Hospital Transfer Rates among US Nursing Home Residents with Advanced Illness before and after Initiatives to Reduce Hospitalizations

Ellen P. McCarthy, Jessica A. Ogarek, Lacey Loomer, Pedro L. Gozalo, Vincent Mor, Mary Beth Hamel, Susan L. Mitchell

Research output: Contribution to journalArticlepeer-review

9 Scopus citations


Importance: Hospital transfers among nursing home residents in the United States who have been diagnosed with advanced illnesses and have limited life expectancy are often burdensome, costly, and of little clinical benefit. National initiatives, introduced since 2012, have focused on reducing such hospitalizations, but little is known about the consequences of these initiatives in this population. Objective: To investigate the change in hospital transfer rates among nursing home residents with advanced illnesses, such as dementia, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD), from 2011 to 2017 - before and after the introduction of national initiatives to reduce hospitalizations. Design, Setting, and Participants: In this cross-sectional study, nationwide Minimum Data Set (MDS) assessments from January 1, 2011, to December 31, 2016 (with the follow-up for transfer rates until December 31, 2017), were used to identify annual inception cohorts of long-stay (>100 days) nursing home residents who had recently progressed to the advanced stages of dementia, CHF, or COPD. The data were analyzed from October 24, 2018, to October 3, 2019. Main Outcomes and Measures: The number of hospital transfers (hospitalizations, observation stays, and emergency department visits) per person-year alive was calculated from the MDS assessment from the date when residents first met the criteria for advanced illness up to 12 months afterward using Medicare claims from 2011 to 2017. Transfer rates for all causes, potentially avoidable conditions (sepsis, pneumonia, dehydration, urinary tract infections, CHF, and COPD), and serious bone fractures (pelvis, hip, wrist, ankle, and long bones of arms or legs) were investigated. Hospice enrollment and mortality were also ascertained. Results: The proportions of residents in the 2011 and 2016 cohorts who underwent any hospital transfer were 56.1% and 45.4% of those with advanced dementia, 77.6% and 69.5% of those with CHF, and 76.2% and 67.2% of those with COPD. The mean (SD) number of transfers per person-year alive for potentially avoidable conditions was higher in the 2011 cohort vs 2016 cohort: advanced dementia, 2.4 (14.0) vs 1.6 (11.2) (adjusted risk ratio [aRR], 0.73; 95% CI, 0.65-0.81); CHF, 8.5 (32.0) vs 6.7 (26.8) (aRR, 0.72; 95% CI, 0.65-0.81); and COPD, 7.8 (30.9) vs 5.5 (24.8) (aRR, 0.64; 95% CI, 0.57-0.72). Transfers for bone fractures remained unchanged, and mortality did not increase. Hospice enrollment was low across all illness groups and years (range, 23%-30%). Conclusions and Relevance: The findings of this study suggest that concurrent with new initiatives aimed at reducing hospitalizations, hospital transfers declined between 2011 and 2017 among nursing home residents with advanced illnesses without increased mortality rates. Opportunities remain to further reduce unnecessary hospital transfers in this population and improve goal-directed care for those residents who opt to forgo hospitalization.

Original languageEnglish (US)
Pages (from-to)385-394
Number of pages10
JournalJAMA internal medicine
Issue number3
StatePublished - Mar 2020
Externally publishedYes

Bibliographical note

Funding Information:
Funding/Support: This work was supported by the NIH Common Fund through a cooperative agreement (NIH-NIA UH3AG49619) from the Office of Strategic Coordination within the Office of the NIH Director and by NIH-NIA P01AG027296 and NIH-NIA K24AG033640 (Dr Mitchell) from the NIH.

Funding Information:
reported receiving personal fees from the American Health Care Association outside the submitted work. Ms Loomer reported receiving grants from the National Institutes of Health (NIH) during the conduct of the study and personal fees from the American Health Care Association outside the submitted work. Dr Gozalo reported receiving grants from NIH-National Institute on Aging (NIA) during the conduct of the study. Dr Mor reported receiving grants from NIA and grants from the NIH Common Fund during the conduct of the study, personal fees from naviHealth, and nonfinancial support from PointRight outside the submitted work. No other disclosures were reported.

PubMed: MeSH publication types

  • Journal Article
  • Research Support, N.I.H., Extramural

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