Potentially avoidable hospitalizations among nursing home residents at the end of life: Associations with facility characteristics

Potentially avoidable hospitalizations (PAHs) are very costly and may be of limited clinical benefit. Nursing home (NH) residents at the end-of-life are particularly vulnerable to the adverse consequences of PAHs. The objectives of this study were to describe variations in the PAH quality measure and to identify factors associated with PAH performance. The Minimum Data Set was linked with Medicare inpatient claims. Poisson regression model was fit to calculate the expected PAH rate. The risk-adjusted measure of PAH was calculated as the ratio of the observed to expected PAH rate. NHs with ratio greater than 1 have worse than expected PAH performance. We then fit a logistic regression model with state fixed-effects to examine the association of facility and county characteristics with PAH performance. Analytical sample: 363,715 decedent long-term residents; 12,839 NHs. The risk-adjusted PAH quality measure showed substantial variation. Chain-affiliated and hospital-based facilities showed better PAH performance (OR=0.86 and OR=0.64, p<0.001, respectively). Facilities with higher nursing staffing had lower odds of worse performance (OR=0.90, p<0.001), as did facilities with higher ratio of skilled to unskilled staffing (OR=0.92, p<0.001). However, rural NHs had higher odds of worse performance (OR=1.59, p<0.001), as did for-profit NHs. For every 10% increase in the proportion of Medicaid or Medicare patients, a facility experienced 22% and 39%, respectively, higher odds of worse performance. The availability of acute-care hospital beds had no impact. Increasing total staffing and the proportion of skilled nursing staff appear to reduce PAHs, potentially leading to better resident outcomes and cost savings.