What's in a Number: Do Transfer Rates Reflect Nursing Home Quality?

Area of Science:

• Healthcare Quality
• Geriatric Medicine
• Health Services Research

Background:

• Nursing home (NH) hospitalization rates are used as quality metrics derived from claims data.
• These claims-based measures may not account for clinical complexity or accurately reflect care quality.
• The alignment between claims data and expert clinical judgment on NH transfers is not well understood.

Purpose of the Study:

• To compare a claims-based measure of potentially avoidable hospitalizations with expert clinician reviews of transfer decisions and care quality.
• To evaluate the agreement between administrative data and clinical judgment in assessing NH quality.

Main Methods:

• A random sample of 252 hospital transfers from eight Veterans Administration (VA) Community Living Centers (CLCs) was selected.
• Eleven expert clinicians conducted Structured Implicit Reviews (SIRs) of medical records to assess transfer appropriateness and care quality.
• VA Corporate Data Warehouse (CDW) data were used to identify potentially avoidable hospitalizations.

Main Results:

• The claims-based measure identified 12% of hospitalizations as potentially avoidable, with only 2 cases matching expert review of inappropriate transfer decisions.
• The claims-based measure identified only 5 of 33 cases with inadequate acute decline treatment and 6 of 17 cases with poor chronic care quality.

Conclusions:

• Expert clinical judgment on transfer appropriateness and care quality differs significantly from claims-based hospitalization metrics.
• Nuanced clinical assessment is essential for evaluating NH quality and identifying areas for improvement to reduce unnecessary hospital transfers.