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Original Investigation
December 30, 2019

Hospital Transfer Rates Among US Nursing Home Residents With Advanced Illness Before and After Initiatives to Reduce Hospitalizations

Author Affiliations
  • 1Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
  • 2Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
  • 3Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island
  • 4Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
  • 5Center of Innovation in Long-Term Services and Supports for Vulnerable Veterans, US Department of Veterans Affairs Medical Center, Providence, Rhode Island
JAMA Intern Med. 2020;180(3):385-394. doi:10.1001/jamainternmed.2019.6130
Key Points

Question  How did the hospital transfer rates change between 2011 and 2017 among nursing home residents diagnosed with advanced illness and limited life expectancy before and after the introduction of national initiatives to reduce hospitalizations?

Findings  In this US nationwide cross-sectional study of 6 cohorts of nursing home residents with advanced illness, such as dementia, congestive heart failure, and chronic obstructive pulmonary disease, although hospital transfers for all causes and for potentially avoidable conditions were common, such transfers were found to have declined considerably from 2011 to 2017, and concurrent hospice use was low across all cohorts.

Meaning  The findings of this study suggest that hospital transfer rates among nursing home residents with advanced illness declined from 2011 to 2017 and that opportunities remain to reduce unnecessary hospital transfers among residents with advanced illness.


Importance  Hospital transfers among nursing home residents in the United States who have been diagnosed with advanced illnesses and have limited life expectancy are often burdensome, costly, and of little clinical benefit. National initiatives, introduced since 2012, have focused on reducing such hospitalizations, but little is known about the consequences of these initiatives in this population.

Objective  To investigate the change in hospital transfer rates among nursing home residents with advanced illnesses, such as dementia, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD), from 2011 to 2017—before and after the introduction of national initiatives to reduce hospitalizations.

Design, Setting, and Participants  In this cross-sectional study, nationwide Minimum Data Set (MDS) assessments from January 1, 2011, to December 31, 2016 (with the follow-up for transfer rates until December 31, 2017), were used to identify annual inception cohorts of long-stay (>100 days) nursing home residents who had recently progressed to the advanced stages of dementia, CHF, or COPD. The data were analyzed from October 24, 2018, to October 3, 2019.

Main Outcomes and Measures  The number of hospital transfers (hospitalizations, observation stays, and emergency department visits) per person-year alive was calculated from the MDS assessment from the date when residents first met the criteria for advanced illness up to 12 months afterward using Medicare claims from 2011 to 2017. Transfer rates for all causes, potentially avoidable conditions (sepsis, pneumonia, dehydration, urinary tract infections, CHF, and COPD), and serious bone fractures (pelvis, hip, wrist, ankle, and long bones of arms or legs) were investigated. Hospice enrollment and mortality were also ascertained.

Results  The proportions of residents in the 2011 and 2016 cohorts who underwent any hospital transfer were 56.1% and 45.4% of those with advanced dementia, 77.6% and 69.5% of those with CHF, and 76.2% and 67.2% of those with COPD. The mean (SD) number of transfers per person-year alive for potentially avoidable conditions was higher in the 2011 cohort vs 2016 cohort: advanced dementia, 2.4 (14.0) vs 1.6 (11.2) (adjusted risk ratio [aRR], 0.73; 95% CI, 0.65-0.81); CHF, 8.5 (32.0) vs 6.7 (26.8) (aRR, 0.72; 95% CI, 0.65-0.81); and COPD, 7.8 (30.9) vs 5.5 (24.8) (aRR, 0.64; 95% CI, 0.57-0.72). Transfers for bone fractures remained unchanged, and mortality did not increase. Hospice enrollment was low across all illness groups and years (range, 23%-30%).

Conclusions and Relevance  The findings of this study suggest that concurrent with new initiatives aimed at reducing hospitalizations, hospital transfers declined between 2011 and 2017 among nursing home residents with advanced illnesses without increased mortality rates. Opportunities remain to further reduce unnecessary hospital transfers in this population and improve goal-directed care for those residents who opt to forgo hospitalization.

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