The Relative Importance of Hospital Discharge and Patient Composition in Changing Post-Acute Care Utilization and Outcomes Among Medicare Beneficiaries

Ying Jessica Cao; Yang Wang; John Mullahy; Marguerite Burns; Yao Liu; Maureen Smith

doi:10.1177/11786329231166522

The Relative Importance of Hospital Discharge and Patient Composition in Changing Post-Acute Care Utilization and Outcomes Among Medicare Beneficiaries

Health Serv Insights. 2023 Apr 14:16:11786329231166522. doi: 10.1177/11786329231166522. eCollection 2023.

Authors

Ying Jessica Cao¹, Yang Wang², John Mullahy¹, Marguerite Burns¹, Yao Liu³, Maureen Smith^{1

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Affiliations

¹ Department of Population Health Sciences, University of Wisconsin-Madison, Madison, WI, USA.
² Robert M. La Follette School of Public Affairs, University of Wisconsin-Madison, Madison, WI, USA.
³ Department of Ophthalmology and Visual Sciences, University of Wisconsin-Madison, Madison, WI, USA.
⁴ Department of Family Medicine and Community Health, University of Wisconsin-Madison, Madison, WI, USA.
⁵ Health Innovation Program, University of Wisconsin-Madison, Madison, WI, USA.

Abstract

Background: The COVID-19 pandemic changed care delivery. But the mechanisms of changes were less understood.

Objectives: Examine the extent to which the volume and pattern of hospital discharge and patient composition contributed to the changes in post-acute care (PAC) utilization and outcomes during the pandemic.

Research design: Retrospective cohort study. Medicare claims data on hospital discharges in a large healthcare system from March 2018 to December 2020.

Subjects: Medicare fee-for-service beneficiaries, 65 years or older, hospitalized for non-COVID diagnoses.

Measures: Hospital discharges to Home Health Agencies (HHA), Skilled Nursing Facilities (SNF), and Inpatient Rehabilitation Facilities (IRF) versus home. Thirty- and ninety-day mortality and readmission rates. Outcomes were compared before and during the pandemic with and without adjustment for patient characteristics and/or interactions with the pandemic onset.

Results: During the pandemic, hospital discharges declined by 27%. Patients were more likely to be discharged to HHA (+4.6%, 95% CI [3.2%, 6.0%]) and less likely to be discharged to either SNF (-3.9%, CI [-5.2%, -2.7%]) or to home (-2.8% CI [-4.4%, -1.3%]). Thirty- and ninety-day mortality rates were significantly higher by 2% to 3% points post-pandemic. Readmission were not significantly different. Up to 15% of the changes in discharge patterns and 5% in mortality rates were attributable to patient characteristics.

Conclusions: Shift in discharge locations were the main driver of changes in PAC utilization during the pandemic. Changes in patient characteristics explained only a small portion of changes in discharge patterns and were mainly channeled through general impacts rather than differentiated responses to the pandemic.

Keywords: COVID-19; Hospital discharge; home health; inpatient rehabilitation; mortality; post-acute care; readmission; skilled nursing facility.