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Skilled Nursing Facility Quality Rating and Surgical Outcomes Following Coronary Artery Bypass Grafting

Published:November 16, 2022DOI:https://doi.org/10.1053/j.semtcvs.2022.11.007
      Centers for Medicare and Medicaid Services created a 5-star quality rating system to evaluate skilled nursing facilities (SNFs). Patient discharge to lower-star quality SNFs has been shown to adversely impact surgical outcomes. Recent data has shown that over 20% of patients are discharged to an SNF after CABG, but the link between SNF quality and CABG outcomes has not been established. The purpose of this study is to evaluate the impact of SNF quality ratings on postoperative outcomes after CABG. Retrospective cohort review of Medicare patients undergoing CABG and discharged to an SNF between the years 2016-2017. Patients were categorized into 3 groups according to the star rating of the SNF with receipt of care after discharge (ie, below average, average, above average). Risk-adjusted 30-day to 1-year outcomes of mortality, readmission, and SNF length of stay were calculated and compared using multivariable logistic regression and Poisson models across SNF quality categories. Of the 73,164 Medicare patients in our sample, 15,522 (21.2%) were discharged to an SNF. Patients in below average SNFs were more likely to be younger, Black, Medicare/Medicaid dual eligible, and have more comorbidities. Compared to above average SNFs, patients discharged to below average SNFs experienced higher risk-adjusted 30-day mortality (2.1% vs 1.6%, P<0.02), readmission (21.6% vs 19.3%, P<0.01) and SNF length of stay (17.3d vs 16.5d, P<0.0001). Within 90-days, below average SNFs experienced higher risk-adjusted readmission rates (31.7% vs 30.0%, P<0.004). Outcomes at 1-year were not statistically significant. Medicare beneficiaries discharged to lower quality SNFs experienced worse postoperative outcomes after CABG. Identifying best practices at high performing SNFs, to potentially implement at low performing facilities, may improve equitable care for patients.

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      References

      1. Report to the Congress: Medicare Payment Policy. https://www.medpac.gov/wp-content/uploads/import_data/scrape_files/docs/default-source/reports/mar21_medpac_report_to_the_congress_sec.pdf

      2. Five-Star Quality Rating System. Published online April 5, 2022. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/FSQRS

        • Thompson M.P.
        • Yost M.L.
        • Syrjamaki J.D.
        • et al.
        Sources of hospital variation in postacute care spending after cardiac surgery.
        Circ Cardiovasc Qual Outcomes. 2020; 13e006449
        • Edgerton J.R.
        • Herbert M.A.
        • Mahoney C.
        • et al.
        Long-term fate of patients discharged to extended care facilities after cardiovascular surgery.
        Ann Thorac Surg. 2013; 96: 871-877
        • Sacks G.D.
        • Lawson E.H.
        • Dawes A.J.
        • et al.
        Variation in hospital use of postacute care after surgery and the association with care quality.
        Med Care. 2016; 54: 172-179
        • Nicolini F.
        • Agostinelli A.
        • Vezzani A.
        • et al.
        The evolution of cardiovascular surgery in elderly patient: A review of current options and outcomes.
        Biomed Res Int. 2014; 2014736298
        • Wang W.
        • Bagshaw S.M.
        • Norris C.M.
        • et al.
        Association between older age and outcome after cardiac surgery: A population-based cohort study.
        J Cardiothorac Surg. 2014; 9: 177
      3. Heart Health and Aging. NIH: National Institute on Aging. Published online June 1, 2018. https://www.nia.nih.gov/health/heart-health-and-aging#:∼:text=Adults%20age%2065%20and%20older,risk%20of%20developing%20cardiovascular%20disease

