Abstract

Background.

Little is known about the role of hospitalization as a risk factor for placement into long-term care. We therefore sought to estimate the percentage of long-term care nursing home stays precipitated by a hospitalization and factors associated with risk of nursing home placement after hospitalization.

Methods.

We studied a retrospective cohort of a 5% sample of Medicare enrollees aged ≥ 66 years. The study included 762,243 patients admitted 1,149,568 times in January–April of 1996–2008, with 3,880,292 nonhospitalized controls. We measured residence in a nursing home 6 months after hospitalization.

Results.

From 1996 through 2008, 5.55% of hospitalized patients resided in a nursing home 6 months later compared with 0.54% of nonhospitalized control patients. Three quarters of new nursing home placements were precipitated by a hospitalization. Independent risk factors for long-term care placement after hospitalization included advanced age (odds ratio [OR] = 3.56 for age 85–94 vs. 66–74 years), female gender (OR = 1.41), dementia (OR = 6.15), and discharge from the hospital to a skilled nursing facility (SNF; OR = 10.83). Having a primary care physician was associated with reduced odds (OR = 0.75). In the adjusted analyses, risk of institutionalization after hospitalization decreased 4% per year from 1996 to 2008. There were very large geographic variations in rates of long-term care after hospitalization, from <2% in some hospital referral regions to >13% in others for patients >75 years in 2007–2008.

Conclusions.

Most placements in nursing homes are preceded by a hospitalization followed by discharge to a SNF. Discharge to a SNF is associated with a high risk of subsequent long-term care.

MAINTENANCE of functional independence is highly valued by older people (1,2). In particular, long-term residence in a nursing home is a feared outcome (1–4). A number of carefully conducted population-based studies of community-dwelling elderly have found that advanced age, cognitive dysfunction, poor social support, physical disability, and depression predict future nursing home utilization (5–12).

There are a number of challenges in assessing risks of institutionalization. One is that population-based studies of community-dwelling elderly can identify underlying factors but typically lack information on the more proximal, acute events that often precipitate a nursing home admission, such as hospitalization for acute illness. An acute illness and the consequent hospitalization can be accompanied by functional decline, physical dependence, and need for long-term care (13–18). Population-based studies of community-dwelling elderly are not structured to be able to identify such information. For example, a recent systematic review of population-based studies of predictors of institutionalization in the elderly concluded that evidence on prior hospitalization as a risk factor was inconclusive (12).

A second challenge is in identifying long-term institutionalization after hospitalization. This has been complicated by the rapid growth in use of skilled nursing facilities (SNFs) after hospital discharge (19). Several studies examining nursing home placement after hospitalization have not separated short-term SNF placement from traditional, long-term nursing home care (20,21).

In this study, we use 5% national Medicare data from 1995 to 2008 to address the following questions. 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? Our underlying 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. We assess risk of being in long-term care 6 months after a hospitalization from 1996 to 2008, compared with a nonhospitalized control group.

METHODS

Participants

Participant claims from the period 1996–2008 from a 5% national sample of Medicare beneficiaries were used. We used Medicare enrollment files, Medicare Provider Analysis and Review (MEDPAR) files, Outpatient Statistical Analysis File, Medicare Carrier files, and Provider of Services files. Institutional review board approval was obtained before studies began.

All acute care hospital admissions in a 4-month period, January through April, for each of the years 1996–2008 in MEDPAR were initially selected (3,482,468 admissions in 1,348,776 patients). For some analyses, we used as a comparison Medicare recipients who had not been hospitalized in that year. To generate this nonhospitalized comparison group for each year, we randomly assigned all enrollees not hospitalized during a year to 1 of the 12 months. We then selected those assigned to January through April for each group and assigned them the 15th of that month as the date to use in comparison with hospital discharge dates in the hospitalized group. We limited the study to hospitalizations in the first 4 months of the year so that nursing home residence 6 month later would occur in that same year. This allowed us to generate data from 1996 through 2008, the last year for which Medicare data are currently available.

Also excluded were 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), leaving 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. We also excluded patients who were less than 66 years of age at hospitalization, leaving 2,296,083 admissions in 1,101,747 patients.

