International Journal for Quality in Health Care, 2016, 28(1), 104–109
doi: 10.1093/intqhc/mzv110
Advance Access Publication Date: 24 December 2015
Article
Article
Prevalence and patterns of potentially avoidable
hospitalizations in the US long-term care setting
ROSEMARY M. MCANDREW1, DAVID C. GRABOWSKI2, ANKIT DANGI1,
and GARY J. YOUNG1,3,4
1
Northeastern University Center for Health Policy and Healthcare Research, Boston, USA, 2Harvard Medical School,
Boston, USA, 3D’Amore-McKim School of Business, Northeastern University, Boston, USA, and 4Bouvé College of
Health Sciences, Northeastern University, Boston, USA
Address reprint requests to: Gary Young, 137 Richards Hall, Northeastern University, Boston, MA 02115, USA.
Tel: +1-617-373-2528; E-mail: [email protected]
Accepted 15 November 2015
Abstract
Objective: We examined the magnitude and related costs of potentially avoidable hospitalizations
including re-hospitalizations for long-stay residents in nursing homes.
Design: We conducted our investigation as a retrospective cohort study where the cohort comprised
individuals who were eligible for Medicare and had spent at least 120 uninterrupted days in a nursing
home in New York State between 2004 and 2007. To conduct the study, we linked the Minimum Data
Set, Medicare Provider Assessment File and Provider of Service File.
Measurements: We defined a potentially avoidable hospitalization as one where a resident was
admitted to a hospital for which the principle diagnosis was 1 of 15 ambulatory care sensitive
(ACS) conditions.
Results: Although the percentage of total hospitalizations for ACS conditions declined during the
study period, 20% or more of annual hospitalizations were for ACS conditions entailing Medicare
payments in excess of $450 million. Approximately 40% of the residents who were hospitalized
once for an ACS condition were re-hospitalized during the study period for the same or different
ACS condition.
Conclusion: During the study period, potentially avoidable hospitalizations from nursing homes
were a common occurrence in New York. A substantial percentage of such hospitalizations
involved residents who had been previously hospitalized, in some cases multiple times, for an
ACS condition. Although the observed decline in ACS-related hospitalizations suggests improvements in nursing home care, various policy and managerial-level initiatives may be needed to
ensure that nursing home residents are not exposed to a substantial risk of avoidable hospitalizations in the future.
Key words: potentially avoidable hospitalizations, long-term care, nursing homes
Introduction
Currently, over 1.5 million individuals reside in nursing homes across
the USA due to physical or mental disabilities [1]. With approximately
seventy-nine million baby boomers scheduled to retire—roughly
ten thousand baby boomers turning sixty-five every day for the next
17 years—a significant increase in the demand for long-term care is
likely [2].
Although the need for long-term care can be expected to increase
during the next decade, the quality of care in nursing homes remains a
long-standing issue in the USA. Over 25 years ago, a seminal report
© The Author 2015. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved
104
Prevalence and patterns of potentially avoidable hospitalizations • Quality Management
from the National Academy of Science’s Institute of Medicine’s Committee on Nursing Home Regulation stated that ‘individuals who are
admitted [to a nursing home] receive very inadequate – sometimes
shockingly deficient care. . . .’ [3] More recently, a series of reports
by the Government Accountability Office point to serious ongoing deficiencies in the quality of care at US nursing homes [4–6].
One key quality indicator for long-term care is potentially avoidable hospitalization of residents. Such hospitalizations are for clinical
conditions that potentially could have been prevented or effectively
treated in the nursing home thus precluding the need for a hospital admission [7–10]. Although evidence suggests that potentially avoidable
hospitalizations are a common occurrence in US nursing homes,
[7, 11–15] little information exists regarding the general pattern of
such hospitalizations including how frequently the same residents
are hospitalized for potentially avoidable conditions and how much
is spent providing hospital care to nursing home residents who have
been admitted for a potentially avoidable hospitalization.
