Potentially Avoidable Hospitalizations Research Articles

Potentially Avoidable Hospitalizations Among Historically Marginalized Nursing Home Residents

Nursing home (NH) transfers to hospitals are common and have been associated with cognitive decline; approximately 45% of NH hospital transfers are potentially avoidable hospitalizations (PAHs). To determine PAH incidence for historically marginalized NH residents with severe cognitive impairment compared with non-Hispanic White residents. This cross-sectional study merged 2018 Centers for Medicaid & Medicare Services datasets and LTCFocus, a public dataset on US NH care, for US NH residents aged 65 years and older who had a hospitalization. Analyses were performed from January to May 2022. Race and ethnicity of NH residents. Racial and ethnic differences in resident-level annual rates of PAHs were estimated for residents with and without severe cognitive impairment (measured using the Cognitive Function Scale), controlling for resident characteristics, comorbidities, dual eligibility, and time at risk. PAHs were defined as NH hospital transfers that resulted from neglectful NH care or for which NH treatment would have been appropriate. Of 2 098 385 NH residents nationwide included in the study, 7151 (0.3%) were American Indian or Alaska Native, 39 873 (1.9%) were Asian, 229 112 (10.9%) were Black or African American, 99 304 (4.7%) were Hispanic, 2785 (0.1%) were Native Hawaiian or Pacific Islander, 1 713 670 (81.7%) were White, and 6490 (0.3%) were multiracial; 1 355 143 (64.6%) were female; 128 997 (6.2%) were severely cognitively impaired; and the mean (SD) age was 81.8 (8.7) years. PAH incidence rate ratios (IRRs) were significantly greater for residents with severe cognitive impairment compared with those without. In unadjusted analyses comparing historically marginalized residents with severe cognitive impairment vs non-Hispanic White residents with severe cognitive impairment, American Indian or Alaska Native residents had a 49% higher PAH incidence (IRR, 1.49 [95% CI, 1.10-2.01]), Black or African American residents had a 64% higher incidence (IRR, 1.64 [95% CI, 1.48-1.81]), and Hispanic residents had a 45% higher incidence (IRR, 1.45 [95% CI, 1.29-1.62]). Higher incidences persisted for historically marginalized residents with severe cognitive impairment vs non-Hispanic White residents with severe cognitive impairment in adjusted analyses. Asian residents had a 24% higher PAH incidence (IRR, 1.24 [95% CI, 1.06-1.45]), Black or African American residents had a 48% higher incidence (IRR, 1.48 [95% CI, 1.36-1.60]), and Hispanic residents had a 27% higher incidence (IRR, 1.27 [95% CI, 1.16-1.39]). In this cross-sectional study of PAHs, compared with non-Hispanic White NH residents, historically marginalized residents had increased PAH incidence. In the presence of severe cognitive impairment, incidence rates increased significantly compared with rates for residents without severe cognitive impairment. These results suggest that identification of residents with severe cognitive impairment and proper NH care may help prevent further cognitive decline by avoiding PAHs.

Potentially Avoidable Hospitalizations by Asthma and COPD in Switzerland from 1998 to 2018: A Cross-Sectional Study.

Potentially avoidable hospitalizations (PAH) are commonly used as an indicator for healthcare quality and primary care performance. However, data are usually presented in a restricted timeframe and for a specific region, limiting the identification of trends and national patterns. We aimed in this study to calculate rates, identify clinical determinants, and estimate costs of PAH for two frequent lung diseases (asthma and COPD) in Switzerland between 1998 and 2018 using hospital discharge data available for patients aged ≥20 years. PAH were defined according to the Health Care Quality Indicators Project (HCQIP) from the Organisation for Economic Co-operation and Development (OECD). The distribution of PAH in seven administrative regions (Leman, Mittelland, Northwest, Zurich, Eastern, Central, and Ticino) was calculated, along with PAH-associated total hospital days and Diagnosis-Related Group (DRG) estimated costs. Totals of 25,260 PAH for asthma and 135,069 PAH for COPD were identified in the 20-year period. The standardized rates of PAH per 100,000 people for asthma fluctuated from 18.7 in 1998 to 22.5 on 2018. The standardized rates of PAH per 100,000 people from COPD almost doubled from 77.4 in 1998 to 142.7 in 2018. In 2018, the estimated total costs of PAH amounted to 7.7 million CHF for asthma and 91.2 million CHF for COPD. We conclude that PAH for asthma and COPD represent a significant and unnecessary burden and costs of hospitalizations in Switzerland.

CMS Initiative to Reduce Potentially Avoidable Hospitalizations Among Long-Stay Nursing Facility Residents: Lessons Learned.