We also excluded any patients who died before the end of the time window (225 days after hospital discharge), leaving 1,777,202 admissions in 907,766 patients. We then excluded those without part A or B or in an health maintenance organization at any time in the 12 months before to 225 days after hospitalization, leaving 1,593,506 admissions in 762,243 patients. Finally, for patients with more than one admission during the 4-month period in any year, we randomly selected one admission per patient, resulting in a final sample of 1,149,568 admissions in 762,243 patients.

The study outcome was residence in a long-term care nursing home 6 months after hospital discharge (or comparison date for the nonhospitalized group). This was assessed by searching for any Evaluation and Management codes associated with nursing home care in the 3-month window 135–225 days after hospital discharge (22). Any nursing facility Evaluation and Management charges that occurred when patients were in an SNF were not counted. Admission and discharge dates to SNFs were obtained from the MEDPAR file. This algorithm has 87% sensitivity and 96% specificity when compared with data from the Medicare Current Beneficiary Survey (22).

Measures

Medicare enrollment files were used to categorize patients by age, gender, and ethnicity (white, black, and other). Information regarding weekend versus weekday admission, admission with intensive care unit stay, and discharge diagnosis–related group were obtained from the MEDPAR files. Elixhauser comorbidity measures (23) were generated using both inpatient and physician claims from MEDPAR, Outpatient Statistical Analysis File and Carrier files in the year prior to the index hospitalization. The comorbidities dementia (International Classification of Disease-9: 290, 331, 294, 310.1, 292.82, 292.83, 2901.3, 292.01), delirium (International Classification of Disease-9: 787.6, 788.3), and incontinence (International Classification of Disease-9: 292, 293, 290.3, 290.11) were generated using inpatient and physician claims from a year prior to 3 months after the index hospitalization. Primary care physician (PCP) was defined as a generalist (general internist, family physician, general practitioner, or geriatrician) who had billed an outpatient Evaluation and Management code for the patient on three or more occasions in the year before the index hospitalization (24).

Hospital information—zip code, county, state, total number of hospital beds, type of hospital, and medical school affiliation—were obtained from the Provider of Services file. Metropolitan size was generated from 2000 Census data. States were grouped by census region; type of hospital was categorized as nonprofit, for profit, or public; and medical school affiliation was categorized as none, minor, or major. Discharge destination (home, SNF, rehabilitation facility, another healthcare facility, or transfer to another acute care hospital) was obtained from MEDPAR file.

Analysis

Differences in percentage of patients in a nursing home 6 months posthospitalization, by age, gender, etc. were tested by chi-square. We used logistic regression to assess the association of specific characteristics with odds of nursing home placement. All analyses were performed using SAS version 9.2 (SAS Institute, Cary, NC). The map of percentage of patients institutionalized 6 months posthospitalization in each of the 306 hospital referral regions defined by the Dartmouth Atlas of Health Care (25) was constructed using ArcMap 9.3 (ESRI, Redlands, CA).

RESULTS

We first assessed the impact of hospitalization on risk of subsequent residence in a nursing home in Medicare 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 nonhospitalized control patients) during 1996–2008 is shown in Table 1. There is an approximate 10-fold higher rate of nursing home residence in the posthospitalization group (5.55% vs. 0.54%). Characteristics associated with increased rates of subsequent institutionalization in both the hospitalized and nonhospitalized groups include older age, female gender, not having a PCP, a prior diagnosis of dementia, delirium or incontinence, and a higher overall comorbidity score (which did not include dementia, delirium, or incontinence). There was a slight decrease in the percentage of patients in nursing homes after hospitalization over the period 1996–2008.

