Abstract
Objective
Patients discharged to skilled nursing facilities (SNFs) have worse outcomes than
those discharged to home, but whether this is due to differences in facility-level
factors in addition to patient characteristics is not known. We aimed to determine
whether SNF-level factors including nurse staffing and patient density are associated
with outcomes after acute hospitalization for trauma or surgery.
Design, setting, participants, and measurements
Retrospective study of patients discharged to Medicare-certified SNFs after trauma
or major surgery from 2007 to 2009. We measured the ratio of beds per nurse and the
proportion of trauma and surgery patients at each facility (density). Outcomes were
1-year mortality, hospital readmission, and failure to discharge home at first discharge
disposition.
Results
For 389,133 patients (mean age 78 years, 63% female) admitted to 3707 SNFs, mortality
was 26%, hospital readmission 26%, and failure to discharge home 44%. After adjusting
for patient-level factors, SNFs with fewer beds per nurse had lower odds of mortality
[odds ratio (OR): trauma 0.84; (95% confidence interval: 0.77-0.91), surgery 0.80
(0.75-0.86)], readmission [OR: trauma 0.81 (0.74-0.88), surgery 0.71 (0.65-0.76)],
and failure to discharge home [OR: trauma 0.82 [0.74-0.91], surgery 0.66 [0.60-0.72]).
SNFs with greater density of specialty patients (>4.3% surgery, >14.1% trauma) had
lower odds of readmission [OR: trauma 0.59 (0.53-0.66), surgery 0.62 (0.58-0.67)]
and failure to discharge home [OR: trauma 0.48 (0.43-0.55), surgery 0.45 (0.42-0.49)].
Conclusions
There are modifiable SNF-level factors that influence long-term outcomes and may be
targets for intervention. Staffing standardization and SNF specialization may reduce
variation of quality in post-acute care.
Keywords
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Article info
Publication history
Published online: October 14, 2017
Footnotes
This research was funded by Washington State's Life Science Discovery Fund and the Agency for Healthcare Research and Quality Grant Number 1 R01 HS 20025-01 through the Comparative Effectiveness Research Translation Network (CERTAIN) and the Harborview Injury Prevention Research Center. Dr Thornblade is supported by a research training grant from the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health under Award Number T32DK070555.
The authors declare no conflicts of interest.
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© 2017 AMDA - The Society for Post-Acute and Long-Term Care Medicine.
