title: Which clinical indicators and resident characteristics are associated with health care practitioner nursing home visits or hospital transfer for urinary tract infections?
abstract: OBJECTIVE
  (1) To determine factors associated with practitioner visitation and/or hospital transfer for skilled nursing facility (SNF) patients who develop a urinary tract infection (UTI) and (2) to determine if SNF patients with a Do Not Resuscitate (DNR) directive are less likely to be personally assessed and/or transferred to the hospital in the event of a UTI when compared to patients without a DNR directive.
  
  
  METHODS
  Retrospective cohort study using nursing home medical record review.
  
  
  METHODS
  Participants were 564 residents from 35 nursing homes in 3 states who became acutely ill with UTI during the first 90 days of their nursing home admission. They were identified from 2832 random nursing home Medicare admissions and divided into 2 groups, those with DNR directives (n = 334) and those without (n = 230).
  
  
  METHODS
  Logistic regression was used to determine factors associated with practitioner in-person assessment and/or hospitalization, and to determine differences in the likelihood of practitioner in-person assessment and/or hospitalization among those with DNR directives versus those without DNR directives.
  
  
  RESULTS
  Only one third (29%) of patients with unstable vital signs were seen by a practitioner or transferred to a hospital. Factors associated with practitioner assessment or hospital transfer were elevated temperature (OR 1.7, CI 1.04-2.64), pulse more than 100 beats per minute (OR 1.7, CI 1.01-2.99), and delirium (OR 2.1, CI 1.267-3.44). White residents were less likely to be assessed by a practitioner or transferred to a hospital (OR 0.45, CI 0.22-0.95). DNR directives were not significantly associated with fewer in-person assessments (P = .067).
  
  
  CONCLUSIONS
  Only one third of SNF patients who developed a UTI with unstable vital signs were personally assessed by a practitioner and/or hospitalized. Patients with delirium were twice as likely to be assessed or transferred to a hospital, suggesting that practitioners use delirium as an indicator of illness severity. However, practitioner visit or transfer was also associated with ethnic background. In the absence of good evidence regarding which nursing home residents are likely to benefit from hospitalization or an urgent practitioner visit, these care decisions will continue to be associated with factors that are unknown.
authors.affiliation: Division of Health Care Policy and Research, University of Colorado Health Sciences Center, Aurora, CO 80011, USA. cari.levy@uchsc.edu <cari.levy@uchsc.edu>
authors.forename: Cari R
authors.initials: CR
authors.lastname: Levy
authors.forename: Terry
authors.initials: T
authors.lastname: Eilertsen
authors.forename: Andrew M
authors.initials: AM
authors.lastname: Kramer
authors.forename: Evelyn
authors.initials: E
authors.lastname: Hutt
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D005260:Female; D006282:Health Personnel; D006305:Health Status Indicators; D006760:Hospitalization; D006801:Humans; D016015:Logistic Models; D008297:Male; D008485:Medical Audit; D008875:Middle Aged; D010360:Patient Transfer; D010818:Practice Patterns, Physicians'; D012189:Retrospective Studies; D012866:Skilled Nursing Facilities; D014481:United States / Q000453:epidemiology; D014552:Urinary Tract Infections