In 2012, the Centers for Medicare and Medicaid Services implemented the Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents. In Phase 1 (2012 to 2016), clinical or education-based interventions (Clinical-Only) aimed to reduce hospitalizations among long-stay nursing home residents. In Phase 2 (2016 to 2020), the Initiative also included a Medicare payment incentive for treating residents with certain conditions within the nursing home. Nursing homes participating in Phase 1 continued their previous interventions and received the incentive (Clinical + Payment) and others received the incentive only (Payment-Only). Mixed methods were used to determine the effectiveness of the Initiative and explore facilitators of and barriers to implementation that participating nursing homes experienced. We used telephone and in-person interviews to investigate aspects of implementation and a difference-in-differences regression model framework comparing residents in participating and nonparticipating nursing homes to determine the effect of the Initiative on measures of utilization, expenditures, and quality. Three key components were necessary for successful implementation of the Initiative-staff retention and leadership stability, leadership and staff support, and provider engagement and support. Nursing homes that lacked one or more of these three components experienced greater challenges. The Clinical-Only intervention in Phase 1 was successful in reducing hospitalizations. We did not find evidence that the Clinical + Payment or Payment-Only interventions were successful in reducing hospitalizations. Reducing hospitalizations among nursing home residents hinges upon the availability and support of clinical staff who can provide ongoing education to direct-care staff in the nursing home, as well as hands-on care. Use of Medicare payment incentives alone to encourage on-site treatment of residents was insufficient to reduce hospitalizations. Unless nursing homes are adequately staffed to treat residents with acute care needs, further reductions in hospitalizations will be difficult to achieve.

Potentially avoidable hospitalizations for older patients transferred from long-term care hospitals: a nationwide cross-sectional analysis of potential healthcare consequences.

Multiple chronic disorders and disabilities among older patients in long term care hospitals (LTCH) tends to increase the healthcare burden by causing overcrowding, particularly in emergency departments. Therefore, access to timely and adequate healthcare for LTCH patients is an increasingly important issue, and potentially avoidable hospitalizations (PAHs) and hospitalizations during non-office hours can result as indicators of emergency department overcrowding. The study aimed to evaluate PAHs and hospitalizations during non-office hours in emergency departments for older patients transferred from LTCH compared to patients living at home. We performed a cross-sectional study using the National Emergency Department Information System database from January 2018 to December 2019, in South Korea, with older patients (≥ 65years) who visited nationwide emergency departments. Adjusted odds ratio (aOR) and 95% confidence interval (CI) for indicators of overcrowding as PAHs and hospitalizations during non-office hours were calculated by logistic regression. Among the 2,177,663 older patients who visited the emergency departments, 98,434 patients were living in LTCH and 2,079,229 patients were living at home. The older patients living in LTCH was associated with PAHs (aOR: 1.90, 95% CI 1.87-1.94) and hospitalizations during non-office hours (aOR: 1.76, 95% CI 1.73-1.78). LTCH patients showed more hospital visits, extended stay in the emergency department, greater prevalence of chronic diseases, greater rates of transfer as well as higher admission rates and mortality as compared to the patients living at home. The LTCH older patients were associated with the indicators of emergency department overcrowding, which impacts health care quality in hospitals. Introduction of policy and training programs for LTCH staff are recommended to manage vulnerable groups in advance.

Does integrated care mean fewer hospitalizations? An evaluation of a French field experiment

This study aims to evaluate the impact of an experimental healthcare policy on hospital use among elderly patients. From 2015 to 2017, French public authorities implemented an integrated care model, the Digital Health Territories (Territoire de Soins Numérique (TSN)) programme designed to improve healthcare coordination and sustain the use of health information (HI) technologies. The TSN programme was expected to reduce hospital healthcare utilization. In the Aquitaine region, the TSN programme was implemented in part of the Landes district and primarily consisted of the creation of a support platform (PTA). Part of the Lot-et-Garonne district was chosen as a “control area” due to its similarities to the experimental district in terms of the population structure and healthcare supply characteristics. In the control area, no integrated care model innovation was implemented over the study period. Using claims data from the French National Health Insurance (Système National d'Information Inter-Régimes de l'Assurance Maladie (SNIIRAM)), the healthcare utilization of the populations living in the experimental and control areas was tracked from 2012 to 2017. To estimate the impact of the TSN programme on three hospitalization outcomes, we used a combination of matching and difference-in-differences (DiD) approaches. The TSN programme shows a significant but weak negative impact on emergency department (ED) visits and no significant impact on 30-day re-hospitalizations (R30) or potentially avoidable hospitalizations (PAHs).

