Determinants and Economic Impact of Avoidable Hospital Referrals From Spanish Nursing Homes: A Value-Based Care...

We aimed to examine hospital referral patterns from Spanish nursing homes within a value-based healthcare framework, with emphasis on potentially avoidable referrals (ie, admissions that could be prevented through timely and effective outpatient/primary care). We also estimated the potential economic implications of these referrals.

In this observational study, we analyzed standardized data from 8 nursing homes in the Marina Alta region of Spain, including 497 residents in 2024. Facility-level aggregated indicators were examined to evaluate associations between referral rates and case-mix characteristics, staffing ratios, and pressure-ulcer prevalence. Logistic regression was used to assess associations with referral probability. A scenario-based economic model estimated the potential national cost burden attributable to potentially avoidable referrals and explored the economic implications of incremental investment in residential care. Bootstrap methods were applied to estimate uncertainty ranges.

Higher hospital referral rates were associated with a greater proportion of grade-3 dependency (OR 1.02) and higher nursing staffing ratios (OR 8.03). Referral patterns were also associated with facility-level pressure-ulcer prevalence. Under model assumptions, potentially avoidable referrals could generate annual costs exceeding €800 million for the Spanish health system. Scenario analyses indicated that incremental residential investments of €10 to €50/day may be associated with lower hospital expenditures, with predicted daily cost differences ranging from €66 to €325 per patient.

Hospital referrals from nursing homes may have important clinical and economic implications in Spain. From a value-based healthcare perspective, strengthening in-place care capacity, improving coordination pathways, and implementing standardized data systems may reduce potentially avoidable referrals.