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From hospital to nursing home

The Boomer Generation is entering retirement age and their “golden years.”  Hopefully they are, and remain, in great good health.  If, however, the years ahead require a hospital stay they, and their families, may wish to note certain trends researchers James S. Goodwin, Bret Howrey, Dong D. Zhang and Yong-Fang Kuo report on in Risk of Continued Institutionalization after Hospitalization in Older Adults in The Journals of Gerontology, Series A.     –Purdy, Director of Publicity, OUP USA

What percentage of long-term care nursing home admissions is precipitated by a hospitalization? How is this changing over time? How does the risk for long-term care placement vary by patient, disease, and health system characteristics?

The hypothesis is that most institutionalization is triggered by an acute event requiring hospitalization, which then interacts with underlying risk factors to result in long-term nursing home care.  Differences in percentage of patients in a nursing home 6 months post-hospitalization, by age, gender, etc. were tested.

The study, Risk of Continued Institutionalization after Hospitalization in Older Adults posted for free online by The Journals of Gerontology, Series A was

• Limited to hospitalizations in the first 4 months of the year so that nursing home residence 6 months later would occur in that same year.
• Data was generated from 1996 through 2008, the last year for which Medicare data are currently available.
• Excluded patients who were admitted to the hospital from an SNF or long-term nursing home or who had any evidence of residence in those facilities in the 3 months prior to hospital admission (or comparison date for control patients)

This criteria left a pool of 2,831,083 admissions in 1,315,272 patients. Residence in a nursing facility prior to admission and discharge to home or other health care facility was obtained from the MEDPAR files, as well as by searching for any Evaluation and Management codes associated with nursing facilities (22) in the 3 months prior to admission. Patients who were less than 66 years of age at hospitalization were excluded, leaving 2,296,083 admissions in 1,101,747 patients.

In both the hospitalized and control groups, patients with evidence of prior nursing home residence were excluded. The percentage of patients residing in a nursing home 6 months after hospital discharge (or a control date for the non-hospitalized control patients) during 1996–2008 is shown in Table 1 (see link below).  Looking at total new nursing home placements in the hospitalized and non-hospitalized groups, prior hospitalization was associated with 75.11% of all nursing home placements.

Table 1:  Percentage of Patients Living in a Nursing Home 6 Months After Hospitalization Compared With Patients Not Hospitalized in a 5% Medicare Sample, 1996–2008

Table 2:  Logistic Regression Estimating Odds of Nursing Home Residence at 6 Months Following Hospitalization in a 5% Medicare Sample, 1996–2008

Table 2 (see link above) presents a multivariable analysis of the odds of nursing home residence 6 months after hospital discharge from 1996 to 2008. In these and all other analyses, patients with evidence of residence in a nursing home or SNF any time in the 3 months prior to admission were removed. In contrast to the unadjusted results in Table 1, in the multivariable analyses:

• There was a 4% decrease per year in odds of institutionalization after hospitalization.
• The odds of institutionalization after hospitalization increased with age, in women, and in patients without a PCP.
• The odds were more than six-fold higher in patients with a dementia diagnosis and were also increased in patients with other co-morbidities.
• The increased risk of institutionalization associated with delirium seen in the bivariate analyses (Table 1) was almost eliminated in the multivariable analyses.
• In other models (not presented), adding a diagnosis of dementia to the model was the largest factor responsible for delirium no longer being strongly associated with subsequent nursing home residence.
• Risk of institutionalization also varied by diagnostic group, with central nervous system disorders having the highest risk.

This is the first study to investigate the role of hospitalization in subsequent nursing home residence in a national, population-based sample. Overall, 75% of incident nursing home admissions were preceded by an acute care hospitalization in the prior 120 days.

Patients with an identified PCP in the year prior to admission were 25% less likely to be in long-term care after hospitalization, after controlling for other factors (Table 2). We and others have shown that participation of a PCP is important in avoiding adverse outcomes of hospitalization, particularly those precipitated by the transition of medical care at hospital discharge (28–30).

Of patients examined who had a PCP prior to hospitalization and were subsequently admitted to a nursing home, only 24.4% of those patients were cared for by their PCP in the nursing home.

The decrease in risk of institutionalization after hospitalization aligns with the declines in the percentage of older individuals residing in nursing homes. For example, the National Nursing Home Survey reported a decline in age-adjusted rates in those 65 years and older from 46.4 per 1000 in 1995 to 34.8 in 2004 (34). The decline was largest in those 85 years and older (34).

The trajectory leading to long-term care placement has shifted over time. The majority of new admissions to long-term care are now preceded by a hospitalization with discharge to an SNF. Initiatives to reduce use of long-term care might focus on older patients undergoing this transition.  For more details, discussion and specific recommendations for how best to identify individuals at risk for institutionalization please visit this article at The Journals of Gerontology, Series A: Biological Sciences and Medical Sciences.

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