Kumar A, et al. - In view of the significant increase in enrollment in Medicare Advantage plans, from 5.3 million in 2003 to 19 million in 2017, researchers compared fee-for-service (FFS) and Medicare Advantage (MA) enrollees in terms of rehabilitation service use, length of stay, and outcomes for patients following hip fracture. MA patients vs FFS patients displayed a shorter course of rehabilitation but were more frequently discharged to the community successfully and were less likely to experience a 30-day hospital readmission. In the case of hip fracture patients in skilled nursing facilities (SNFs), longer lengths of stay may not translate into better outcomes.

Methods

• Researchers performed a retrospective cohort study examining differences in health service utilization and outcomes between FFS and MA patients in SNFs following hip fracture hospitalization during the period January 1, 2011, to June 30, 2015, and followed up until December 31, 2015.
• The Master Beneficiary Summary File, Medicare Provider and Analysis Review data, Healthcare Effectiveness Data and Information Set data, the Minimum Data Set, and the American Community Survey were linked.
• Two process measures and 4 patient-centered outcomes were included as the 6 primary outcomes of interest in this study.
• Length of stay in the SNF and average rehabilitation therapy minutes (physical and occupational therapy) received per day were included in process measures.
• Thirty-day hospital readmission, changes in functional status as measured by the 28-point late loss MDS-ADL scale, likelihood of becoming a long-term resident, and successful discharge to the community were assessed as the patient-centered outcomes.
• Discharge to the community within 100 days of SNF admission and remaining alive in the community without being institutionalized in any acute or post-acute setting for at least 30 days were defined as successful discharge from a SNF.
• Treatments and outcomes between MA and FFS patients were compared using inverse probability of treatment weighting (IPTW) and nursing facility fixed effects regression models.

Results

• Analysis of 211,296 FFS and 75,554 MA patients with hip fracture was performed.
• These patients were admitted directly to a SNF following an index hospitalization and were not in a nursing facility or hospital in the preceding year.
• Compared to FFS patients, MA patients were younger and less cognitively impaired upon SNF admission.
• Demographic and clinical characteristics of MA patients and FFS patients were comparable after applying IPTW.
• MA patients vs FFS patients spent 5.1 (95% CI -5.4 to -4.8) fewer days in the SNF and received 463 (95% CI to -483.2 to -442.4) fewer minutes of total rehabilitation therapy during the first 40 days following SNF admission, ie, 12.1 (95% CI -12.7 to -11.4) fewer minutes of rehabilitation therapy per day, after adjusting for risk factors using IPTW-weighted fixed effects regression models.
• Furthermore, MA patients, compared to FFS patients, displayed a 1.2 percentage point (95% CI -1.5 to -1.1) lower 30-day readmission rate, 0.6 percentage point (95% CI -0.8 to -0.3) lower rate of becoming a long-stay resident, and a 3.2 percentage point (95% CI 2.7 to 3.7) higher rate of successful discharge to the community.