Relative contributions of hospital versus skilled nursing facility quality on patient outcomes

Hospitals and health systems worldwide have adopted value-based payment to improve quality and reduce costs. In the USA, skilled nursing facilities (SNFs) are now financially penalised for higher-than-expected readmission rates. However, the extent to which SNFs contribute to, and should thus be held accountable for, readmission rates is unknown. To compare the relative contributions of hospital and SNF quality on readmission rates while controlling for unobserved patient characteristics.

Retrospective cohort study of Medicare beneficiaries, 2010-2016. Acute care hospitals and SNFs in the USA. Medicare beneficiaries with two hospitalisations followed by SNF admissions, divided into two groups: (1) patients who went to different hospitals but were discharged to the same SNF after both hospitalisations and (2) patients who went to the same hospital but were discharged to different SNFs. Hospital-level and SNF-level quality, using a lagged measure of 30-day risk-standardised readmission rates (RSRRs). Readmission within 30 days of hospital discharge.

There were 140 583 patients who changed hospitals but not SNFs, and 183 232 who changed SNFs but not hospitals. Patients who went to the lowest-performing hospitals (highest RSRR) had a 0.9% higher likelihood of readmission (p=0.005) compared with patients who went to the highest-performing hospitals (lowest RSRR). In contrast, patients who went to the lowest-performing SNFs had a 2% higher likelihood of readmission (p<0.001) compared with patients to went to the highest-performing SNFs.

The association between SNF quality and patient outcomes was larger than the association between hospital quality and patient outcomes among postacute care patients. Holding postacute care providers accountable for their quality may be an effective strategy to improve SNF quality.