Associations among processes and outcomes of care for Medicare nursing home residents with acute heart failure.

OBJECTIVE: To characterize Medicare skilled nursing facility (SNF) residents who become acutely ill with heart failure (HF) and assess the association between the outcomes of rehospitalization and mortality, and severity of the acute exacerbation, comorbidity, and processes of care.
DESIGN: SNF medical record review of Medicare patients who developed an acute exacerbation of heart failure (HF) during the 90 days following nursing home admission.
SETTING: A total of 58 SNFs in 5 states during 1994 and 1997. PARTICIPANTS: Patients with 156 episodes of acute HF among 4693 random Medicare nursing home admissions. MEASUREMENTS: Demographic variables, symptoms, signs, comorbidity, nursing home characteristics, nurse staffing ratios, and processes of care were compared between acute HF subjects transferred to hospital and those not transferred; and between subjects who died within 30 days of an acute exacerbation and those who survived.
RESULTS: After adjusting for age, disease severity, and comorbidity, residents whose change in condition was evaluated during the night shift were more likely to be hospitalized (OR 4.20, 95%CI 1.01-17.50). Residents who were prescribed an angiotensin-converting enzyme inhibitor or who received an order for skilled nursing observation more often than once a shift were 1/3 as likely to die as those who did not (OR 0.303, 95%CI 0.11-0.82), after adjusting for hypotension, delirium, do not resuscitate orders, and prior hospital length of stay.
CONCLUSION: For residents who develop an acute exacerbation of HF during a SNF stay, there is an association between attributes of nursing home care and the outcomes of rehospitalization and mortality.