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Risk of Readmission After Discharge From Skilled Nursing Facilities Following Heart Failure Hospitalization: A Retrospective Cohort Study

      Abstract

      Objective

      Discharge to skilled nursing facilities (SNFs) is common in patients with heart failure (HF). It is unknown whether the transition from SNF to home is risky for these patients. Our objective was to study outcomes for the 30 days after discharge from SNF to home among Medicare patients hospitalized with HF who had subsequent SNF stays of 30 days or less.

      Design

      Retrospective cohort study.

      Setting and participants

      All Medicare fee-for-service beneficiaries 65 and older admitted during 2012-2015 with a HF diagnosis discharged to SNF then subsequently discharged home.

      Measures

      Patients were followed for 30 days following SNF discharge. We categorized patients by SNF length of stay: 1 to 6 days, 7 to 13 days, and 14 to 30 days. For each group, we modeled time to a composite outcome of unplanned readmission or death after SNF discharge. Our model examined 0-2 days and 3-30 days post-SNF discharge.

      Results

      Our study included 67,585 HF hospitalizations discharged to SNF and subsequently discharged home. Overall, 16,333 (24.2%) SNF discharges to home were readmitted within 30 days of SNF discharge. The hazard rate of the composite outcome for each group was significantly increased on days 0 to 2 after SNF discharge compared to days 3 to 30, as reflected in their hazard rate ratios: for patients with SNF length of stay 1 to 6 days, 4.60 (4.23-5.00); SNF length of stay 7 to 13 days, 2.61 (2.45-2.78); SNF length of stay 14 to 30 days, 1.70 (1.62-1.78).

      Conclusions/implications

      The hazard rate of readmission after SNF discharge following HF hospitalization is highest during the first 2 days home. This risk attenuated with longer SNF length of stay. Interventions to improve postdischarge outcomes have primarily focused on hospital discharge. This evidence suggests that interventions to reduce readmissions may be more effective if they also incorporate the SNF-to-home transition.

