Hospitalizations Among Nursing Home Residents with Pneumonia R

Hospitalizations Among Nursing Home Residents with Pneumonia R. Tamara Hodlewsky, MA, MS William Spector, Ph. D Tom Shaffer, MHS

Purpose of the Study n To determine resident-level and facility-level risk factors for hospitalization among nursing facility residents with suspected pneumonia n To focus on the hospitalization decision separately from the risk of acquiring pneumonia

Importance n Approximately 14% of 1. 7 million nursing facility residents get pneumonia during the course of a year n Hospitalization is expensive n Appropriateness of hospitalization not always clear: – Stress of transfer – Risk of nosocomial infection

Literature Review: Large Studies n Larger studies of hospitalization not focused on pneumonia (Freiman & Murtaugh, 1993; Intrator et al. , 1999; Garrard/Kane et al. , 1990) n Hospitalization positively associated with: – Male, Age (up to age 85) – ADL dependency – For-profit status of facility n Hospitalization negatively associated with: – Resident’s tenure in facility – Higher professional staffing

Literature Review: Smaller Studies n Smaller studies including clinical data were specific to hospitalization for pneumonia among nursing home residents n Thompson et al (1997 and 1999): no significant differences in clinical risk factors between hospitalized and unhospitalized n 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: Conclusion n Risk factors for hospitalization for pneumonia remain unclear n No large-scale, national studies of hospitalization from nursing homes focusing on pneumonia

Hypotheses n Probability of hospitalization should be lower for frailer residents n Residents in facilities with higher staffing ratios and more skilled nursing services should have a lower probability of hospitalization n Residents in not-for-profit facilities should have a lower probability of hospitalization

Data n 1996 Medical Expenditure Panel Survey Nursing Home Component (MEPS NHC) n Nationally representative sample of 3, 209 residents as of January 1, 1996 and 2, 690 residents admitted during the year in 815 facilities n 760 residents 65 and older had pneumonia during the year n Of those with pneumonia, 258 (34%) were hospitalized for pneumonia at least once

Capturing Pneumonia n Pneumonia cases are self-reported by facility n Data on incident pneumonias collected in three rounds to ensure complete coverage for all of 1996 n Pneumonias include both incident and at admission

Pneumonia Hospitalizations n Pneumonia hospitalizations were defined as an inpatient admission with reason for admission being pneumonia n Facility self-report

Model 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 Variables n n n n n ADL dependence Incontinence Cognitive performance Trouble chewing Trouble swallowing Body Mass Index Heart Disease Cancer Emphysema/COPD n n n n Stroke Depression Other comorbidities DNH advance directive Gender Race Level of education Age 95+

Facility-Level Variables n For-profit, not-for-profit, or government status n Chain or independent n Rural or urban n Total number of beds n Percent of beds certified for Medicare n RN- and LPN- to resident ratio n Nurse aide-to-resident ratio n Skilled nursing services offered: tube-feeding, IV therapy, isolation, dialysis, ventilator care

Preliminary Results: Facility-Level (Dep. Var. : Hospitalization) n n n 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. Level (Dep. Var. : Hospitalization) n n n Problems chewing** (negative) Cancer** (negative) Depression* (positive) High school education* (negative) Education beyond high school** (negative) **p<. 05 *p<. 10

Limitations n Lack of clinical data on pneumonia infections, such as respiratory rate n No clinical definition for pneumonia used n Pneumonia and hospitalization based on facility report

Key Findings of No Statistical Significance n Race and gender n Urban/rural n Chain/Independent

Implications n Potential to reduce pneumonia hospitalizations and associated costs through increased professional staffing and skilled nursing capabilities in nursing facilities n Need for outcomes data to assess avoidable and unavoidable hospitalizations for pneumonia

Next Steps n Sensitivity Analyses n More input on clinical significance of risk factors and magnitudes of effects