title: Utilization of acute care among patients with ESRD discharged home from skilled nursing facilities.
abstract: OBJECTIVE
  Older adults with ESRD often receive care in skilled nursing facilities (SNFs) after an acute hospitalization; however, little is known about acute care use after SNF discharge to home.
  
  
  METHODS
  This study used Medicare claims for North and South Carolina to identify patients with ESRD who were discharged home from a SNF between January 1, 2010 and August 31, 2011. Nursing Home Compare data were used to ascertain SNF characteristics. The primary outcome was time from SNF discharge to first acute care use (hospitalization or emergency department visit) within 30 days. Cox proportional hazards models were used to identify patient and facility characteristics associated with the outcome.
  
  
  RESULTS
  Among 1223 patients with ESRD discharged home from a SNF after an acute hospitalization, 531 (43%) had at least one rehospitalization or emergency department visit within 30 days. The median time to first acute care use was 37 days. Characteristics associated with a shorter time to acute care use were black race (hazard ratio [HR], 1.25; 95% confidence interval [95% CI], 1.04 to 1.51), dual Medicare-Medicaid coverage (HR, 1.24; 95% CI, 1.03 to 1.50), higher Charlson comorbidity score (HR, 1.07; 95% CI, 1.01 to 1.12), number of hospitalizations during the 90 days before SNF admission (HR, 1.12; 95% CI, 1.03 to 1.22), and index hospital discharge diagnoses of cellulitis, abscess, and/or skin ulcer (HR, 2.59; 95% CI, 1.36 to 4.45). Home health use after SNF discharge was associated with a lower rate of acute care use (HR, 0.72; 95% CI, 0.59 to 0.87). There were no statistically significant associations between SNF characteristics and time to first acute care use.
  
  
  CONCLUSIONS
  Almost one in every two older adults with ESRD discharged home after a post-acute SNF stay used acute care services within 30 days of discharge. Strategies to reduce acute care utilization in these patients are needed.
authors: Durham Veterans Affairs Geriatric Research, Education, and Clinical Center, Durham, North Carolina; Divisions of Nephrology and rasheeda.stephens@duke.edu.
authors: Rasheeda K
authors: RK
authors: Hall
authors: University of North Carolina at Chapel Hill, Chapel Hill, North Carolina;
authors: Mark
authors: M
authors: Toles
authors: University of North Carolina at Chapel Hill, Chapel Hill, North Carolina;
authors: Mark
authors: M
authors: Massing
authors: Carolinas Center for Medical Excellence Inc, Cary, North Carolina;
authors: Eric
authors: E
authors: Jackson
authors: Carolinas Center for Medical Excellence Inc, Cary, North Carolina;
authors: Sharon
authors: S
authors: Peacock-Hinton
authors: Hospital and Specialty Medicine and Health Services R&D Center of Excellence, Veterans Affairs Puget Sound Healthcare System, Seattle, Washington; and Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington.
authors: Ann M
authors: AM
authors: O'Hare
authors: Durham Veterans Affairs Geriatric Research, Education, and Clinical Center, Durham, North Carolina; Geriatrics, Department of Medicine, Duke University Medical Center, Durham, North Carolina;
authors: Cathleen
authors: C
authors: Colón-Emeric
mesh_terms: D000038:Abscess / Q000453:epidemiology; D001741:Black or African American / Q000706:statistics & numerical data; D000368:Aged; D000369:Aged, 80 and over; D002481:Cellulitis / Q000453:epidemiology; D015897:Comorbidity; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D018574:Home Care Agencies / Q000706:statistics & numerical data; D006801:Humans; D019458:Insurance Coverage / Q000706:statistics & numerical data; D007676:Kidney Failure, Chronic / Q000401:mortality / Q000451:nursing; D008297:Male; D008484:Medicaid / Q000706:statistics & numerical data; D006278:Medicare / Q000706:statistics & numerical data; D010351:Patient Discharge / Q000706:statistics & numerical data; D010359:Patient Readmission / Q000706:statistics & numerical data*; D012866:Skilled Nursing Facilities; D012883:Skin Ulcer / Q000453:epidemiology; D013997:Time Factors; D014481:United States / Q000453:epidemiology
keywords: frail elderly; nursing home; renal failure
references: Arch Phys Med Rehabil. 2004 Jan;85(1):51-3
references: 14970967
references: J Am Geriatr Soc. 2004 May;52(5):675-84
references: 15086645
references: Milbank Q. 2004;82(2):227-56
references: 15225329
references: J Clin Epidemiol. 1992 Jun;45(6):613-9
references: 1607900
references: Ann Intern Med. 1993 Oct 15;119(8):844-50
references: 8018127
references: J Gerontol B Psychol Sci Soc Sci. 1998 Mar;53(2):S104-12
references: 9520935
references: Arch Intern Med. 2006 Sep 25;166(17):1822-8
references: 17000937
references: Adv Chronic Kidney Dis. 2007 Oct;14(4):402-8
references: 17904507
references: Health Serv Res. 2008 Jun;43(3):1025-42
references: 18454779
references: Ann Intern Med. 2009 Feb 3;150(3):178-87
references: 19189907
references: N Engl J Med. 2009 Apr 2;360(14):1418-28
references: 19339721
references: N Engl J Med. 2009 Oct 15;361(16):1612-3
references: 19828543
references: Kidney Int. 2009 Aug;76(3):331-41
references: 19516243
references: Health Aff (Millwood). 2011 Apr;30(4):746-54
references: 21471497
references: Health Serv Res. 2012 Jun;47(3 Pt 2):1300-21
references: 22515953
references: J Am Med Dir Assoc. 2013 Oct;14(10):736-40
references: 23608528
references: J Palliat Med. 2013 Dec;16(12):1515-22
references: 24206008
references: J Am Soc Nephrol. 2014 Feb;25(2):370-9
references: 24158988
references: JAMA. 2014 Feb 12;311(6):604-14
references: 24519300
references: Ann Intern Med. 2014 Jun 3;160(11):774-84
references: 24862840
references: J Am Geriatr Soc. 2014 Jan;62(1):79-85
references: 24383890
references: J Am Soc Nephrol. 2014 Sep;25(9):2079-87
references: 24812168
references: J Vasc Surg. 2014 Nov;60(5):1315-24
references: 24985536
references: J Am Geriatr Soc. 2003 Apr;51(4):556-7
references: 12657079
references: Am J Med Sci. 2002 Feb;323(2):65-71
references: 11863081