Facility and resident characteristics associated with variation in nursing home transfers: evidence from the OPTIMISTIC demonstration project

BackgroundCenters for Medicare and Medicaid Services (CMS) funded demonstration project to evaluate financial incentives for nursing facilities providing care for 6 clinical conditions to reduce potentially avoidable hospitalizations (PAHs). The Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) site tested payment incentives alone and in combination with the successful nurse-led OPTIMISTIC clinical model. Our objective was to identify facility and resident characteristics associated with transfers, including financial incentives with or without the clinical model.MethodsThis was a longitudinal analysis from April 2017 to June 2018 of transfers among nursing home residents in 40 nursing facilities, 17 had the full clinical + payment model (1726 residents) and 23 had payment only model (2142 residents). Using CMS claims data, the Minimum Data Set, and Nursing Home Compare, multilevel logit models estimated the likelihood of all-cause transfers and PAHs (based on CMS claims data and ICD-codes) associated with facility and resident characteristics.ResultsThe clinical + payment model was associated with 4.1 percentage points (pps) lower risk of all-cause transfers (95% confidence interval [CI] − 6.2 to − 2.1). Characteristics associated with lower PAH risk included residents aged 95+ years (− 2.4 pps; 95% CI − 3.8 to − 1.1), Medicare-Medicaid dual-eligibility (− 2.5 pps; 95% CI − 3.3 to − 1.7), advanced and moderate cognitive impairment (− 3.3 pps; 95% CI − 4.4 to − 2.1; − 1.2 pps; 95% CI − 2.2 to − 0.2). Changes in Health, End-stage disease and Symptoms and Signs (CHESS) score above most stable (CHESS score 4) increased the risk of PAH by 7.3 pps (95% CI 1.5 to 13.1).ConclusionsMultiple resident and facility characteristics are associated with transfers. Facilities with the clinical + payment model demonstrated lower risk of all-cause transfers compared to those with payment only, but not for PAHs.

Primary care visits can reduce the risk of potentially avoidable hospitalizations among persons with diabetes in France.

Diabetes is a frequent chronic condition, which can lead to costly complications if not managed well in the primary care setting. Potentially avoidable hospitalizations (PAH) are considered as an indirect measure of primary care. However, the association between primary care use and PAH in diabetic patients has not been investigated in France. We investigate the association between primary care indicators and PAH at an individual level among persons with diabetes in a population-based cohort study on the French national health insurance database (EGB sample). PAH occurrence in 2013 was modeled as a function of primary care use and access, health status and socio-economic indicators over the exposure period 2011-12 using a cause-specific hazards model with death as a competing event. We included 25 293 diabetics in our cohort, among which 385 (1.5%) experienced at least 1 PAH in 2013. After adjustment on health status indicators, primary care use had a protective effect against PAH. Diabetic patients who had seen a general practitioner (GP) 10-14 times had a reduced hazard of PAH compared to less frequent encounters (HR=0.49, P<0.001). The effect size decreased when the number of encounters increased, suggesting a remaining confounding effect of health status. For the first time in France, this study shows a protective effect of the number of GP encounters against PAH at an individual level and highlights the importance of a frequent monitoring of diabetic patients in the primary care setting to prevent PAH occurrence.

Nursing Home Residents with Dementia Experience Better End‐of‐Life Care and Outcomes in Nursing Homes with Alzheimer’s Special Care Units

