Rural-Urban Differences in Nursing Home Risk-adjusted Rates of Emergency Department Visits: A Decomposition Analysis.
Aged
Emergency Service, Hospital
/ statistics & numerical data
Female
Humans
Insurance Claim Review
/ statistics & numerical data
Male
Medical Overuse
/ statistics & numerical data
Medicare
Models, Statistical
Nursing Homes
/ statistics & numerical data
Risk Adjustment
Rural Population
/ statistics & numerical data
United States
Urban Population
/ statistics & numerical data
Journal
Medical care
ISSN: 1537-1948
Titre abrégé: Med Care
Pays: United States
ID NLM: 0230027
Informations de publication
Date de publication:
01 2021
01 2021
Historique:
pubmed:
10
11
2020
medline:
20
2
2021
entrez:
9
11
2020
Statut:
ppublish
Résumé
Higher risk-adjusted rate of emergency department (ED) visits might reflect poor quality of nursing home (NH) care; however, existing evidence is limited regarding rural-urban differences in ED rates of NHs, especially for long-stay residents. To determine and quantify sources of rural-urban differences in NH risk-adjusted rates of any ED visit, ED without hospitalization or observation stay (outpatient ED), and potentially avoidable ED visits (PAED) of long-stay residents. We calculated quarterly NH risk-adjusted rates using 2011-2013 national Medicare claims and Minimum Data Set 3.0, and then implemented Generalized Estimating Equation models to examine rural-urban differences in ED rates and Blinder-Oaxaca decomposition to quantify the contributions of NH and market factors. Privately owned, free-standing NHs in the United States (N=13,260). Over the study period, risk-adjusted rates averaged 9.8% for any ED, 3.3% for outpatient ED, and 3.2% for PAED. Compared with urban NHs, rural NHs were associated with significantly lower rates of any ED, outpatient ED, and PAED (β=-1.67%, -0.44%, and -0.28%; all P<0.01). Observable differences in market factors (nursing home bed concentration, hospital beds, and the existence of a critical access hospital) explained about half of the rural-urban differences in rates of any ED and PAED, but not outpatient ED. Decomposition analyses suggested that lower ED rates in rural NHs appear to be related to market availability of hospital resources. Policymakers may focus on not only reducing unnecessary ED visits but also ensuring equitable hospital access in rural areas.
Sections du résumé
BACKGROUND
Higher risk-adjusted rate of emergency department (ED) visits might reflect poor quality of nursing home (NH) care; however, existing evidence is limited regarding rural-urban differences in ED rates of NHs, especially for long-stay residents.
OBJECTIVES
To determine and quantify sources of rural-urban differences in NH risk-adjusted rates of any ED visit, ED without hospitalization or observation stay (outpatient ED), and potentially avoidable ED visits (PAED) of long-stay residents.
RESEARCH DESIGN
We calculated quarterly NH risk-adjusted rates using 2011-2013 national Medicare claims and Minimum Data Set 3.0, and then implemented Generalized Estimating Equation models to examine rural-urban differences in ED rates and Blinder-Oaxaca decomposition to quantify the contributions of NH and market factors.
SUBJECTS
Privately owned, free-standing NHs in the United States (N=13,260).
RESULTS
Over the study period, risk-adjusted rates averaged 9.8% for any ED, 3.3% for outpatient ED, and 3.2% for PAED. Compared with urban NHs, rural NHs were associated with significantly lower rates of any ED, outpatient ED, and PAED (β=-1.67%, -0.44%, and -0.28%; all P<0.01). Observable differences in market factors (nursing home bed concentration, hospital beds, and the existence of a critical access hospital) explained about half of the rural-urban differences in rates of any ED and PAED, but not outpatient ED.
CONCLUSIONS
Decomposition analyses suggested that lower ED rates in rural NHs appear to be related to market availability of hospital resources. Policymakers may focus on not only reducing unnecessary ED visits but also ensuring equitable hospital access in rural areas.
