Higher hospital referral concentration associated with lower-risk patients in skilled nursing facilities.

OBJECTIVE To examine whether stronger referral relationships between hospitals and skilled nursing facilities (SNF) are associated with lower-risk patients being admitted to SNF. DATA SOURCES/COLLECTION We used MedPAR data to estimate referral relationship strength and nursing home survey data (OSCAR and CASPER) to determine the risk of patient admissions at nearly 14 000 SNFs from 2008 to 2014. STUDY DESIGN We examined the association of hospital referral concentration with the percentage of higher-risk patients admitted to non-hospital-based (freestanding) SNFs using an instrumental variables approach. We used the distance between patients and SNFs and hospitals and SNFs as the instrument. DATA COLLECTION/EXTRACTION METHODS We used previously collected MedPAR and OSCAR/CASPER survey data. PRINCIPAL FINDINGS We find greater observed referral concentration among freestanding SNFs is associated with lower percentages of patients with pressure sores (coefficient, -2.64; 95% CI, [-2.82 to -2.46]), catheters (-0.55; [-0.74 to -0.36]), and physical restraints (-0.16; [-0.29 to -0.03]) at admission to a skilled nursing facility. CONCLUSIONS We find evidence that freestanding SNFs with stronger hospital referral relationships may be admitting less risky patients, possibly contributing to disparities across SNFs.