Research ObjectiveNursing homes (NHs) are critical end‐of‐life (EOL) care settings for 70% of Americans dying with Alzheimer’s disease/related dementia (ADRD). Associations between facility‐level organization of care, including presence of Alzheimer’s special care units (ASCUs), and EOL care quality in NHs are unclear. Our objective was to examine variations in EOL care/outcomes (in‐hospital/NH death, death with pressure ulcers, potentially avoidable hospitalizations (PAHs), and hospice use in the last 90 days of life) among residents who died with mild, moderate, or severe ADRD in NHs with/without ASCUs.Study DesignWe used descriptive analyses and multivariate logistic regression models, adjusting for resident, NH, county, and state‐level factors, to examine associations between EOL care/outcomes and presence of ASCUs among NH decedents with ADRD.Population StudiedWe used CY2016‐2017 national Medicare claims data and the Minimum Data Set (MDS) to identify long‐stay NH residents with ADRD who died in 2017. The sample included residents who died in a NH or hospital shortly following NH discharge, were not comatose, and were at least 65 years old at time of death. We used ICD‐10 diagnosis codes and the cognitive function scale to determine ADRD presence and severity. Medicare claims, the MDS, and several public data sets were used to assess EOL quality and identify resident, NH, and market‐level covariates. The study sample included 191 435 decedents with ADRD from 14 618 NHs.Principal FindingsAs severity of ADRD increased, adjusted rates of in‐hospital death and PAHs decreased (17.2%‐6.4% for in‐hospital death; 12.0%‐7.3% for PAHs; P‐values:&lt; 0.001), while adjusted rates of dying with pressure ulcers and hospice use increased (8.4%‐13.7% for deaths with pressure ulcers; 23.4%‐39.7% for hospice use; P‐values:&lt; 0.001). Presence of ASCUs lowered the adjusted rate of in‐hospital death (3.7%, 2.2%, 2.5%; P‐values:&lt; 0.001), dying with pressure ulcers (0.6%, 2.1%, 4.3%; P‐values:&lt; 0.001), and PAHs (1.8%, 1.5%, 2.3%; P‐values:&lt; 0.001) among decedents with mild, moderate, and severe ADRD, respectively. Adjusted rates of hospice use were not as clinically significant or consistent across decedents with differing levels of ADRD severity. Decedents in for‐profit NHs with ASCUs had higher odds of in‐hospital death (OR:1.17; P‐value: 0.032) and hospice use (OR:1.19; P‐value: 0.030). In NHs with ASCUs, higher skilled nurse staffing was associated with lower odds of PAHs (OR:0.07; P‐value: 0.002) and hospice use (OR:0.16; P‐value:&lt; 0.001). In more competitive NH markets, presence of ASCUs was associated with higher odds of hospice use (ORs: 1.74, 1.33; P‐values:&lt; 0.001, 0.035).ConclusionsNH decedents with ADRD residing in NHs with ASCUs were consistently more likely to die in NHs rather than in hospital and had fewer pressure ulcers and PAHs at EOL.Implications for Policy or PracticeOur findings suggest that presence of ASCUs may create environments in which better outcomes are possible for residents dying with ADRD. However, because there is no definition as to what constitutes ASCUs, it is difficult to identify specific dimensions promoting better care. Future research to understand NH practice/care processes associated with presence of ASCUs is needed to identify possible interventions/policy initiatives to increase ASCU presence.Primary Funding SourceAgency for Healthcare Research and Quality.

End-of-Life Care among Nursing Home Residents with Dementia Varies by Nursing Home and Market Characteristics

ObjectivesNursing homes (NHs) are critical end-of-life (EOL) care settings for 70% of Americans dying with Alzheimer's disease/related dementias (ADRD). Whether EOL care/outcomes vary by NH/market characteristics for this population is unknown but essential information for improving NH EOL care/outcomes. Our objectives were to examine variations in EOL care/outcomes among decedents with ADRD and identify associations with NH/market characteristics. DesignCross-sectional. OutcomesPlace-of-death (hospital/NH), presence of pressure ulcers, potentially avoidable hospitalizations (PAHs), and hospice use at EOL. Key covariates were ownership, staffing, presence of Alzheimer's units, and market competition. Setting and ParticipantsLong-stay NH residents with ADRD, age 65 + years of age, who died in 2017 (N = 191,435; 14,618 NHs) in NHs or hospitals shortly after NH discharge. MethodsNational Medicare claims, Minimum Data Set, public datasets. Descriptive analyses and multivariable logistic regressions. ResultsAs ADRD severity increased, adjusted rates of in-hospital deaths and PAHs decreased (17.0% to 6.3%; 11.2% to 7.0%); adjusted rates of dying with pressure ulcers and hospice use increased (8.2% to 13.5%; 24.5% to 40.7%). Decedents with moderate and severe ADRD had 16% and 13% higher likelihoods of in-hospital deaths in for-profit NHs. In NHs with Alzheimer's units, likelihoods of in-hospital deaths, dying with pressure ulcers, and PAHs were significantly lower. As ADRD severity increased, higher licensed nurse staffing was associated with 14%‒27% lower likelihoods of PAHs. Increased NH market competition was associated with higher likelihood of hospice use, and lower likelihood of in-hospital deaths among decedents with moderate ADRD. Conclusions and ImplicationsDecedents with ADRD in NHs that were nonprofit, had Alzheimer's units, higher licensed nurse staffing, and in more competitive markets, had better EOL care/outcomes. Modifications to state Medicaid NH payments may promote better EOL care/outcomes for this population. Future research to understand NH care practices associated with presence of Alzheimer's units is warranted to identify mechanisms possibly promoting higher-quality EOL care.

