title: Hospital Variation in Rates of New Institutionalizations Within 6 Months of Discharge.
abstract: OBJECTIVE
  Hospitalization in community-dwelling elderly is often accompanied by functional loss, increasing the risk for continued functional decline and future institutionalization. The primary objective of our study was to examine the hospital-level variation in rates of new institutionalizations among Medicare beneficiaries.
  
  
  METHODS
  Retrospective cohort study.
  
  
  METHODS
  Hospitals and nursing homes.
  
  
  METHODS
  Medicare fee-for-service beneficiaries discharged from 4,469 hospitals in 2013 (N = 4,824,040).
  
  
  METHODS
  New institutionalization, defined as new long term care nursing home residence (not skilled nursing facility) of at least 90 days duration within 6 months of hospital discharge.
  
  
  RESULTS
  The overall observed rate of new institutionalizations was 3.6% (N = 173,998). Older age, white race, Medicaid eligibility, longer hospitalization, and having a skilled nursing facility stay over the 6 months before hospitalization were associated with higher adjusted odds. Observed rates ranged from 0.9% to 5.9% across states. The variation in rates attributable to the hospital after adjusting for case-mix and state was 5.1%. Odds were higher for patients treated in smaller (OR = 1.36, 95% CI: 1.27-1.45, ≤50 vs >500 beds), government owned (OR = 1.15, 95% CI: 1.09-1.21 compared to for-profit), limited medical school affiliation (OR = 1.13, 95% CI: 1.07-1.19 compared to major) hospitals and lower for patients treated in urban hospitals (OR = 0.79, 95% CI: 0.76-0.82 compared to rural). Higher Summary Star ratings (OR = 0.75, 95% CI: 0.67-0.93, five vs one stars) and Overall Hospital Rating (OR = 0.62, 95% CI: 0.57-0.67, ratings of 9-10 vs 0) were associated with lower odds of institutionalization.
  
  
  CONCLUSIONS
  Hospitalization may be a critical period for preventing future institutionalization among elderly patients. The variation in rates across hospitals and its association with hospital quality ratings suggest some of these institutionalizations are avoidable and may represent targets for care improvement.
authors.affiliation: Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, Texas.
authors.forename: Addie
authors.initials: A
authors.lastname: Middleton
authors.affiliation: Sealy Center on Aging, University of Texas Medical Branch, Galveston, Texas.
authors.forename: Jie
authors.initials: J
authors.lastname: Zhou
authors.affiliation: Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, Texas.
authors.forename: Kenneth J
authors.initials: KJ
authors.lastname: Ottenbacher
authors.affiliation: Division of Geriatric Medicine, Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas.
authors.forename: James S
authors.initials: JS
authors.lastname: Goodwin
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D005006:Ethnicity; D005260:Female; D006761:Hospitals; D006801:Humans; D008297:Male; D008484:Medicaid; D006278:Medicare; D009735:Nursing Homes / Q000706:statistics & numerical data*; D010351:Patient Discharge; D012189:Retrospective Studies; D014481:United States
keywords: elderly; functional status; hospital ratings; nursing home; quality of care