Hospitalizations Among Nursing Home Residents with Pneumonia

1
Hospitalizations Among Nursing Home Residents
with Pneumonia

• R. Tamara Hodlewsky, MA, MS
• William Spector, PhD
• Tom Shaffer, MHS

2
Purpose of the Study

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

3
Importance

• Approximately 14 of 1.7 million nursing facility
  residents get pneumonia during the course of a
  year
• Hospitalization is expensive
• Appropriateness of hospitalization not always
  clear
• Stress of transfer
• Risk of nosocomial infection

4
Literature Review Large Studies

• Larger studies of hospitalization not focused on
  pneumonia (Freiman Murtaugh, 1993 Intrator et
  al., 1999 Garrard/Kane et al., 1990)
• Hospitalization positively associated with
• Male, Age (up to age 85)
• ADL dependency
• For-profit status of facility
• Hospitalization negatively associated with
• Residents tenure in facility
• Higher professional staffing

5
Literature Review Smaller Studies

• Smaller studies including clinical data were
  specific to hospitalization for pneumonia among
  nursing home residents
• Thompson et al (1997 and 1999) no significant
  differences in clinical risk factors between
  hospitalized and unhospitalized
• 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.

6
Literature Review Conclusion

• Risk factors for hospitalization for pneumonia
  remain unclear
• No large-scale, national studies of
  hospitalization from nursing homes focusing on
  pneumonia

7
Hypotheses

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

8
Data

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

9
Capturing Pneumonia

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

10
Pneumonia Hospitalizations

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

11
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

12
Resident-Level Variables

• ADL dependence
• Incontinence
• Cognitive performance
• Trouble chewing
• Trouble swallowing
• Body Mass Index
• Heart Disease
• Cancer
• Emphysema/COPD

• Stroke
• Depression
• Other comorbidities
• DNH advance directive
• Gender
• Race
• Level of education
• Age 95

13
Facility-Level Variables

• For-profit, not-for-profit, or government status
• Chain or independent
• Rural or urban
• Total number of beds
• Percent of beds certified for Medicare

• RN- and LPN- to resident ratio
• Nurse aide-to-resident ratio
• Skilled nursing services offered tube-feeding,
  IV therapy, isolation, dialysis, ventilator care

14
Preliminary Results Facility-Level(Dep. Var.
Hospitalization)

• Not-for-profit status (negative)
• RNLPN-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)
• plt.05

15
Preliminary Results Resident-Level (Dep. Var.
Hospitalization)

• Problems chewing (negative)
• Cancer (negative)
• Depression (positive)
• High school education (negative)
• Education beyond high school (negative)
• plt.05
• plt.10

16
Limitations

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

17
Key Findings of No Statistical Significance

• Race and gender
• Urban/rural
• Chain/Independent

18
Implications

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

19
Next Steps

• Sensitivity Analyses
• More input on clinical significance of risk
  factors and magnitudes of effects