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

 Hospitalized*
 
Nonhospitalized*
 
Category* Number in Sample Percent in Nursing Home Number in Sample Percent in Nursing Home (%) 
Entire sample 1,149,568 5.55% 3,880,292 0.54 
Age group (years)     
    66–74 447,978 2.26 2,036,329 0.14 
    75–84 496,483 5.45 1,444,627 0.56 
    85–94 191,883 12.48 375,006 2.30 
    95+ 13,224 19.91 24,330 5.29 
Gender     
    Male 468,502 4.01 1,584,475 0.33 
    Female 681,066 6.60 2,295,817 0.68 
Race group     
    White 1,007,770 5.48 3,433,129 0.55 
    Black 93,581 6.68 275,918 0.53 
    Other 48,217 4.81 171,245 0.35 
Had primary care physician in year prior     
    No 498,651 6.33 2,313,518 0.60 
    Yes 650,917 4.94 1,566,774 0.44 
Dementia (prior and current)     
    No 1,014,027 3.11 3,794,756 0.34 
    Yes 135,541 23.74 85,536 9.12 
Delirium (prior and current)     
    No 1,132,974 5.40 3,870,790 0.52 
    Yes 16,594 15.13 9,502 6.77 
Incontinence (prior and current)     
    No 1,107,032 5.31 3,840,140 0.52 
    Yes 42,536 11.59 40,152 2.24 
Other comorbidity     
    0 481,633 4.48 2,783,304 0.34 
    1 305,544 5.05 761,414 0.75 
    2 171,742 6.43 226,250 1.36 
    3 or more 190,649 8.24 109,324 2.21 
Region     
    New England 57,429 7.18 210,336 0.60 
    Middle Atlantic 163,573 6.71 537,625 0.53 
    East North Central 203,366 6.23 695,562 0.58 
    West South Central 91,833 5.29 313,452 0.69 
    South Atlantic 247,029 5.05 800,981 0.51 
    East South Central 94,416 5.36 265,549 0.45 
    West South Central 128,670 5.21 400,981 0.58 
    Mountain 54,711 3.77 211,561 0.43 
    Pacific 98,746 4.78 398,085 0.45 
Admission year     
    1996 88,155 5.61 308,838 0.54 
    1997 88,168 5.73 297,504 0.55 
    1998 87,477 5.87 290,902 0.56 
    1999 87,310 5.77 286,026 0.53 
    2000 85,805 5.80 285,886 0.53 
    2001 88,234 5.53 290,110 0.064 
    2002 91,745 5.66 299,079 0.56 
    2003 90,693 5.61 308,345 0.52 
    2004 93,023 5.52 313,396 0.50 
    2005 92,671 5.36 311,372 0.47 
    2006 89,534 5.46 301,795 0.50 
    2007 84,242 5.00 296,029 0.52 
    2008 82,511 5.15 291,010 0.56 
 Hospitalized*
 
Nonhospitalized*
 
Category* Number in Sample Percent in Nursing Home Number in Sample Percent in Nursing Home (%) 
Entire sample 1,149,568 5.55% 3,880,292 0.54 
Age group (years)     
    66–74 447,978 2.26 2,036,329 0.14 
    75–84 496,483 5.45 1,444,627 0.56 
    85–94 191,883 12.48 375,006 2.30 
    95+ 13,224 19.91 24,330 5.29 
Gender     
    Male 468,502 4.01 1,584,475 0.33 
    Female 681,066 6.60 2,295,817 0.68 
Race group     
    White 1,007,770 5.48 3,433,129 0.55 
    Black 93,581 6.68 275,918 0.53 
    Other 48,217 4.81 171,245 0.35 
Had primary care physician in year prior     
    No 498,651 6.33 2,313,518 0.60 
    Yes 650,917 4.94 1,566,774 0.44 
Dementia (prior and current)     
    No 1,014,027 3.11 3,794,756 0.34 
    Yes 135,541 23.74 85,536 9.12 
Delirium (prior and current)     
    No 1,132,974 5.40 3,870,790 0.52 
    Yes 16,594 15.13 9,502 6.77 
Incontinence (prior and current)     
    No 1,107,032 5.31 3,840,140 0.52 
    Yes 42,536 11.59 40,152 2.24 
Other comorbidity     
    0 481,633 4.48 2,783,304 0.34 
    1 305,544 5.05 761,414 0.75 
    2 171,742 6.43 226,250 1.36 
    3 or more 190,649 8.24 109,324 2.21 
Region     
    New England 57,429 7.18 210,336 0.60 
    Middle Atlantic 163,573 6.71 537,625 0.53 
    East North Central 203,366 6.23 695,562 0.58 
    West South Central 91,833 5.29 313,452 0.69 
    South Atlantic 247,029 5.05 800,981 0.51 
    East South Central 94,416 5.36 265,549 0.45 
    West South Central 128,670 5.21 400,981 0.58 
    Mountain 54,711 3.77 211,561 0.43 
    Pacific 98,746 4.78 398,085 0.45 
Admission year     
    1996 88,155 5.61 308,838 0.54 
    1997 88,168 5.73 297,504 0.55 
    1998 87,477 5.87 290,902 0.56 
    1999 87,310 5.77 286,026 0.53 
    2000 85,805 5.80 285,886 0.53 
    2001 88,234 5.53 290,110 0.064 
    2002 91,745 5.66 299,079 0.56 
    2003 90,693 5.61 308,345 0.52 
    2004 93,023 5.52 313,396 0.50 
    2005 92,671 5.36 311,372 0.47 
    2006 89,534 5.46 301,795 0.50 
    2007 84,242 5.00 296,029 0.52 
    2008 82,511 5.15 291,010 0.56 
*

