Background
In the health reform era, rehospitalization following discharge may result in financial penalties to hospitals. The effect of increased hospital-skilled nursing facility (SNF) linkage on readmission reduction following 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 (2011-12) and evaluated patients who received one of five surgical procedures (coronary artery bypass grafting, hip fracture repair, total hip arthroplasty, colectomy, 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<0.001) 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 (RC −0.04, 95% CI [−0.07, −0.02]). These findings were preserved in IV analysis. Increasing hospital-SNF linkage was found to significantly reduce the likelihood of readmission for patients receiving lumbar spine surgery, CABG and hip fracture repair.
Conclusions
The benefits of increased hospital-SNF linkage appear to include meaningful reductions in hospital readmission following surgery. Overall, a 10% increase in the proportion of surgical referrals to a particular SNF is estimated to reduce readmissions by 4%. This may impact hospital-SNF networks participating in risk-based reimbursement models.
Purpose: To examine racial and geographic disparities in the use of—and outcomes associated with—Medicare observation stays versus short-stay hospitalizations.Methods: We used 2007–2010 fee-for-service Medicare claims, including 3,555,994 observation and short-stay hospitalizations for individuals over age 65. We estimated linear probability models with hospital fixed effects to identify within-facility disparities in observation stay use, estimated in-hospital mortality, 30- and 90-day postdischarge mortality, return emergency department (ED) visits, and hospital readmissions as a function of placement in observation using linear probability models, propensity-score matching, and interaction terms.Results: We identified racial and geographic disparities in the likelihood of observation stay use within hospitals (blacks 3.9% points more likely than whites, rural 5.4% points less likely than urban). Observation is associated with an increased likelihood of returning to the ED within 30 or 90 days and a decreased likelihood of readmission or mortality, but there are racial and geographic disparities in these outcomes.Conclusion: While observation generally results in improved outcomes, disparities in these outcomes and the use of observation stays within hospitals are concerning and may be driven by clinical and nonclinical factors.
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