In this paper, we report the results of our investigation of potentially avoidable hospitalizations in nursing facilities in the state of
New York. This investigation was part of a larger research project
on nursing home quality of care. We chose New York as the study setting for two reasons. One, it is a populous state with many nursing
homes offering long-term care. Two, related research had previously
been undertaken in the state that provided useful baseline information
[7]. Based on our study, we report the magnitude of potentially avoidable hospitalizations for residents of nursing homes in New York State
between 2004 and 2007 and some of the related costs of these hospitalizations. For costs, we report actual payments to hospitals for these
hospitalizations, which is an extension of previous work that reported
hospitals’ own costs only [7]. In addition, we report the number of residents who, once hospitalized with a potentially avoidable condition,
were re-hospitalized with the same or different potentially avoidable
condition. To identify potentially avoidable hospitalizations, we
used a list of diagnostic codes for ambulatory care sensitive (ACS) conditions, which is a widely used methodology for this purpose but also
one that has generated controversy [7–10]. We discuss this controversy
as it relates to the validity of the results from our investigation.
Methods
Design and sample
We conducted our investigation as a retrospective cohort study. We
defined the cohort of interest as all nursing home residents who
were eligible for Medicare and had spent at least 120 uninterrupted
days in a nursing home in New York between 2004 and 2007. Most
residents of nursing homes are over the age of 65 and thus qualify for
Medicare in the event of hospitalization [16]. Some residents under the
age of 65 also qualify for Medicare based on long-term disability.
Although no universal definition exists for a long-stay nursing home
resident, we followed previous research by defining a long-term care
resident as one who has >120 uninterrupted days of stay within the
same nursing home [7, 17]. The 120 criterion serves as a screener
for separating out the ‘sickest of the sick’, as it is unlikely that critically
ill residents would be able to remain in the nursing home for 120 uninterrupted days without requiring hospital care.
Data
The key data sources for the study came from the Centers for Medicare
and Medicaid Services of the US federal government: Minimum Data
Set (MDS), Medicare Provider Analysis and Review File (MEDPAR)
105
and the Provider of Service file (POS). MDS is a standardized, primary
screening and assessment tool of health status that forms the foundation of the comprehensive assessment for all residents in a Medicare
and/or Medicaid-certified long-term care facility. Nursing homes
must complete it for each resident upon admission, and periodically
thereafter, at least quarterly [18]. We used the MDS to identify longstay residents who met the criteria for the study cohort. The MEDPAR
contains inpatient hospital data, including diagnostic and payment information, for all Medicare beneficiaries who experienced a hospital
stay [19]. To identify members of the cohort who were admitted to
an acute-care hospital, we linked the MDS with the MEDPAR. For
each member of the cohort, we used the MEDPAR to determine
whether and how many times a resident had been admitted to an
acute-care hospital at some point after spending at least 120 uninterrupted days in the nursing home that defined his/her membership in
the study cohort. The POS file contains information on structural
and operating characteristics for each Medicare-approved nursing
home. The POS file contains data on characteristics of hospitals and
other types of healthcare facilities, including the name and address
of the facility and the type of Medicare services the facility provides,
among other information [20].
Measures
For all members of the study cohort who were hospitalized at least
once during the study period, we determined whether the hospitalization was potentially avoidable based on whether the principle diagnosis, as listed on their MEDPAR file, was one of 15 ACS conditions
[12]. Precedent exists for the use of these ACS diagnostic codes in
the nursing home setting [7, 17, 21, 22]. Ambulatory care sensitive
conditions are clinical cases for which appropriate ambulatory care
should either prevent the condition from occurring or, if the condition
does occur, reduce the need for admission to the hospital [23]. This
concept is critical as avoidable hospitalizations and re-hospitalizations
have the potential to send the nursing home resident on a path of failing health, which is a function of inadequate or nonexistent care. At
the same time, as previously mentioned, the use of ACS conditions for
identifying avoidable hospitalizations from nursing homes has been
controversial. A central concern is that the methodology was not developed specifically for a nursing home population [24]. The clinical
status of long-stay residents can be highly complex as many such patients have multiple chronic conditions [25]. As such, nursing homes
face a difficult challenge in managing the care of these patients. Nevertheless, ACS-related hospitalizations continue to be used as an important quality indicator for nursing home care in the USA. For example,
the USA will soon begin including these events as a measure for its
public reporting initiative for nursing home quality [26] and is also developing payment models for nursing homes that are designed in part
to create financial incentives to reduce ACS-related hospitalizations
[27]. Moreover, a recent study of potentially avoidable hospitalizations in Canada supports the validity of using ACS conditions in a
nursing home population [28].
