-day readmission rates after hospitalization for heart failure.

The objective of the study was to assess the association between care quality of skilled nursing facilities (SNFs) and 30-day risk-adjusted readmissio...
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