Notes: All differences in percentages between the hospitalized vs. nonhospitalized patients and all differences in percentages between categories within the hospitalized and nonhospitalized groups (eg, age categories, gender, etc.) were significant by chi-square with p > .0001.

In a multivariable analysis, including both the hospitalized and nonhospitalized cohorts and controlling for the factors listed in Table 1, prior hospitalization was associated with a 5.31 higher odds of subsequent residence in long-term care. Looking at total new nursing home placements in the hospitalized and nonhospitalized groups, prior hospitalization was associated with 75.11% of all nursing home placements.

All subsequent analyses in this study involve risk of subsequent nursing home residence in hospitalized patients. Table 2 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 sixfold higher in patients with a dementia diagnosis and were also increased in patients with other comorbidities. 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.

Table 2.

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

Characteristics OR 95% CI 
Year (each 1 year increase) 0.96 0.96–0.96 
Age group   
    66–74  
    75–84 1.86 1.82–1.91 
    85–94 3.56 3.47–3.65 
    95+ 5.58 5.30–5.88 
Gender   
    Male  
    Female 1.41 1.38–1.43 
Race group   
    White  
    Black 1.04 1.01–1.07 
    Other 0.96 0.92–1.01 
Has primary care physician 0.75 0.74–0.77 
Dementia 6.15 6.04–6.26 
Incontinence 1.50 1.45–1.56 
Delirium 1.39 1.33–1.46 
Other comorbidity   
    0  
    1 1.16 1.13–1.18 
    2 1.43 1.39–1.47 
    3+ 1.92 1.87–1.96 
Region   
    Mountain  
    New England 1.62 1.53–1.72 
    Middle Atlantic 1.56 1.48–1.64 
    East North Central 1.56 1.48–1.64 
    West North Central 1.48 1.40–1.56 
    South Atlantic 1.23 1.17–1.30 
    East South Central 1.27 1.20–1.34 
    West South Central 1.25 1.19–1.32 
    Pacific 1.14 1.08–1.21 
Diagnosis related group   
    Circulatory  
    Central nervous system 2.23 2.17–2.30 
    Respiratory 1.33 1.29–1.37 
    Gastrointestinal 1.07 1.04–1.11 
    Musculoskeletal 1.92 1.86–1.98 
    Endocrine 1.78 1.72–1.84 
    Other 1.83 1.78–1.88 
    Emergency admission 1.46 1.44–1.49 
Metropolitan area size (thousands)   
 <100  
    100–249 0.98 0.92–1.04 
    250–999 1.01 0.98–1.04 
    ≥1,000 1.04 1.02–1.07 
Hospital teaching status   
    Nonteaching  
    Major 0.88 0.86–0.90 
    Minor 0.97 0.95–0.99 
Hospital type   
    For profit  
    Nonprofit 0.98 0.95–1.00 
    Government 1.03 0.99–1.07 
Hospital size (beds)   
    500+  
    <200 1.19 1.16–1.23 
    200–349 1.07 1.04–1.10 
    350–499 1.05 1.02–1.08 
Characteristics OR 95% CI 
Year (each 1 year increase) 0.96 0.96–0.96 
Age group   
    66–74  
    75–84 1.86 1.82–1.91 
    85–94 3.56 3.47–3.65 
    95+ 5.58 5.30–5.88 
Gender   
    Male  
    Female 1.41 1.38–1.43 
Race group   
    White  
    Black 1.04 1.01–1.07 
    Other 0.96 0.92–1.01 
Has primary care physician 0.75 0.74–0.77 
Dementia 6.15 6.04–6.26 
Incontinence 1.50 1.45–1.56 
Delirium 1.39 1.33–1.46 
Other comorbidity   
    0  
    1 1.16 1.13–1.18 
    2 1.43 1.39–1.47 
    3+ 1.92 1.87–1.96 
Region   
    Mountain  
    New England 1.62 1.53–1.72 
    Middle Atlantic 1.56 1.48–1.64 
    East North Central 1.56 1.48–1.64 
    West North Central 1.48 1.40–1.56 
    South Atlantic 1.23 1.17–1.30 
    East South Central 1.27 1.20–1.34 
    West South Central 1.25 1.19–1.32 
    Pacific 1.14 1.08–1.21 
Diagnosis related group   
    Circulatory  
    Central nervous system 2.23 2.17–2.30 
    Respiratory 1.33 1.29–1.37 
    Gastrointestinal 1.07 1.04–1.11 
    Musculoskeletal 1.92 1.86–1.98 
    Endocrine 1.78 1.72–1.84 
    Other 1.83 1.78–1.88 
    Emergency admission 1.46 1.44–1.49 
Metropolitan area size (thousands)   
 <100  
    100–249 0.98 0.92–1.04 
    250–999 1.01 0.98–1.04 
    ≥1,000 1.04 1.02–1.07 
Hospital teaching status   
    Nonteaching  
    Major 0.88 0.86–0.90 
    Minor 0.97 0.95–0.99 
Hospital type   
    For profit  
    Nonprofit 0.98 0.95–1.00 
    Government 1.03 0.99–1.07 
Hospital size (beds)   
    500+  
    <200 1.19 1.16–1.23 
    200–349 1.07 1.04–1.10 
    350–499 1.05 1.02–1.08 