We used a list of ACS conditions that other researchers have
modified for application to older populations [13]. The primary
modifications are the inclusion of pneumonia and sepsis and exclusion
of myocardial infarction. The 15 ACS conditions and associated
ICD-9 diagnostic codes are the following: angina (411.1, 411.8,
413); asthma (493); cellulitis (681, 682, 683, 686); chronic obstructive
pulmonary disease (466, 491, 492, 494, 496); congestive heart failure (428, 518.4); dehydration (276.5); diabetes mellitus (250,
250.8,250.9, 250.1–250.3); gastroenteritis (588.8); epilepsy (345,
Rosemary et al.
106
780.3); hypertension (401.0, 401.9, 402.0, 402.1, 402.9); hypoglycemia (251.2); urinary tract infections (590, 599.0, 599.9); pneumonia (468, 481, 482.2, 492.3, 482.9, 483); and severe ear, nose, and
throat infections (382, 462, 463, 465, 472.1) and sepsis (038, 039,
995.91, 683).
As noted, we identified and examined initial hospitalizations
and re-hospitalizations for ACS conditions. We counted and examined
two types of re-hospitalizations: (1) a cohort member was rehospitalized for any ACS condition and (2) a cohort member
was re-hospitalized for the same ACS condition as the previous
hospitalization.
For purposes of assessing the associated costs of potentially avoidable hospitalizations, we examined how much Medicare paid hospitals for the ACS-related hospitalizations that were included in our
analysis. This information was obtained from the MEDPAR file. We
were unable to capture other costs related to potentially avoidable hospitalizations due to data limitations. These include bed hold payments
that are paid to the nursing home to reserve the bed for qualifying
residents who are hospitalized, which would include potentially avoidable hospitalizations. We also do not have data on the transportation costs between the nursing home and the hospital. Other
post-hospitalization costs include increased medication costs and the
admission of the resident to a rehabilitation facility prior to returning
to the nursing home as an intermediary medical necessity. We also
note that while some of the nursing home residents included in the
study were eligible for Medicaid as well as Medicare so that Medicaid
was a secondary payer, we did not have reliable data on Medicaid payments for nursing home residents who were hospitalized. We report
hospital payments in 2004 dollars.
Analysis
We conducted our analysis by examining patterns in the descriptive
statistics we compiled for the frequency, cost, and type of condition
for ACS-related hospitalizations. We examined re-hospitalizations
based on the frequency with which residents were re-hospitalized for
the same as well different ACS conditions.
Results
Table 1 presents data for each year of the study pertaining to the magnitude and related costs of potentially avoidable hospitalizations. The
total number of unique nursing home residents during the study period was 533 982. The number of residents reported for each year of the
study period is not unique cases because many of the same residents
remained in nursing homes for multiple years during the study period.
These residents were located at any one of 660 nursing homes in
New York State during the study period. While the number of annual
hospitalizations per resident remained relatively stable during the
study period, the percentage of total hospitalizations that were for
ACS conditions (i.e. ACS-related hospitalizations) declined consistently from 36.8% at the beginning of the study period to 22.8% at the
end (see also Fig. 1). Total annual Medicare payments for ACS-related
hospitalizations were in excess of $450 million year for each year of
the study period but were lower in real terms at the end of the study
period than at the beginning. As indicated in Table 2, pneumonia was
the most common ACS condition accounting for 50% of ACS-related
hospitalizations.
