Post-Acute Care Location Matters for Readmissions

Discharge to home healthcare may have yielded more readmissions than discharge to a skilled nursing facility (SNF) but was associated with similar functional and survival outcomes, a retrospective Medicare cohort study found.

Heading home after the hospital was associated with a 15.8% readmission rate at 30 days compared with 17.8% with SNF patients, which persisted after adjustment for initial hospitalization type and comorbidities (1.6 percentage points, P<.001).

However, after adjusting for the association with proximity to a home healthcare agency versus an SNF, the difference was a 5.6-percentage point greater rate of readmission at 30 days with discharge home (P=0.02), reported Rachel Werner, MD, PhD, of the University of Pennsylvania in Philadelphia, and colleagues in JAMA Internal Medicine.

There were no significant differences in improvement in functional status (absolute difference 1.9%, P=0.71) or 30-day mortality (absolute difference 2.0%, P =0.12).

Among patients discharged to home, Medicare payments were significantly lower than those of patients discharged to an SNF (absolute difference $5,384, P<0.001), and so were total payments within the initial 60 days following admission (absolute difference $4,514, P<0.001).

The use of post-acute care has increased considerably over the last few decades.

“There is a tradeoff between how much we spend on health care and what we get out of it. While patients at SNFs were less likely to be readmitted to the hospital, caring for patients in SNFs is expensive. There are likely alternative approaches such as providing more intensive treatment at home, that could balance these tradeoffs,” Werner told MedPage Today.

Prior investigations yielded inconsistent results and have been small and assessed few conditions, and the majority inadequately controlled for the considerable differences in patient characteristics across settings, the study authors noted.

“Combine the ease and standardization of transferring a patient to another medical facility with the administrative complexity and effort required to coordinate simultaneous delivery of medications, equipment, and multiple staff to a Medicare beneficiary’s home and it becomes clear why there is a structural preference for discharge to an SNF,” wrote Vincent Mor, PhD, of Brown University in Providence, Rhode Island, in an accompanying editorial.

Werner’s group assessed over 17 million hospitalizations using Medicare claims information collected from SNF and short-term acute care hospitals in the U.S. Participants had an average age of 80.5 years and were 62.2% female. There were over 6.5 million patients in the home healthcare group and over 10.5 million patients in the SNF group.

Patients were included if they were discharged from a hospital to SNF or from a hospital to home with home agency care. Exclusion criteria included: being discharged to hospice, having a hospital length of stay under 3 days, being in a nursing home in the 30 days leading up to hospitalization, and being younger than 66 years.

The researchers acknowledged the limitations of their study as the findings are only applicable to Medicare beneficiaries. “While our instrumental variable approach provides a higher level of evidence than most prior studies of how outcomes differ between home and SNF settings, this approach may not fully address unobserved confounding.”

“These results warrant further investigation of these postacute care settings and others given the common use and high costs associated with postacute care,” the researchers concluded.