Obesity among Nursing Home Residents: Association with Potentially Avoidable Hospitalizations

Background/ObjectivesStudies show that in nursing homes (NHs), the prevalence of moderate-to-severe obesity has doubled in the last decade and continues to increase. Obese residents are often complex and costly, and this increase in prevalence has come at a time when NHs struggle to decrease hospitalizations, particularly those that are potentially avoidable. This study examined the association between obesity and hospitalizations. DesignWe linked 2011-2014 national data using Medicare NH assessments, hospital claims, and the NH Compare. Setting and ParticipantsIndividuals aged ≥65 years, newly admitted to NHs, who became long-term residents between July 1, 2011 and March 26, 2014. The analytical sample included 490,086 residents. MethodsNH-originating hospitalization was the outcome; a categorical variable defined as no hospitalization, potentially avoidable hospitalization (PAH), and other hospitalization (non-PAH). The main independent variable was body mass index (BMI) defined as normal weight (30 >BMI ≥18.5 kg/m2), mildly obese (35 >BMI ≥30 kg/m2), or moderately-to-severely obese (BMI ≥35 kg/m2). Covariates included individual and NH characteristics. Multinomial models with NH random effects and state dummies were estimated. ResultsAfter adjusting for individual level covariates, the risk of non-PAH for the mildly and moderate/severely obese was not different from normal weight residents. But the risk of PAH remained significantly higher for the moderate/severely obese (relative risk ratio = 1.055; 95% confidence interval 1.018, 1.094). Several NH-level factors also influenced hospitalization risk. Conclusions and ImplicationsObese residents are more likely to experience PAH but not non-PAH. Efforts to improve care for these residents may need to broadly consider the ability of NHs to commit additional resources to fully integrate care for this growing segment of the population.

Hospitalizations for heart failure: Epidemiology and health system burden based on data gathered in routine practice

PurposeTo analyze the epidemiological characteristics of heart failure (HF) and estimate the burden of the disease on the health service by means of real world data (RWD). Patients and methodsAll patients discharged from any Basque Health Service hospital after a first admission for HF between 2011 and 2015. Data sourcesDatabases of our health service. Outcomes30- and 365-day admissions, potentially avoidable hospitalizations (PAHs), mortality. Statistical analysisDescriptive statistics, age-standardized event rates. ResultsThe cohort was composed of 15,109 patients (mean age 79.8±10.1 years). At discharge patients had a median of 8 chronic conditions. 36% of them had had hospitalizations and 83% had visited a specialist (42% of them a cardiologist) during the previous year. Mortality was 24.5% within 365 days after discharge.Within 30 days after discharge, there were 2608 unplanned admissions, 49% for non-cardiovascular disease (CVD), 36% for HF and 15% for a CVD other than HF. 34% were classified as PAH. In the first 365 days after discharge, there were 14,559 hospitalizations, 54% for non-CVD reasons, 32% for HF and 13% for a CVD other than HF. Overall, 35% were PAHs. Conclusion(1) People admitted for HF are old, and they have multimorbidity and high rates of admissions due to non-CVD reasons and PAHs after discharge. These finding suggest the need of strengthening continuity of care and managing comorbidities. (2) Besides, most people admitted for HF have previous contacts with the Healthcare system, which suggests opportunities for prevention before disease worsening.

Estimating cost implications of potentially avoidable hospitalizations among oncology care model patients with prostate cancer

Purpose/ObjectivesWe sought to estimate the expected cost savings generated if a set of potentially avoidable hospitalizations (PAHs) among oncology care model (OCM) patients with prostate cancer were shifted to an acute care model in the outpatient setting. MethodsWe previously identified a set of 28 PAHs among OCM prostate cancer patients. Outpatient management costs for a characteristically similar cohort of cancer patients were obtained from our institution’s ambulatory acute-care Oncology Care Unit (OCU). We excluded OCU visits resulting in hospitalization, involving non-cancer diagnoses, and those missing clinical/financial information. Exact-matching based on the strata of age, categorically-defined presenting complaint, and systemic disease was used to match PAHs to OCU acute care visits. PAH costs obtained from OCM data were compared to costs from matched OCU visits. ResultsWe identified 130 acute care OCU visits, of which 47 met inclusion criteria. Twenty-four PAHs (89%) matched to 26 of these OCU visits. PAHs accounted for 5.8% of OCM expenditures during our study period. The mean inpatient cost among matched PAHs was $15,885 compared to $6227 for matched OCU visits. Boot strapping within each match stratum produced a mean estimated cost savings of $12,151 (95% CI $10,488 to $13,814) per PAH. We estimate this per event savings to yield a 4.4% (95% CI 3.8% to 5.0%) an overall spending decrement for OCM prostate cancer episodes. ConclusionsPAHs contribute meaningfully to costs of care in oncology. Investment in specialized ambulatory acute care services for oncology patients could lead to substantial cost savings.

Cost implications of potentially avoidable hospitalizations among Oncology Care Model patients with prostate cancer.