Table 3 presents the frequency of re-hospitalizations for residents
who were hospitalized at least once during the study period with an
ACS condition. Approximately 40% of the residents who were hospitalized at least once during the study period for an ACS-related hospitalization were re-hospitalized for an ACS condition. Approximately
15% of the residents were re-hospitalized multiple times, between 3
and 34 times. When the data are examined based on hospitalizations
(versus residents), over 60% of total ACS-related hospitalizations
involved residents who had already been hospitalized at least once
during the study period for an ACS condition. For a substantial percentage of these re-hospitalizations, ∼26% was for the same ACS condition as the previous hospitalization.
Discussion
Our study examined the pattern of potentially avoidable hospitalizations for long-stay nursing home residents based on ACS conditions.
The findings of our investigation indicate that potentially avoidable
hospitalizations are a common occurrence in nursing homes for
these residents and result in significant costs in both human and financial terms. Even after a steady decline in these events during the study
period, a substantial percentage, over 20%, of the total hospitalizations involved long-stay residents whose principle diagnosis was 1 of
15 ACS conditions. Previous estimates of the percentage of total hospitalizations that are potentially avoidable in the nursing home setting
have varied somewhat by time frame, geographic location and methodology. For studies that use the ACS methodology to identify potentially avoidable hospitalizations, estimates appear generally to be
somewhere in the range of ∼25% to 40% [e.g. 7, 13, 14]. Grabowski
et al., who also focused on New York State but for an earlier study
period than our own (i.e. prior to 2004), estimated potentially avoidable hospitalizations to be above 30%, which is comparable to what
we reported for the beginning of our study period [7]. However, one
study that used structured implicit review based on samples of medical
Table 1 Long-stay nursing home resident hospitalizations for ambulatory care sensitive conditions in New York, 2004–2007
Residents
Number of nursing home residents
Number of hospitalized residents
Number of ACS-related hospitalized residents
Hospitalizations
Number of hospitalizations
Number of ACS-related hospitalizations
Payments
Total Medicare payments to hospitals for ACS-related
hospitalizations (in Millions $)
2004
2005
2006
2007
223 162
24 956
13 739
235 192
27 561
12 801
234 671
28 713
10 368
237 785
27 676
8745
46 173
17 020
46 597
16 759
48 208
13 603
50 259
11 460
550.4
642.1
530.6
461.2
Prevalence and patterns of potentially avoidable hospitalizations • Quality Management
Figure 1 Long-stay nursing home resident hospitalizations for ambulatory care
sensitive conditions in New York, 2004–2007.
Table 2 Frequency of ambulatory care sensitive hospitalizations
for long-stay nursing home residents in New York by diagnostic
category, 2004–2007
Diagnostic categories
Hospitalizations
Angina
Chronic obstructive pulmonary disease
Congestive heart failure
Dehydration
Gastroenteritis
Hypoglycemia
Kidney/urinary tract infection
Pneumonia
Sepsis
Other
Total
Frequency
%
2494
4400
453
5019
1385
1183
13 585
29 717
634
10
58 880
4.24
7.47
0.77
8.52
2.35
2.01
23.07
50.47
1.08
0.02
100
Table 3 Frequency of ambulatory care sensitive re-hospitalizations
for long-stay nursing home residents in New York, 2004–2007
Hospitalizations
Residents
Frequency
Frequency
%
1
2
3
4
5
>5
Total
21 074
8790
3187
1206
521
436
35 214
59.85
24.96
9.05
3.42
1.48
1.24
100
charts produced estimates of potentially avoidable hospitalizations
that exceeded 60% [15].
Additionally, our study is among the first to estimate rehospitalizations over a period of multiple years and also the cost of
ACS-related hospital admissions to Medicare which pays for most of
the hospital care that these events entail. Specifically, we found that a
high percentage of residents, ∼40%, were re-hospitalized for ACS conditions following an initial ACS-related hospitalization. The total cost
of these hospitalizations to Medicare during the four-year study period exceeded $2 billion, or more than $20 000 per hospitalization.
The decline that we observed in ACS-related hospitalizations during the study period is quite possibly attributable to improvements in
the quality of nursing home care. One alternative explanation is that
107
the decline is due to changes in the demographic profile of the residents. We examined whether any such changes occurred but found
that the demographic profile of nursing home residents remained
very stable during the study period in terms of age (80.5 in 2004 vs.