Note: OR = odds ratio.

Patients cared for in larger hospitals and major teaching hospitals were less likely to be in a long-term care nursing home 6 months after discharge. In Tables 1 and 2, there were also regional differences in posthospitalization nursing home placement. These are further explored in Figure 1, which shows rates of nursing residence 6 months after hospitalization for those aged 75 years and older hospitalized in 2007 or 2008 in the 306 health referral regions in the United States. In general, rates were lower in the Western states. The rates range from less than 2% in Bend, OR and Grand Forks, ND, to greater than 13% in Johnson City, TN and Temple, TX.

Figure 1.

Percentage of beneficiaries 75 years and older in a nursing home 6 months after hospitalization across health referral regions, 5% Medicare sample, 2007–2008.

Figure 1.

Percentage of beneficiaries 75 years and older in a nursing home 6 months after hospitalization across health referral regions, 5% Medicare sample, 2007–2008.

The yearly decline in adjusted odds of nursing home residence after hospitalization from 1996 to 2008 in the multivariable analyses was greater than the decrease in the actual percentage of patients in a nursing home after hospitalization in the unadjusted analyses (Table 1). That was due to an increase over time in the prevalence of risk factors for nursing home residence. For example, the median age of the hospitalized cohort in 2008 was 2 years older than in 1996. There was a significant interaction (p < .0001) between age of the patient and year of hospitalization on risk of subsequent institutionalization. This is shown in Figure 2, which presents time trends in percentage of patients in nursing homes 6 months after hospitalization, stratified by age. There is a clear decline over time in the institutionalization rate for participants in the oldest age categories, for example, for those aged 85+ years, from 14.63% in 1996 to 11.38% in 2008, a 23% decline, with virtually no change in the rate for those aged 65–74 years.

Figure 2.

Percentage of beneficiaries living in a nursing home 6 months after hospitalization, by age of patient and year of hospitalization.

Figure 2.

Percentage of beneficiaries living in a nursing home 6 months after hospitalization, by age of patient and year of hospitalization.

We also assessed the association of discharge location on subsequent risk of nursing home residence. In a multivariable analysis containing all the variables in Table 2, transfer to an SNF on hospital discharge conveyed the largest risk of subsequent long-term care (odds ratio = 10.83, 95% CI = 10.60, 11.06). The percentage of hospitalized Medicare patients transferred to SNF on discharge also increased over time, from 10.8% in 1996 to 16.5% in 2008. In multivariable analyses on odds of subsequent nursing home residence, there was a significant interaction (p < .001) between year of hospitalization and discharge location. Patients who were discharged directly home experienced a 6.2% yearly decrease from 1996 to 2008 in odds of nursing home residence 6 months later, versus a 4.1% yearly decrease in those discharged to a SNF. In 1996, 50.4% of the patients who were in a nursing home 6 months after a hospitalization had first been transferred to a SNF on hospital discharge. This increased to 64.7% by 2008.