114 Background: Hospital-based care remains a major contributor to cost in oncology and thus represents an important cost-saving opportunity. We previously developed a rigorous two-stage consensus driven review process to identify potentially avoidable hospitalizations (PAHs) among oncology care model (OCM) patients with prostate cancer and reported a 28% rate of PAHs between 1/2012-6/2015. Our current objective was to estimate the magnitude of any expected cost savings generated if inpatient care from these PAHs were shifted to an acute care model in the outpatient setting. Methods: Costs for ambulatory acute care management among a separate but characteristically similar cohort of cancer patients were obtained from our institution’s recently established Oncology Care Unit (OCU), where acute clinical issues are managed in an enhanced ambulatory setting. We used an exact-matching algorithm to match previously identified PAHs to OCU visits based on strata of age (≤ 70 years vs. &gt; 70 years), categorically defined chief complaint (infusion/transfusion, lab abnormalities, symptom control, and diagnostic work-up), and the presence of “systemic disease” (metastatic disease or hematologic malignancy). PAH costs obtained from OCM data were compared to costs from these matched OCU encounters. Results: We identified 89 acute care OCU visits occurring from 5/2017-12/2018, of which 48 were fully evaluable based on documentation. Twenty-five of our initial 28 PAHs (89%) matched to 29 OCU acute care visits. The mean inpatient cost among matched PAHs was $15,879 compared to $975 for matched OCU visits. Boot strapping within each match produced a mean estimated cost savings of $15,120 (95% CI $13,682 to $16,557) per PAH. We estimate this per event savings to yield an overall spending decrement of 5.7% for OCM prostate cancer episodes. Conclusions: PAHs contribute substantially to costs of care in oncology. Investment in specialized ambulatory acute care services for oncology patients could lead to meaningful cost savings by shifting avoidable inpatient care to the outpatient setting.

Preventable Hospitalizations Among Nursing Home Residents With Dementia and Behavioral Health Disorders

ObjectiveNursing home (NH) residents with Alzheimer's disease/related dementias (ADRD) and/or behavioral health disorders (BHD) are at high risk of hospitalizations, many of which are potentially avoidable. Empirical evidence regarding potentially avoidable hospitalizations (PAHs) among these residents is quite sparse and mixed. The objectives of this study were to (1) examine the risk of PAH among residents with ADRD only, BHD only, ADRD and BHD compared to residents with neither and (2) identify associations between individual- and facility-level factors and PAH in these subgroups. DesignRetrospective, CY2014-2015. Setting and ParticipantsLong-term residents age 65+ (N = 807,630) residing in 15,234 NHs. MethodsWe employed the Minimum Data Set, MedPAR, Medicare beneficiary summary, and Nursing Home Compare. Hospitalization risk was the outcome of interest. Individual-level covariates were used to adjust for health conditions. Facility-level covariates and state dummies were included. Multinomial logistic regression models were fit to estimate the risk of PAH and non–potentially avoidable hospitalizations (N-PAH). ResultsCompared to residents without ADRD or BHD, those with ADRD had at least a 10% lower relative risk ratio (RRR) of N-PAH and a significantly lower risk of PAH, at 16% (P < .0001). Residents with BHD only had a statistically higher, but clinically very modest (RRR = 1.03) risk of N-PAH, with no difference in the risk of PAH. Focusing on specific BHD conditions, we found no difference in N-PAH or PAH among residents with depression, lower PAH risk among those with schizophrenia/psychosis (RRR = 0.92), and an increased risk of both N-PAH (RRR = 1.15) and PAH (RRR = 1.09) among residents with bipolar disorders. Conclusions and RelevanceWe observed a lower risk of PAH and N-PAH among residents with ADRD, with the risk for residents with BHD varying by condition. Substantial variations in PAH and N-PAH were evident across states. Future research is needed to identify state-level modifiable factors that explain these variations.

Identifying Potentially Avoidable Hospitalizations in Medicare Patients With Prostate Cancer: A Retrospective Analysis.

If identifiable, potentially avoidable hospitalizations (PAHs) can serve as an important target for cost containment efforts in oncology. PAHs among a cohort of Medicare patients with prostate cancer were identified using a two-stage consensus-driven review process. In stage 1, two clinicians independently evaluated admissions records using a case review form, which we modified from a previous study to assess for PAHs. In stage 2, any admissions that the reviewers disagreed on or were unsure of were re-examined in a larger group of clinicians to yield a consensus determination regarding avoidability. Univariable and multivariable regression analyses were performed to identify factors predictive of PAH. There were 160 admissions among this cohort of 210 patients from January 2012 to June 2015, of which 99 were evaluable. Consensus-driven clinical review yielded an overall PAH rate of 28.3%. Factors associated with increased PAH risk were admission for symptoms related to cancer (odds ratio [OR], 7.33; P < .001), presence of a social contributor to admission (OR, 4.40; P = .014), and history of alcohol or drug abuse (OR, 4.93; P = .025). Admission for a noncancer condition was associated with decreased PAH risk (OR, 0.32; P = .011). On multivariable analysis, presence of a social contributor to admission (OR, 9.35; P = .002) and admission as a result of a noncancer condition (OR, 0.16; P = .038) remained predictive of PAH risk. A significant proportion of hospitalizations among patients with prostate cancer are potentially avoidable. Understanding factors predictive of risk for PAH can help inform programs aimed at avoiding such admissions to improve overall care quality and value.

