title: Is a Skilled Nursing Facility's Rehospitalization Rate a Valid Quality Measure?
abstract: OBJECTIVE
  To determine whether the observed differences in the risk-adjusted rehospitalization rates across skilled nursing facilities (SNFs) reflect true differences or merely differences in patient severity.
  
  
  METHODS
  Elderly Medicare beneficiaries newly admitted to an SNF following hospitalization.
  
  
  METHODS
  We used 2009-2012 Medicare data to calculate SNFs' risk-adjusted rehospitalization rate. We then estimated the effect of these rehospitalization rates on the rehospitalization of incident patients in 2013, using an instrumental variable (IV) method and controlling for patient's demographic and clinical characteristics and residential zip code fixed effects. We used the number of empty beds in a patient's proximate SNFs during hospital discharge to create the IV.
  
  
  RESULTS
  The risk-adjusted rehospitalization rate varies widely; about one-quarter of the SNFs have a rehospitalization rate lower than 17 percent, and for one-quarter, it is higher than 23 percent. All the IV models result in a robust finding that an increase in a SNF's rehospitalization rate of 1 percentage point over the period 2009-2012 leads to an increase in a patient's likelihood of rehospitalization by 0.8 percentage points in 2013.
  
  
  CONCLUSIONS
  Treatment in SNFs with historically low rehospitalization causally reduces a patient's likelihood of rehospitalization. Observed differences in rehospitalization rates reflect true differences and are not an artifact of selection.
authors.affiliation: Department of Health Services Policy and Practice, Brown University, Providence, RI.
authors.forename: Momotazur
authors.initials: M
authors.lastname: Rahman
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 Program, Providence Veterans Administration Medical Center, Providence, RI.
authors.forename: Vincent
authors.initials: V
authors.lastname: Mor
authors.affiliation: Department of Health Management and Policy and Department of Economics, University of Michigan, Ann Arbor, MI.|National Bureau of Economic Research, Cambridge, MA.
authors.forename: Edward C
authors.initials: EC
authors.lastname: Norton
mesh_terms: D000368:Aged; D006760:Hospitalization; D006801:Humans; D007345:Insurance Claim Review; D006278:Medicare / Q000706:statistics & numerical data; D010351:Patient Discharge / Q000706:statistics & numerical data; D010359:Patient Readmission / Q000706:statistics & numerical data*; D019984:Quality Indicators, Health Care; D012866:Skilled Nursing Facilities / Q000706:statistics & numerical data*; D014481:United States
keywords: 
  ACA
  ; Skilled nursing facility; quality of care; readmission; rehospitalization