        • Nallamothu B.K.
        • Rogers M.A.M.
        • Saint S.
        • et al.
        Skilled care requirements for elderly patients after coronary artery bypass grafting.
        J Am Geriatr Soc. 2005; 53: 1133-1137
        • Paredes A.Z.
        • Hyer J.M.
        • Tsilimigras D.I.
        • et al.
        Skilled nursing facility (SNF) utilization and impact of SNF star-quality ratings on outcomes following hepatectomy among Medicare beneficiaries.
        HPB. 2020; 22: 109-115
        • Paredes A.Z.
        • Hyer J.M.
        • Beal E.W.
        • et al.
        Impact of skilled nursing facility quality on postoperative outcomes after pancreatic surgery.
        Surgery. 2019; 166: 1-7
        • Lawthers A.G.
        • McCarthy E.P.
        • Davis R.B.
        • et al.
        Identification of in-hospital complications from claims data. Is it valid?.
        Med Care. 2000; 38: 785-795
        • Weingart S.N.
        • Iezzoni L.I.
        • Davis R.B.
        • et al.
        Use of administrative data to find substandard care: Validation of the complications screening program.
        Med Care. 2000; 38: 796-806
        • Iezzoni L.I.
        • Daley J.
        • Heeren T.
        • et al.
        Identifying complications of care using administrative data.
        Med Care. 1994; 32: 700-715
        • Neuman M.D.
        • Wirtalla C.
        • Werner R.M.
        Association between skilled nursing facility quality indicators and hospital readmissions.
        JAMA. 2014; 312: 1542-1551
        • Ogunneye O.
        • Rothberg M.B.
        • Friderici J.
        • et al.
        The association between skilled nursing facility care quality and 30-day readmission rates after hospitalization for heart failure.
        Am J Med Qual. 2015; 30: 205-213
        • Edgerton J.
        • Filardo G.
        • Ryan W.H.
        • et al.
        Risk of not being discharged home after isolated coronary artery bypass graft operations.
        Ann Thorac Surg. 2013; 96: 1287-1292
        • Rivera-Hernandez M.
        • Fabius C.D.
        • Fashaw S.
        • et al.
        Quality of post-acute care in skilled nursing facilities that disproportionately serve Hispanics with Dementia.
        J Am Medl Dir Assoc. 2020; 21 (e3): 1705-1711https://doi.org/10.1016/j.jamda.2020.06.030
      4. Worcester S. Hospital-SNF partnerships prevent readmissions. caring for the ages. 2015;16:9. doi:10.1016/j.carage.2015.05.014

        • David S.
        • David S.
        • Sheikh F.
        • et al.
        Preventing avoidable re-hospitalizations through a hospital skilled nursing facilities (SNF) partnership: Systematic review of clinical protocols.
        J Am Med Dir Assoc. 2015; 16: B21
        • Dolansky M.A.
        • Zullo M.D.
        • Hassanein S.
        • et al.
        Cardiac rehabilitation in skilled nursing facilities: A missed opportunity.
        Heart Lung. 2012; 41: 115-124
        • Shih T.
        • Chen L.M.
        • Nallamothu B.K.
        Will bundled payments change health care? Examining the evidence thus far in cardiovascular care.
        Circulation. 2015; 131: 2151-2158
        • Tsai T.C.
        • Joynt K.E.
        • Wild R.C.
        • et al.
        Medicare's bundled payment initiative: Most hospitals are focused on a few high-volume conditions.
        Health Aff. 2015; 34: 371-380
      5. What Are Bundled Payments? NEJM Catalyst. Published online February 28, 2018. https://catalyst.nejm.org/doi/full/10.1056/CAT.18.0247

      Linked Article

      • Commentary: Time to Move Beyond the Operating Room
        Seminars in Thoracic and Cardiovascular Surgery
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          Outcomes after cardiac surgery have steadily improved in recent decades because of advances in surgical techniques, less-invasive approaches, perioperative management, and enhanced recovery after surgery (ERAS) protocols.1 Nevertheless, cardiac surgical practice patterns vary widely and have a considerable impact on patients’ early and long-term outcomes.2 In the United States, skilled nursing facilities (SNF) have become increasingly available and used to support frail or high-risk patients who undergo cardiac surgery and are safely discharged.
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