Fewer Hospital Transfers for Nursing Home Residents After National Initiatives

By Will Boggs MD

January 03, 2020

NEW YORK (Reuters Health) - National efforts to reduce hospitalizations appear to have cut hospital-transfer rates among U.S. nursing home residents with advanced illnesses, according to a study of Minimum Data Set (MDS) assessments.

"Reductions in hospital transfers for potentially avoidable conditions are encouraging, yet many residents with advanced illness still experience multiple transfers for infections and chronic heart failure (CHF) or chronic obstructive pulmonary disease (COPD) exacerbations in their last year of life," Dr. Ellen P. McCarthy from Hebrew SeniorLife and Harvard Medical School, in Boston, told Reuters Health by email. "Moreover, the vast majority of these residents are not receiving hospice care."

The Patient Protection and Affordable Care Act brought several initiatives aimed at reducing hospital transfers of nursing home residents. But the impact of such initiatives on transfer rates among nursing home residents with advanced illnesses remains unclear.

Dr. McCarthy and colleagues used MDS assessments linked to Medicare data to examine the national trends of hospital transfer rates from 2011 to 2017 among residents of long-stay, fee-for-service, federally licensed nursing homes who had advanced dementia, CHF, or COPD. They focused on transfers for conditions that were deemed to be potentially avoidable and were the target of recent policy initiatives.

All-cause hospital transfers decreased significantly from 2011 to 2012 and from 2012 to 2013, after which there was no further reduction and, in fact, rates were higher in 2016 than in 2015, especially in the CHF and COPD groups.

The adjusted proportion of nursing home residents who had at least one hospital transfer for any cause in the 2011 and 2016 cohorts were 56.1% and 45.4%, respectively, for those with advanced dementia, 77.6% and 69.5% for those with CHF, and 76.2% and 67.2% for those with COPD, the researchers report in JAMA Internal Medicine.

In each illness group, reductions in hospital-transfer rates over time were almost entirely attributable to declines in acute hospitalizations.

Between 2011 and 2016, the adjusted proportions of residents having at least one hospital transfer for a potentially avoidable condition declined from 26.5% to 20.4% for those with advanced dementia, from 50.0% to 42.9% for those with CHF, and from 49.2% to 40.7% for those with COPD.

By comparison, hospital transfers for a primary diagnosis of serious bone fractures were relatively uncommon and, as expected, remained unchanged for all advanced illness groups across these years.

Mortality within one year exceeded 50% for all advanced illness groups across all years, with no significant change over time in any illness group, and hospice use remained low throughout the study period (but with a slight increase in 2016 for those with advanced dementia).

"These findings point to important opportunities to improve care of nursing home residents in the setting of advanced illness through improvements in advance care planning, acute care management, and the delivery of high-quality palliative care," Dr. McCarthy said.

"Hospital transfers for nursing home residents with advanced illness and limited life expectancy can be burdensome, of little clinical benefit, and distressing to family members," she said. "Advance care planning between providers, residents, and family members presents a critical opportunity for informed decision-making about wishes for future hospitalizations in anticipation of expected clinical complications."

"Care provided to nursing home residents should align with their preferences and goals of care (e.g., prolongation of life versus comfort)," Dr. McCarthy said. "Decisions regarding hospital transfers should be guided by the goals of care, which for most residents with advanced illness is to promote comfort. With rare exceptions (e.g., serious bone fractures), hospitalization seldom promotes a goal."

Dr. Mark A. Unruh of Weill Cornell Medical College, in New York City, who has also researched factors associated with rehospitalization rates of nursing home residents, told Reuters Health by email, "National initiatives appear to have reduced transfer rates of nursing home residents with advanced illness, but there is still substantial room for improvement. Additional research is needed to measure the impact of specific initiatives on these events and to identify new policies and delivery interventions to further reduce the occurrence of them."

"Transfers are fraught with risk for nursing home residents, increase health care costs for these individuals, and are often indicators of low quality care," he said.

Dr. Kira L. Ryskina of the University of Pennsylvania Perelman School of Medicine, in Philadelphia, has studied outcomes of patients transferred to nursing homes. She told Reuters Health by email, "While transfer rates were lower in 2016 compared to 2011, the increases in transfer rates observed in the last few years of the study are alarming."

"One change in nursing home care delivery over the same time interval was the marked increase in physicians and advanced practitioners who focus their practice in the nursing home or skilled-nursing facilities (colloquially known as 'SNFists')," said Dr. Ryskina, who was also not involved in the new work. "Early evidence suggests that skilled-nursing-facility patients under the care of SNFists had lower rates of rehospitalizations compared to patients of non-SNFists."

SOURCE: https://bit.ly/2ubs6Bf JAMA Internal Medicine, online December 30, 2019.