The Impact of Nursing Home Transfer Policies At the End of Life on a Public Acute Care Hospital

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Abstract
OBJECTIVES: To determine whether nursing homes transferred their terminal care patients to one public hospital, and if so, the impact of these transfers on nursing home and hospital mortality rates. DESIGN: A retrospective cohort study using both Medicare claims and hospital data to construct a mortality prediction model, as well as a cross‐sectional descriptive comparison of state nursing home mortality rates. SETTING: A public hospital, one of 32 hospitals designated as overall mortality outliers for each of the first three Medicare mortality reports. PARTICIPANTS: Patients (n = 1235) included in the index hospital's 1988 Medicare mortality report; nursing homes (n = 289) included in state data on 1988 nursing home mortality rates. MEASUREMENTS AND RESULTS: Patients transferred from nursing homes to the index hospital were nearly twice as likely to die as the hospital's other Medicare patients in univariate (P = .0001) as well as multivariate analysis (OR = 1.68, 95% CI = 1.17–2.40). Terminal care admissions accounted for 33.9% of deaths from nursing homes but only 16.2% of other deaths (P = .009). The 1988 death/discharge rate at one of two nursing homes responsible for nearly all transfers was 15.2%, less than half the state average. Yet it contributed 59.3% of nursing home deaths and 22.7% of terminal care patients to the hospital. The hospital's 20.0% 1988 Medicare mortality rate was just above the expected range. CONCLUSIONS: Two nursing homes transferred terminal care to a single hospital. This resulted in a lower‐than‐average mortality rate for one of the nursing homes and a higher‐than‐expected Medicare mortality for the hospital. Without these end‐of‐life transfers, the hospital's Medicare mortality rate would have been within the expected range.

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