80.3 in 2007), gender (38.9% male in 2004 vs. 39.1% in 2007), and
race (78.7% white in 2004 vs. 78.3% in 2007). Another alternative
explanation is that the decline in avoidable hospitalizations reflects
systematic changes in coding practices including efforts to bill for
more extensive and costly services than actually delivered, or ‘upcoding’. Although based on the present analysis we cannot rule out such
changes in coding practices, the consistent and substantial decline that
we observed in potentially avoidable hospitalizations during the study
period points to actual improvements in nursing home quality.
At the same time, we also recognize that the use of ACS conditions
for identifying potentially avoidable hospitalizations in nursing home
settings is controversial and constitutes a potential limitation for our
study. As noted, these conditions were not developed specifically for a
population of chronically ill residents in nursing homes. To strengthen
the rigor of our investigation, we restricted the study cohort to nursing
home residents who had spent 120 uninterrupted days in the same
nursing home, an inclusion criterion that should have screened out
many of the sickest residents including the frail elderly. These are
the residents who are likely to be at highest risk for hospital care
and for whom ACS conditions are least applicable as a valid method
for identifying avoidable hospitalizations. Additionally, we used a
modified list of ACS conditions that included pneumonia, a condition
which is considered to be particularly relevant for identifying avoidable hospitalizations in an older population, and pneumonia accounted for 50% of the potentially avoidable hospitalizations we
observed in the study. Pneumonia is not only a condition which
good nursing home care can often prevent but also one which, should
it occur, can be managed effectively in a nursing home setting so that a
hospital admission is unnecessary [25].
We also acknowledge that our study focused on nursing homes in
New York and thus the pattern of avoidable hospitalizations observed
in this study may not generalize to nursing homes in other states. Various state-specific factors may influence the rate of potentially avoidable hospitalizations including the level of Medicaid payments to
nursing homes, oversight by regulators, workforce availability and
training, and health status of nursing home residents [25].
The limitations of our study notwithstanding, the results point to
the need for continued efforts to monitor and improve the quality of
care for long-term residents. ACS-related hospitalizations should
occur infrequently if at all, let alone repeatedly, for the same resident.
Yet, we found that many residents experience multiple hospitalizations for the same ACS condition. In addition, although a comparative
analysis of potentially avoidable hospitalizations among nursing
homes was beyond the scope of our study, we did observe that the frequency of such hospitalizations varied substantially among nursing
homes in New York after accounting for each nursing home’s total
hospitalizations and number of certified beds. Thus, some nursing
homes may be performing much better than others in terms of preventing avoidable hospitalizations for their residents.
From a public policy perspective, several approaches should be
considered to reduce the occurrence of potentially avoidable hospitalizations in long-term care settings. One approach is to strengthen existing federal and state regulation of nursing home care. Although a
substantial regulatory apparatus for nursing homes already exists,
its effectiveness is reportedly limited due to a host of factors including
inadequate and untimely complaint investigations, poor documentation of quality problems and inexperienced state surveyors [29].
Rosemary et al.
108
A positive step in this direction is Section 6102 (c) of the Affordable
Care Act, which requires that all nursing homes develop Quality Assurance and Performance Improvement (QAPI) programs. QAPI is a
merger of two approaches to quality: quality assurance and process
improvement. This initiative entails collaboration between federal
and state agencies responsible for the quality of nursing home care.
Another approach is the federal government’s efforts to prosecute
nursing homes under the False Claims Act (FCA) based on the worthless service theory. This theory asserts that under some circumstances
the provision of inadequate care is tantamount to no care at all and
billing the government for such services constitutes a fraudulent or
false claim under the FCA. For purpose of this theory, nursing
homes that bill for services that preceded but were in close proximity
to the time a resident experienced an avoidable hospitalization may be
submitting false claims as the services were of little or no value, hence
‘worthless services’. Although federal cases alleging the worthless services theory have had difficulty making their way through the legal system to become a bona fide basis for action, several recent successful
outcomes in FCA worthless services actions against nursing homes
suggests that the pendulum is swinging in the direction of favoring
the government’s approach [30]. Still, this approach to the problem
is limited as it is likely to focus on the most egregious cases rather
than promoting system-wide quality improvement.