Identifiants
pubmed: 33165147
doi: 10.1097/MLR.0000000000001451
pii: 00005650-202101000-00006
doi:
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
38-45Références
James CV. Putting patients first: Today’s disparities research leading to health equity tomorrow. Health Serv Res. 2019;54(suppl 1):203–205.
Phillips CD, Holan S, Sherman M, et al. Rurality and nursing home quality: results from a national sample of nursing home admissions. Am J Public Health. 2004;94:1717–1722.
Roberts AR, Bowblis JR. How does rurality influence the staffing of social service departments in nursing homes. Gerontologist. 2018;58:540–545.
Coburn AF, Bolda EJ, Keith RG. Variations in nursing home discharge rates for urban and rural nursing facility residents with hip fracture. J Rural Health. 2003;19:148–155.
Bowblis JR, Meng H, Hyer K. The urban-rural disparity in nursing home quality indicators: the case of facility-acquired contractures. Health Serv Res. 2013;48:47–69.
Mor V, Intrator O, Feng Z, et al. The revolving door of rehospitalization from skilled nursing facilities. Health Aff (Millwood). 2010;29:57–64.
Temkin-Greener H, Zheng NT, Mukamel DB. Rural-urban differences in end-of-life nursing home care: facility and environmental factors. Gerontologist. 2012;52:335–344.
Lutfiyya MN, Gessert CE, Lipsky MS. Nursing home quality: a comparative analysis using CMS Nursing Home Compare data to examine differences between rural and nonrural facilities. J Am Med Dir Assoc. 2013;14:593–598.
Clement JP, Khushalani J, Baernholdt M. Urban-rural differences in skilled nursing facility rehospitalization rates. J Am Med Dir Assoc. 2018;19:902–906.
Centers for Medicare & Medicaid Services. CMS Rural Health Strategy. 2018. Available at: https://www.cms.gov/About-CMS/Agency-Information/OMH/Downloads/Rural-Strategy-2018.pdf . Accessed March 5, 2019.
Centers for Medicare & Medicaid Services. Ensuring Safety and Quality in America’s Nursing Homes. 2019. Available at: https://www.cms.gov/blog/ensuring-safety-and-quality-americas-nursing-homes . Accessed December 8, 2019.
Saliba D, Weimer DL, Shi Y, et al. Examination of the new short-stay nursing home quality measures: rehospitalizations, emergency department visits, and successful returns to the community. Inquiry. 2018;55:46958018786816.
Xu H, Bowblis JR, Li Y, et al. Construction and validation of risk-adjusted rates of emergency department visits for long-stay nursing home residents. Med Care. 2020;58:174–182.
Feng Z, Coots LA, Kaganova Y, et al. Hospital and ED use among Medicare beneficiaries with dementia varies by setting and proximity to death. Health Aff (Millwood). 2014;33:683–690.
LaMantia MA, Lane KA, Tu W, et al. Patterns of emergency department use among long-stay nursing home residents with differing levels of dementia severity. J Am Med Dir Assoc. 2016;17:541–546.
Gruneir A, Bell CM, Bronskill SE, et al. Frequency and pattern of emergency department visits by long-term care residents—a population-based study. J Am Geriatr Soc. 2010;58:510–517.
Brownell J, Wang J, Smith A, et al. Trends in emergency department visits for ambulatory care sensitive conditions by elderly nursing home residents, 2001 to 2010. JAMA Intern Med. 2014;174:156–158.
Obermeyer Z, Cohn B, Wilson M, et al. Early death after discharge from emergency departments: analysis of national US insurance claims data. BMJ. 2017;356:j239.
Centers for Medicare & Medicaid Services. SNF Quality Reporting Program (IMPACT Act 2014). 2018. Available at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Overview.html . Accessed June 27, 2019.
Edwards W. The theory of decision making. Psychol Bull. 1954;51:380–417.
Intrator O, Grabowski DC, Zinn J, et al. Hospitalization of nursing home residents: the effects of states’ Medicaid payment and bed-hold policies. Health Serv Res. 2007;42:1651–1671.