Impaired Physical Performance Predicts Hospitalization Risk for Participants in the Program of All-Inclusive Care for the Elderly.

Medicaid spending on the Program of All-Inclusive Care for the Elderly (PACE) has grown rapidly over the last 5 years. Reducing hospitalization rates is a major goal for PACE. However, there is a paucity of research evaluating the relationship between impaired physical performance and hospitalizations in PACE. This study tested whether physical therapist-assessed physical performance, measured by the Short Physical Performance Battery (SPPB), can be used to identify participants in PACE at risk for all-cause hospitalizations or potentially avoidable hospitalizations (PAH). This was a retrospective cohort study of 1093 participants in PACE facilities in the Denver, Colorado, area. Data were acquired from linked electronic medical record data and hospitalization claims. Unadjusted and adjusted Cox proportional hazards regression models were used to evaluate the relationship between SPPB scores and the probabilities of both all-cause hospitalizations and PAH. The unadjusted likelihood of hospitalization increased with greater physical performance impairment (for SPPB scores ≥8/12: 12.2%; for SPPB scores of 4/12 to 7/12: 15.7%; for SPPB scores <4/12: 21.1%). Compared with participants with SPPB scores ≥8/12, participants with SPPB scores <4/12 had nearly double the unadjusted hazard for hospitalization (hazard ratio=1.99; 95% CI=1.34-2.96). In adjusted Cox regression models, participants with SPPB scores <4/12 remained significantly more likely to be hospitalized (hazard ratio=1.87; 95% CI=1.24-2.84). Similar relationships were observed for PAH. The use of data from a single network of PACE facilities might limit generalizability to states with different Medicaid guidelines. The findings suggest that impaired physical performance is an independent risk factor for hospitalization among participants in PACE. These findings could help guide the development of PACE program modifications for measuring and intervening on impairments in physical function.

Prospectively identifying older adults at risk for potentially avoidable hospitalizations in Korea using population-based data.

The purpose of this study is to develop and validate a prediction model to identify older adults at risk for potentially avoidable hospitalizations (PAHs) using variables readily available in routinely collected health administrative data. Population-based, retrospective observational study using National Health Insurance Service-National Sample Cohort (NHIS-NSC) data. Primary care settings in South Korea. The sample includes 113 612 older NHI beneficiaries in the year 2011, among which 2856 had one or more PAHs in 2012. We examined multi-dimensional risk factors of PAHs in the base year and developed and validated prediction models of hospitalization risk using the following year. The predictive power of the developed models was examined with samples generated by the bootstrap method. The performance of the final model was evaluated with further test statistics at different risk thresholds. Predicting PAHs. The c-statistic of the final predictive model was 0.784 (CI: 0.769-0.799). The final model including all selected predictors showed the greatest marginal improvement (integrated discrimination improvement of 365%) compared to the base model. The positive predictive value was good. Our prediction model based on health administrative data can assist the insurer and practitioners to proactively identify and intervene with older adults at risk for a PAH.

PRM224 - ARE POTENTIALLY AVOIDABLE HOSPITALIZATIONS EXPLAINED BY PRIMARY CARE? BEWARE OF SPATIAL HETEROGENEITY.

Potentially avoidable hospitalizations (PAH) are used as indirect measures of access to primary care. However, the evidence about the impact of primary care utilization on PAH is mixed. This study investigates the associations between PAH and measures of access and utilization of primary care in the French region Occitanie, while adjusting for socio-economic and epidemiologic determinants. We also highlight the importance of taking into account spatial autocorrelation and heterogeneity in ecological analyses of PAH. A retrospective analysis of claims and socio-economic data was performed for the French region Occitanie in 2014. The age- and sex-adjusted potentially avoidable hospitalization rates were modelled at the ZIP code level using spatial regression techniques. The standardized rates of PAH vary from 1 to 14.6 per 1000 inhabitants at the ZIP code level; with a mean annual incidence of 4.85 cases per 1000 inhabitants. Congestive heart failure (47%) and chronic obstructive pulmonary disease (25%) were the most frequent categories of PAH. Results of our spatial models revealed the presence of spatial autocorrelation and spatial heterogeneity, which led to identifying two different zones in the Occitanie region based on socio-economic disparities. Separate spatial lag models were fitted in the two zones. Increased nurse density was associated to lower rates of PAH in both zones, but other primary care indicators differed in the two zones. Utilization of primary care had a more contrasted effect: at least one contact with general practitioners was associated with lower PAH rates in one zone, while increased number of contacts with specialist physicians and nurses were associated with higher PAH rates. This study illustrates the importance of taking into account spatial heterogeneity when assessing and interpreting the role of primary care in geographic variations in PAH, by showing that PAH determinants might differ in different areas.