A third potential approach is an enhanced use of financial incentives
or penalties for nursing homes based on their performance with respect
to potentially avoidable hospitalizations. As noted, the USA is developing payment approaches for nursing homes that include incentives for
reducing avoidable hospitalizations [27, 31]. This initiative is similar to
the Hospital Readmission Reduction Program, which the US federal
government has already implemented to reduce the number of avoidable hospital readmissions for Medicare patients who were treated for
pneumonia, heart attack and heart failure [32]. Although such incentive
programs hold promise for better quality of care, whether they can lead
to consistent and substantial improvements in patient outcomes such as
potentially avoidable hospitalizations is not yet clear.
Beyond policy-level initiatives to improve the quality of nursing
home care, efforts are being put forth to develop management approaches and tools that potentially can help nursing homes reduce potentially avoidable hospitalizations. Staffing models have been a
subject of study. One literature review identified several studies indicating that staffing models that included highly skilled health professionals (e.g. nurse practitioners) have relatively fewer potentially
avoidable hospitalizations [33]. Further, a recent study found that
nursing home residents were at lower risk for ACS conditions if
their nursing home had higher staffing levels and a work environment
that supported nurses’ professional development [34]. Researchers
have also studied the value of system-based interventions including
quality improvement programs for reducing avoidable hospitalizations. In particular, INTERACT is a quality improvement program designed to improve the care of long-stay residents experiencing acute
changes in health conditions [35]. Interventions are based on internal
process improvement at the facility level supported by nurse practitioners, coupled with checklists addressing differing critical activities,
and availability of onsite training, web-based training and telephonic
consultations. Preliminary outcomes indicate a 17% reduction in allcause hospitalizations across all INTERACT facilities versus a 3% reduction in comparison facilities. Additionally, new methodologies are
being developed and tested for assessing a patient’s risk for hospital
readmissions, and some of these tools may be adaptable to nursing
home settings. For example, the Better Outcomes for Older Adults
Through Safe Transitions program (i.e. Boost) incorporates a 7-point
screening tool that may be useful for identifying patients at high risk
for requiring intensive interventions such as hospitalization [36].
In conclusion, our study offers additional insights regarding the
quality of care in nursing homes. A central finding from our study is
the high frequency of re-hospitalizations that long-stay residents experienced for ACS conditions. This finding combined with the fact
that so many of these potentially avoidable hospitalizations were for
pneumonia highlights the concern among researchers that potentially
avoidable hospitalizations are a serious quality problem in the USA.
Certainly, it is not reasonable to expect that all potentially avoidable
hospitalizations can be eliminated through better quality of nursing
home care. There exist numerous additional factors influencing the decision to hospitalize nursing home residents. These include costshifting pressures arising from conflicting payer incentives across
chronic and acute-care settings, regulatory and legal liability issues,
the limited supply of geriatric specialists, and time constraints in
many of the nation’s emergency departments [25]. Family dynamics
and patient preferences also play a role. As such, the ACS condition
methodology cannot discriminate perfectly between all hospitalizations that are and are not potentially avoidable. Indeed, one of the concerns of using ACS conditions for identifying potentially avoidable
hospitalizations is that this methodology could deter nursing homes
from admitting residents to hospitals where such care is indeed appropriate [24]. Safeguards, of course, need to be in place so that nursing
homes are not penalized for appropriate hospital admissions. But, the
evidence from our study as well as others indicates that long-stay nursing home residents are exposed to avoidable and re-occurring hospital
admissions and this warrants serious attention. Indeed, given the prospect that a growing proportion of the US population will need nursing home care, as a society we need to devote the resources, both
financial and intellectual, to ensure that the care nursing home residents receive is at a high level of quality.
Authors’ contributions
All authors contributed to all aspects of the production of this
manuscript.
Funding
The study was approved by the Northeastern University IRB
(12-04-19).
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