Hospitalizations Among Nursing Home Hospitalizations Among Nursing Home Residents with PneumoniaResidents with Pneumonia

R. Tamara Hodlewsky, MA, MSR. Tamara Hodlewsky, MA, MS

William Spector, PhDWilliam Spector, PhD

Tom Shaffer, MHSTom Shaffer, MHS

Purpose of the StudyPurpose of the Study

To determine resident-level and facility-level risk factors for hospitalization among nursing facility residents with suspected pneumonia

To focus on the hospitalization decision separately from the risk of acquiring pneumonia

ImportanceImportance

Approximately 14% of 1.7 million nursing facility residents get pneumonia during the course of a year

Hospitalization is expensive

Appropriateness of hospitalization not always clear: – Stress of transfer– Risk of nosocomial infection

Literature Review: Large StudiesLiterature Review: Large Studies

Larger studies of hospitalization not focused on pneumonia (Freiman & Murtaugh, 1993; Intrator et al., 1999; Garrard/Kane et al., 1990)

Hospitalization positively associated with:– Male, Age (up to age 85)– ADL dependency– For-profit status of facility

Hospitalization negatively associated with:– Resident’s tenure in facility– Higher professional staffing

Literature Review: Smaller StudiesLiterature Review: Smaller Studies

Smaller studies including clinical data were specific to hospitalization for pneumonia among nursing home residents

Thompson et al (1997 and 1999): no significant differences in clinical risk factors between hospitalized and unhospitalized

Fried et al (1995 and 1997): Pneumonia cases with higher respiratory rate better off in hospital; pneumonia cases with lower respiratory rate better off staying in facility.

Literature Review: ConclusionLiterature Review: Conclusion

Risk factors for hospitalization for pneumonia remain unclear

No large-scale, national studies of hospitalization from nursing homes focusing on pneumonia

HypothesesHypotheses

Probability of hospitalization should be lower for frailer residents

Residents in facilities with higher staffing ratios and more skilled nursing services should have a lower probability of hospitalization

Residents in not-for-profit facilities should have a lower probability of hospitalization

DataData

1996 Medical Expenditure Panel Survey Nursing Home Component (MEPS NHC)

Nationally representative sample of 3,209 residents as of January 1, 1996 and 2,690 residents admitted during the year in 815 facilities

760 residents 65 and older had pneumonia during the year Of those with pneumonia, 258 (34%) were hospitalized for

pneumonia at least once

Capturing PneumoniaCapturing Pneumonia

Pneumonia cases are self-reported by facility

Data on incident pneumonias collected in three rounds to ensure complete coverage for all of 1996

Pneumonias include both incident and at admission

Pneumonia HospitalizationsPneumonia Hospitalizations

Pneumonia hospitalizations were defined as an inpatient admission with reason for admission being pneumonia

Facility self-report

ModelModel

LOGIT Model:

Hospitalization= f (resident health status, frailty, and diagnoses; resident demographics; facility characteristics and staffing)

*Clustering with robust standard errors used to account for correlation among residents in the same facility

*Probability weights used to account for complex survey design

Resident-Level VariablesResident-Level Variables

ADL dependence Incontinence Cognitive performance Trouble chewing Trouble swallowing Body Mass Index Heart Disease Cancer Emphysema/COPD

Stroke Depression Other comorbidities DNH advance directive Gender Race Level of education Age 95+

Facility-Level VariablesFacility-Level Variables

For-profit, not-for-profit, or government status

Chain or independent Rural or urban Total number of beds Percent of beds certified for

Medicare

RN- and LPN- to resident ratio

Nurse aide-to-resident ratio Skilled nursing services

offered: tube-feeding, IV therapy, isolation, dialysis, ventilator care

Preliminary Results: Facility-LevelPreliminary Results: Facility-Level(Dep. Var.: Hospitalization)(Dep. Var.: Hospitalization)

Not-for-profit status** (negative) RN+LPN-to-resident ratio** (negative) Aide-to-resident ratio** (positive) Percent Medicare beds** (negative) Skilled nursing services available** (negative) (tube feeding, isolation, vent care, dialysis, IV)

**p<.05

Preliminary Results: Resident-Preliminary Results: Resident-Level (Dep. Var.: Hospitalization)Level (Dep. Var.: Hospitalization)

Problems chewing** (negative) Cancer** (negative) Depression* (positive) High school education* (negative) Education beyond high school** (negative)

**p<.05*p<.10

LimitationsLimitations

Lack of clinical data on pneumonia infections, such as respiratory rate

No clinical definition for pneumonia used

Pneumonia and hospitalization based on facility report

Key Findings of No Statistical Key Findings of No Statistical SignificanceSignificance

Race and gender

Urban/rural

Chain/Independent

ImplicationsImplications

Potential to reduce pneumonia hospitalizations and associated costs through increased professional staffing and skilled nursing capabilities in nursing facilities

Need for outcomes data to assess avoidable and unavoidable hospitalizations for pneumonia

Next StepsNext Steps

Sensitivity Analyses

More input on clinical significance of risk factors and magnitudes of effects