      Keywords

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      References

        • Allen L.A.
        • Hernandez A.F.
        • Peterson E.D.
        • et al.
        Discharge to a skilled nursing facility and subsequent clinical outcomes among older patients hospitalized for heart failure: Clinical perspective.
        Circ Heart Fail. 2011; 4: 293-300
        • Mor V.
        • Intrator O.
        • Feng Z.
        • Grabowski D.C.
        The revolving door of rehospitalization from skilled nursing facilities.
        Health Aff (Millwood). 2010; 29: 57-64
        • Forster A.J.
        • Murff H.J.
        • Peterson J.F.
        • et al.
        The incidence and severity of adverse events affecting patients after discharge from the hospital.
        Ann Intern Med. 2003; 138: 161-167
        • Roy C.L.
        • Poon E.G.
        • Karson A.S.
        • et al.
        Patient safety concerns arising from test results that return after hospital discharge.
        Ann Intern Med. 2005; 143: 121-128
        • Horwitz L.
        • Jenq G.
        • Brewster U.
        • et al.
        Comprehensive quality of discharge summaries at an academic medical center.
        J Hosp Med. 2013; 8: 436-443
        • Ziaeian B.
        • Araujo K.
        • Van N.
        • et al.
        Medication reconciliation accuracy and patient understanding of intended medication changes on hospital discharge.
        J Gen Intern Med. 2012; 27: 1513-1520
        • Horwitz L.I.
        • Moriarty J.P.
        • Chen C.
        • et al.
        Quality of discharge practices and patient understanding at an academic medical center.
        JAMA Intern Med. 2013; 173: 1715-1722
        • Centers for Medicare & Medicaid Services
        Medicare coverage of skilled nursing facility care.
        2015: 23
        • Centers for Medicare & Medicaid
        The Skilled Nursing Facility Value-Based Purchasing Program.
        SNFVBP, 2017 (Available at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/Other-VBPs/SNF-VBP.html. Accessed February 19, 2019.)
        • Horwitz L.I.
        • Grady J.N.
        • Cohen D.
        • et al.
        Development and validation of an algorithm to identify planned readmissions from claims data.
        J Hosp Med. 2015; 10: 670-677
        • Keenan P.S.
        • Normand S.T.
        • Lin Z.
        • et al.
        An administrative claims measure suitable for profiling hospital performance on the basis of 30-day all-cause readmission rates among patients with heart failure.
        Circ Cardiovasc Qual Outcomes. 2008; 1: 29-37
        • Virnig B.
        • Parsons H.
        Strengths and limitations of CMS administrative data in research.
        Research Data Assistance Center, 2018
        • Kubo J.
        • Cullen M.R.
        • Cantley L.
        • et al.
        Piecewise exponential models to assess the influence of job-specific experience on the hazard of acute injury for hourly factory workers.
        BMC Med Res Methodol. 2013; 13: 89
        • Clark D.E.
        • Ryan L.M.
        • Lucas F.L.
        A multi-state piecewise exponential model of hospital outcomes after injury.
        J Appl Stat. 2007; 34: 1225-1239
        • Rodríguez G.
        Generalized linear models: The piece-wise exponential model.
        (Available at:) (Accessed 2018)
        • SAS Institute Inc
        Example 64.14 Bayesian Analysis of Piecewise Exponential Model.
        SAS/STAT(R) 9.2 User's Guide. 2nd ed. SAS Institute Inc., Cary, NC2008
        • Lindquist L.A.
        • Miller R.K.
        • Saltsman W.S.
        • et al.
        SGIM-AMDA-AGS consensus best practice recommendations for transitioning patients' healthcare from skilled nursing facilities to the community.
        J Gen Intern Med. 2017; 32: 199-203
        • Orr N.M.
        • Forman D.E.
        • De Matteis G.
        • Gambassi G.
        Heart failure among older adults in skilled nursing facilities: More of a dilemma than many now realize.
        Curr Geriatr Rep. 2015; 4: 318-326
        • Burke R.E.
        • Lawrence E.
        • Ladebue A.
        • et al.
        How hospital clinicians select patients for skilled nursing facilities.
        J Am Geriatr Soc. 2017; 65: 2466-2472
        • Centers for Medicare and Medicaid Services
        Hospital Compare.
        (Available at:)
        https://www.medicare.gov/hospitalcompare/Data/Data-Updated.html#
        Date: 2017
        Date accessed: September 12, 2018
        • Hesselink G.
        • Zegers M.
        • Vernooij-Dassen M.
        • et al.
        Improving patient discharge and reducing hospital readmissions by using intervention mapping.
        BMC Health Serv Res. 2014; 14: 389
        • Hernandez A.F.
        • Greiner M.A.
        • Fonarow G.C.
        • et al.
        Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure.
        JAMA. 2010; 303: 1716-1722
        • Snow V.
        • Beck D.
        • Budnitz T.
        • et al.
        Transitions of care consensus policy statement: American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College of Emergency Physicians, Society of Academic Emergency Medicine.
        J Gen Intern Med. 2009; 24: 971-976
        • Kind A.J.H.
        • Smith M.A.
        Documentation of mandated discharge summary components in transitions from acute to subacute care.
        in: Henriksen K. Battles J.B. Keyes M.A. Grady M.L. Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 2: Culture and Redesign). Agency for Healthcare Research and Quality, Rockville, MD2008
        • The Joint Commission
        Hospital: National Patient Safety Goals.
        2017
        • Society of Hospital Medicine
        Project BOOST® Implementation Toolkit, 2014.
        2017
        • Berkowitz R.E.
        • Fang Z.
        • Helfand B.K.
        • et al.
        Project ReEngineered Discharge (RED) lowers hospital readmissions of patients discharged from a skilled nursing facility.
        J Am Med Dir Assoc. 2013; 14: 736-740
        • Park H.K.
        • Branch L.G.
        • Bulat T.
        • et al.
        Influence of a transitional care clinic on subsequent 30-day hospitalizations and emergency department visits in individuals discharged from a skilled nursing facility.
        J Am Geriatr Soc. 2013; 61: 137-142
        • Toles M.
        • Colon-Emeric C.
        • Naylor M.D.
        • et al.
        Connect-home: Transitional care of skilled nursing facility patients and their caregivers.
        J Am Geriatr Soc. 2017; 65: 2322-2328
        • Carnahan J.L.
        • Slaven J.E.
        • Callahan C.M.
        • et al.
        Transitions from skilled nursing facility to home: The relationship of early outpatient care to hospital readmission.
        J Am Med Dir Assoc. 2017; 18: 853-859
        • Bueno H.
        • Ross J.S.
        • Wang Y.
        • et al.
        Trends in length of stay and short-term outcomes among Medicare patients hospitalized for heart failure, 1993-2006.
        JAMA. 2010; 303: 2141-2147
        • Heckman G.A.
        • Shamji A.K.
        • Ladha R.
        • et al.
        Heart failure management in nursing homes: A scoping literature review.
        Can J Cardiol. 2018; 34: 871-880
        • McIlvennan C.K.
        • Eapen Z.J.
        • Allen L.A.
        Hospital readmissions reduction program.
        Circulation. 2015; 131: 1796-1803
        • Dharmarajan K.
        • Hsieh A.F.
        • Lin Z.
        • et al.
        Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia.
        JAMA. 2013; 309: 355-363
        • Dharmarajan K.
        • Hsieh A.F.
        • Kulkarni V.T.
        • et al.
        Trajectories of risk after hospitalization for heart failure, acute myocardial infarction, or pneumonia: Retrospective cohort study.
        BMJ. 2015; 350: h411
        • Burke R.E.
        • Whitfield E.A.
        • Hittle D.
        • et al.
        Hospital readmission from post-acute care facilities: Risk factors, timing, and outcomes.
        J Am Med Dir Assoc. 2016; 17: 249-255
        • Horney C.
        • Capp R.
        • Boxer R.
        • Burke R.E.
        Factors associated with early readmission among patients discharged to post-acute care facilities.
        J Am Geriatr Soc. 2017; 65: 1199-1205
        • Toles M.
        • Anderson R.A.
        • Massing M.
        • et al.
        Restarting the cycle: Incidence and predictors of first acute care use after nursing home discharge.
        J Am Geriatr Soc. 2014; 62: 79-85
        • Hall R.K.
        • Toles M.
        • Massing M.
        • et al.
        Utilization of acute care among patients with ESRD discharged home from skilled nursing facilities.
        Clin J Am Soc Nephrol. 2015; 10: 428-434
        • Gheorghiade M.
        • Vaduganathan M.
        • Fonarow G.C.
        • Bonow R.O.
        Rehospitalization for heart failure: Problems and perspectives.
        J Am Coll Cardiol. 2013; 61: 391-403