title: Hospital-skilled nursing facility referral linkage reduces readmission rates among Medicare patients receiving major surgery.
abstract: BACKGROUND
  In the health reform era, rehospitalization after discharge may result in financial penalties to hospitals. The effect of increased hospital-skilled nursing facility (SNF) linkage on readmission reduction after surgery has not been explored.
  
  
  METHODS
  To determine whether enhanced hospital-SNF linkage, as measured by the proportion of surgical patients referred from a hospital to a particular SNF, would result in reduced 30-day readmission rates for surgical patients, we used national Medicare data (2011-2012) and evaluated patients who underwent 1 of 5 operative procedures (coronary artery bypass grafting [CABG], hip fracture repair, total hip arthroplasty, colectomy, or lumbar spine surgery). Initial evaluation was performed using regression modeling. Patient choice in SNF referral was adjusted for using instrumental variable (IV) analysis with distance between an individuals' home and the SNF as the IV.
  
  
  RESULTS
  A strong negative correlation (P < .001) was observed between the proportion of selected surgical discharges received by a SNF and the rate of hospital readmission. Increasing the proportion of surgical discharges decreased the likelihood of rehospitalization (regression coefficient, -0.04; 95% CI, -0.07 to -0.02). These findings were preserved in IV analysis. Increasing hospital-SNF linkage was found to reduce significantly the likelihood of readmission for patients receiving lumbar spine surgery, CABG, and hip fracture repair.
  
  
  CONCLUSIONS
  The benefits of increased hospital-SNF linkage seem to include meaningful reductions in hospital readmission after surgery. Overall, a 10% increase in the proportion of surgical referrals to a particular SNF is estimated to decrease readmissions by 4%. This may impact hospital-SNF networks participating in risk-based reimbursement models.
authors.affiliation: Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA. Electronic address: ajschoen@neomed.edu.
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Schoenfeld
authors.affiliation: Department of Health Services, Policy, and Practice, Brown University, Providence, RI.
authors.forename: Xuan
authors.initials: X
authors.lastname: Zhang
authors.affiliation: Department of Health Care Policy, Harvard Medical School, Boston, MA.
authors.forename: David C
authors.initials: DC
authors.lastname: Grabowski
authors.affiliation: Department of Health Services, Policy, and Practice, Brown University, Providence, RI; Health Services Research, Providence Veterans Administration Medical Center, Providence, RI.
authors.forename: Vincent
authors.initials: V
authors.lastname: Mor
authors.affiliation: Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
authors.forename: Joel S
authors.initials: JS
authors.lastname: Weissman
authors.affiliation: Department of Health Services, Policy, and Practice, Brown University, Providence, RI.
authors.forename: Momotazur
authors.initials: M
authors.lastname: Rahman
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003266:Continuity of Patient Care / Q000458:organization & administration* / Q000706:statistics & numerical data; D016208:Databases, Factual; D005260:Female; D006801:Humans; D008297:Male; D006278:Medicare; D010359:Patient Readmission / Q000706:statistics & numerical data*; D012017:Referral and Consultation / Q000458:organization & administration* / Q000706:statistics & numerical data; D012866:Skilled Nursing Facilities; D013514:Surgical Procedures, Operative; D014481:United States
references.citation: Spine J. 2014 Dec 1;14(12):2793-8
references.pmid: 25017141
references.citation: Ann Thorac Surg. 2014 Apr;97(4):1214-8
references.pmid: 24492060
references.citation: Med Care Res Rev. 2014 Aug;71(4):384-401
references.pmid: 24830381
references.citation: Crit Care Med. 2015 May;43(5):989-95
references.pmid: 25746747
references.citation: Soc Sci Med. 2009 Mar;68(5):933-40
references.pmid: 19128865
references.citation: Pharmacoepidemiol Drug Saf. 2014 Sep;23(9):891-901
references.pmid: 24962929
references.citation: Med Care. 1998 Jan;36(1):8-27
references.pmid: 9431328
references.citation: Gerontologist. 2008 Aug;48(4):464-76
references.pmid: 18728296
references.citation: Gerontologist. 2003 Apr;43(2):175-91
references.pmid: 12677075
references.citation: Health Serv Res. 2013 Dec;48(6 Pt 1):1898-919
references.pmid: 24134773
references.citation: Health Aff (Millwood). 2011 Nov;30(11):2107-15
references.pmid: 22068403
references.citation: JAMA Surg. 2013 Jun;148(6):549-54
references.pmid: 23426556
references.citation: Health Aff (Millwood). 2014 Jun;33(6):972-9
references.pmid: 24889946
references.citation: Hosp Health Serv Adm. 1997 Summer;42(2):179-91
references.pmid: 10167453
references.citation: J Clin Epidemiol. 1992 Jun;45(6):613-9
references.pmid: 1607900
references.citation: Med Care Res Rev. 2006 Jun;63(3):347-68
references.pmid: 16651397
references.citation: Dis Colon Rectum. 2011 Nov;54(11):1362-7
references.pmid: 21979179
references.citation: Med Care. 2011 Jun;49(6):545-52
references.pmid: 21577182
references.citation: Milbank Q. 2004;82(2):227-56
references.pmid: 15225329
references.citation: Ann Am Thorac Soc. 2013 Jun;10(3):255-60
references.pmid: 23802827
references.citation: JAMA Surg. 2014 Aug;149(8):829-36
references.pmid: 24988945
references.citation: Med Care. 1999 Mar;37(3):228-37
references.pmid: 10098567
references.citation: Lancet. 2015 Aug 29;386(9996):837-9
references.pmid: 26093916
references.citation: Health Serv Res. 2014 Jun;49(3):798-817
references.pmid: 24354695
references.citation: Gerontologist. 2011 Oct;51(5):610-6
references.pmid: 21602292
references.citation: J Health Econ. 2015 Jan;39:1-16
references.pmid: 25461895