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: – – Resident’s 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) 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

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