ABSTRACT
Background
Hospitalization rates from nursing homes (NHs) have gained traction as pragmatic quality measures that can be derived from claims data. However, claims-based hospitalization measures do not account for clinical complexity and the extent to which they reflect quality of care or quality of transfer decision making is unknown. We aim to examine agreement between a claims-based measure of potentially avoidable hospitalizations and expert clinician review of transfer decision making and care quality.
Methods
We randomly selected 252 hospital transfers across eight Veterans Administration (VA) NHs, known as Community Living Centers (CLCs). Eleven expert clinicians independently completed Structured Implicit Reviews (SIRs) of medical records to assess: (1) whether the transfer decision was appropriate (i.e., hospital was the lowest safe level-of-care given the resident’s acute condition); (2) quality of care for evaluation or treatment of the acute change (adequate management of acute change), (3) quality of care for chronic conditions and preventing decline. We used VA Corporate Data Warehouse (CDW) data to determine a claims-based measure of potentially avoidable hospitalization.
Results
CDW data were available for 242 VA hospitalizations. The claims-based measure categorized 29 (12%) hospitalizations as potentially avoidable; only 2 of which matched the 20 SIR identified as inappropriate decisions to transfer. Furthermore, the claims-based measure flagged only 5 of 33 cases rated as inadequate treatment of acute decline and 6 of 17 rated as poor quality of chronic disease or preventive care.
Conclusions
In a geographically diverse sample of CLC transfers, independent clinical experts’ judgments of transfer decision appropriateness, quality of care for acute decline, and quality of chronic care differ from a claims-based potentially avoidable hospitalizations measure. Findings underscore the need for nuanced clinical consideration of hospitalization metrics for assessing quality and for understanding which aspects of care should be addressed to safely reduce NH transfers to hospitals.