In the analyses presented, we deleted the 55,997 patients who died during the 90-day window where we assessed nursing home care. If they are included, the overall rate of nursing home placement posthospitalization is 5.9% (compared with 5.6%). None of the results of other analyses were appreciably altered by their inclusion.

DISCUSSION

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.

Several points bear emphasis. First, we assessed traditional nursing home residence, not short-term posthospital stays in SNFs. We chose a time window of 135–225 days after hospital discharge because we were interested in long-term institutionalization.

Second, there was a steady decrease over time in overall risk of long-term nursing home residence after hospitalization, in analyses adjusting for risk factors for institutionalization. These decreases in risk were greatest for certain categories of patients at high risk for institutionalization, such as the oldest old. The decrease in risk of nursing home placement for these oldest patients may be due to the growth of community-based alternatives such as assisted living facilities. On the other hand, because of the increasing age of the Medicare population, the overall unadjusted rate of institutionalization after hospitalization declined only slightly over time (Table 1).

Third, the trajectory from hospitalization to long-term care also changed over time. By 2008, most patients who were in long-term care 6 months after hospitalization were first transferred to a SNF on hospital discharge, with later placement in long-term care. The risk of long-term institutionalization after hospitalization for patients transferred home was quite low and decreased over time.

Fourth, there are marked geographic variations in risk of nursing home residence after a hospitalization, with most of the health referral regions with low rates in the Midwest and West. Similar geographic variation in hospitalization rates for some chronic conditions such as asthma or congestive heart failure contributed to the realization that many of those admissions were potentially preventable—so called ambulatory-sensitive admissions (26,27). A similar lesson might be drawn from the geographic variations in long-term institutionalization after hospitalization.

The link between hospitalization and subsequent long-term institutionalization may proceed along several causal pathways. First, an acute event such as a stroke or myocardial infarction that precipitates a hospitalization can permanently change functional status, requiring some sort of long-term care. Second, the hospitalization process itself can be accompanied by deconditioning, which, if not appropriately prevented or treated, can result in loss of function and independence. Finally, the process of institutionalization itself may promote continued institutionalization. As more patients are discharged to SNFs, which are often coupled with a long-term nursing home, the decision to transfer to a patient to long-term care might be facilitated.

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). Kane has recently discussed the pivotal role for knowledgeable physicians in facilitating appropriate decisions among long-term care options (31). The overall availability of PCPs and the percentage of hospitalized patients seen by their PCPs are both declining (32,33). Such discontinuities often result in patients receiving care by physicians unfamiliar with their values and wishes, which may in turn lead to less than optimal choices, such as nursing home placement. We also examined those patients 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).

This study has a number of limitations. First, the findings relate to enrollees aged 66 years and older with parts A and B Medicare not in an health maintenance organization. Younger patients and patients enrolled in an health maintenance organization may have different risks for long-term care after hospitalization. Second, administrative data such as the Medicare data used in these analyses do not contain information on important risk factors for institutionalization such as poor social support and impaired functional status (5,7,8,21,35). Also missing is information on preferences of individual patients (4,36). The role of rehospitalization after the initial hospitalization was not assessed in these analyses. Finally, we do not assess survival of the patients admitted to long-term care nursing homes (37).

The results presented here are highly relevant to efforts to continue the reductions in institutionalization of the elderly. First, as mentioned earlier, the substantial geographical variation in risk of nursing home placement suggests that many nursing home admissions may be preventable. It is not plausible that the risk factors for institutionalization would vary across geographical areas as much as the variation seen in the rates of nursing home placement after hospitalization. Second, because 75% of all nursing home placements in the Medicare population are preceded, and presumably precipitated, by a hospitalization, then an appropriate time to initiate programs to prevent long-term institutionalization is at hospitalization. Indeed, residence in a nursing home at 6 months postdischarge could evolve as a quality outcome of hospitalization. Another point for potential intervention is during an SNF stay, which now occurs in almost two thirds of all patients who go into long-term care after hospitalization. Medicare data could be used to determine whether SNFs vary in their success in discharging posthospitalization patients back to the community.

In conclusion, 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.

FUNDING

National Institutes of Health (grants R01 AG033134, K05 CA134923, and P30 AG024832).

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Author notes

Decision Editor: Luigi Ferrucci, MD, PhD