Degree of Implementation of the Interventions to Reduce Acute Care Transfers (INTERACT) Quality Improvement Program Associated with Number of Hospitalizations

To determine whether degree of implementation of the Interventions to Reduce Acute Care Transfers (INTERACT) program is associated with number of hospitalizations and emergency department (ED) visits of skilled nursing facility (SNF) residents. Secondary analysis from a randomized controlled trial. SNFs from across the United States (N=264). Two hundred of the SNFs from the randomized trial that provided baseline and intervention data on INTERACT use. During a 12-month period, intervention SNFs received remote training and support for INTERACT implementation; control SNFs did not, although most control facilities were using various components of the INTERACT program before and during the trial on their own. INTERACT use data were based on monthly self-reports for SNFs randomized to the intervention group and pre- and postintervention surveys for control SNFs. Primary outcomes were rates of all-cause hospitalizations, potentially avoidable hospitalizations (PAHs), ED visits without admission, and 30-day hospital readmissions. The 65 SNFs (32 intervention, 33 control) that reported increases in INTERACT use had reductions in all-cause hospitalizations (0.427 per 1,000 resident-days; 11.2% relative reduction from baseline, p<.001) and PAHs (0.221 per 1,000 resident-days; 18.9% relative reduction, p<.001). The 34 SNFs (12 intervention, 22 control) that reported consistently low or moderate INTERACT use had statistically insignificant changes in hospitalizations and ED visit rates. Increased reported use of core INTERACT tools was associated with significantly greater reductions in all-cause hospitalizations and PAHs in both intervention and control SNFs, suggesting that motivation and incentives to reduce hospitalizations were more important than the training and support provided in the trial in improving outcomes. Further research is needed to better understand the most effective strategies to motivate SNFs to implement and sustain quality improvement programs such as INTERACT.

Patterns of unavoidable and potentially avoidable hospitalizations among cancer patients.

e18030 Background: Hospitalizations can be distressing to patients and caregivers as well as costly to the healthcare system. Prior research in the non-oncology setting indicates that up to 50% of admissions are potentially avoidable. Our aims were to characterize the patterns of hospitalizations in cancer patients within a universal healthcare system and describe factors associated with potentially avoidable admissions. Methods: We reviewed all patients admitted to the British Columbia Cancer Agency over an 18 month period from 2013 to 2014. Pre-planned hospitalizations for inpatient treatments were excluded. Eligible hospitalizations were divided into 2 groups: unavoidable (UH) and potentially avoidable hospitalizations (PAH) based on pre-defined criteria, with discrepancies resolved via a consensus of clinicians. A multivariate analysis was conducted to test the associations of patient, disease, and treatment factors with UH and PAH. Results: Of 701 hospitalizations reviewed, 350 were eligible for inclusion. Among them, 286 (82%) and 64 (18%) were UH and PAH, respectively. Comparing between the UH and PAH groups, median ages at admission were 64 and 63 years, 48% and 45% were men, 67% and 66% were receiving palliative therapy, and median lengths of stay were 5 and 7 days, respectively (all p &gt; 0.05). Patients with PAH were more likely to have a non-hematologic malignancy (92% vs 76% p &lt; 0.01) and undergo a palliative care discussion while in hospital (14% vs 9% p = 0.03). The 30-day mortality rate after discharge was higher in the PAH subset (34% vs 13% p &lt; 0.01). In multivariate analysis, significant factors associated with PAH included presence of cancer-related symptoms (OR 4.7 95% CI 1.7-13.3 p &lt; 0.01), treatment toxicities (OR 3.9 95% CI 1.2-12 p = 0.02) and admissions in the preceding year (OR 3.4 95% CI 1.7-6.8 p &lt; 0.01). In the 64 patients with PAH, admissions may be prevented with intensive follow-up (52%), better coordination of community supports (25%) and early palliative care discussions (20%). Conclusions: In our cohort, PAH were frequent in cancer patients and associated with poor short term outcomes. Optimization of outpatient care and better utilization of community and palliative care resources may reduce PAH.