Huckfeldt PJ, Escarce JJ, Pane JD, et al. A decomposition method to assess the contributions of geographic and nongeographic factors to White-Black disparities in health care. Med Care. 2020;58:e16–e22.
Centers for Medicare & Medicaid Services. CMS Adds New Quality Measures to Nursing Home Compare. 2016. Available at: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2016-Press-releases-items/2016-04-27.html . Accessed January 28, 2018.
Grabowski DC, McGuire TG. Black-White disparities in care in nursing homes. Atl Econ J. 2009;37:299–314.
Hart G. Rural-Urban Commuting Areas Codes (RUCAs) 2010. 2014. Available at: https://ruralhealth.und.edu/ruca . Accessed August 1, 2018.
Bowblis JR, Applebaum R. How does medicaid reimbursement impact nursing home quality? The effects of small anticipatory changes. Health Serv Res. 2017;52:1729–1748.
WWAMI Rural Health Research Center. Using RUCA Data. 2017. Available at: http://depts.washington.edu/uwruca/ruca-uses.php . Accessed November 26, 2017.
Trahan LM, Spiers JA, Cummings GG. Decisions to transfer nursing home residents to emergency departments: a scoping review of contributing factors and staff perspectives. J Am Med Dir Assoc. 2016;17:994–1005.
Walker JD, Teare GF, Hogan DB, et al. Identifying potentially avoidable hospital admissions from canadian long-term care facilities. Med Care. 2009;47:250–254.
Grabowski DC, Stewart KA, Broderick SM, et al. Predictors of nursing home hospitalization: a review of the literature. Med Care Res Rev. 2008;65:3–39.
Freeman S, Bishop K, Spirgiene L, et al. Factors affecting residents transition from long term care facilities to the community: a scoping review. BMC Health Serv Res. 2017;17:689.
Rahman M, Norton EC, Grabowski DC. Do hospital-owned skilled nursing facilities provide better post-acute care quality. J Health Econ. 2016;50:36–46.
Bowblis JR, North P. Geographic market definition: the case of Medicare-reimbursed skilled nursing facility care. Inquiry. 2011;48:138–154.
Gaston SM, Walker BW. Critical access hospitals: meeting underserved community needs. Nursing. 2018;48:51–54.
Hubbard AE, Ahern J, Fleischer NL, et al. To GEE or not to GEE: comparing population average and mixed models for estimating the associations between neighborhood risk factors and health. Epidemiology. 2010;21:467–474.
Jann B. The Blinder-Oaxaca decomposition for linear regression models. Stata J. 2008;8:453–479.
Bennett KJ, Borders TF, Holmes GM, et al. What is rural? Challenges and implications of definitions that inadequately encompass rural people and places. Health Aff (Millwood). 2019;38:1985–1992.
Kosar CM, Loomer L, Ferdows NB, et al. Assessment of rural-urban differences in postacute care utilization and outcomes among older US adults. JAMA Netw Open. 2020;3:e1918738.
Intrator O, Zinn J, Mor V. Nursing home characteristics and potentially preventable hospitalizations of long-stay residents. J Am Geriatr Soc. 2004;52:1730–1736.
Duggan M, Gruber J, Vabson B. The consequences of health care privatization: evidence from Medicare Advantage exits. Am Econ J-Econ Policy. 2018;10:153–186.
Kaufman BG, Thomas SR, Randolph RK, et al. The rising rate of rural hospital closures. J Rural Health. 2016;32:35–43.
Vadnais AJ, Vreeland E, Coomer NM, et al. Reducing transfers among long-stay nursing facility residents to acute care settings: effect of the 2013-2016 Centers for Medicare and Medicaid Services Initiative. J Am Med Dir Assoc. 2020;21:1341–1345.
Geng F, Stevenson DG, Grabowski DC. Daily nursing home staffing levels highly variable, often below CMS expectations. Health Aff (Millwood). 2019;38:1095–1100.