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Frequency and Costs of Hospital Transfers for Ambulatory Care-Sensitive Conditions
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Frequency and Costs of Hospital Transfers for Ambulatory Care-Sensitive Conditions

R. Neal Axon, MD, MSCR; Mulugeta Gebregziabher, PhD; Janet Craig, PhD, RN; Jingwen Zhang, MS; Patrick Mauldin, PhD; and William P. Moran, MD, MS
This article outlines the frequency of transfers of patients with ambulatory care-sensitive conditions from nursing homes to emergency departments or hospitals, and provides reliable estimates of associated costs.
Table 1 describes the types of treated ACSCs grouped according to acute and preventable conditions or chronic conditions. Over the 3-year study period, 4680 patients were treated in the ED and/or hospital for a total of 5433 episodes of acute and preventable conditions. Dehydration/volume depletion and kidney/urinary tract infections were the most frequent acute ACSCs treated. More patients were seen for chronic ACSCs than acute/preventable, with 8637 subjects treated for a total of 11,627 episodes of care per year. Hypertension, DM, and congestive heart failure were the most frequent chronic conditions treated.

Healthcare Utilization

Table 3 displays several domains of acute ED and hospital utilization in ACSC subjects compared with non-ACSC subjects. During the 3-year study period, the 20,867 NH patients experienced 27,382 episodes of care for ACSC compared with only 7200 episodes of care without ACSC. A significantly higher proportion of NH patients seen in the ED with ACSC diagnoses were subsequently admitted to the hospital (50.4% vs 24%; P <.0001). NH-to-hospital transfers representing hospital readmissions were not significantly different between the ACSC and non-ACSC condition groups (15.1% vs 16%; P = .26). ICU admission was almost twice as common in the ACSC condition group (10.2% vs 5.6%; P <.0001). Patients treated for ACSC diagnoses had higher mean numbers of ED visits per subject (1.5 vs 1.2; P <.0001) and hospitalizations per subject (1.3 vs 1.1; P <.0001) than did non-ACSC subjects, with the total number of ED visits and hospital visits occurring in similar proportions.

Attributable Costs

Table 4 highlights estimated costs for ED care and hospitalization among NH subjects transferred for ED care and hospitalization for ACSCs compared with non-ACSCs after adjustment for demographic factors and comorbid chronic diseases. Adjusted mean ED costs were approximately $100 more ($401 vs $294; P <.0001) for episodes of ED care for ACSC patients compared with non-ACSC patients. However, adjusted mean hospitalization costs were approximately $1900 less ($8356 vs $10,226; P <.0001) for ACSC patients compared with non-ACSC patients. Given the markedly higher numbers of ACSC subjects, total annual expenditures for ACSCs were significantly higher in each category. Model coefficients are displayed in Table 5.


This report represents the first study to analyze ED and acute hospital utilization in a Medicare cohort at the state level while using robust methods for estimating attributable healthcare costs. Our results confirm that a majority of patients transferred from NHs to hospitals for ED care and/or hospitalization are treated for ACSCs as a primary or secondary diagnosis. ACSC patients appear more likely to be admitted to the hospital from the ED and more likely to be admitted to the ICU, based on bivariate analyses. In fully adjusted regression models, overall utilization and Medicare expenditures are higher for patients with ACSCs transferred from NHs to EDs than for patients without ACSCs. Total annual costs were significantly higher in ACSC patients compared with non-ACSC patients. This is important because prior studies have suggested that early access to primary and preventive care may obviate or diminish the need for acute care in patients with these conditions. Clearly, most acute care transfers are likely appropriate, especially in instances of critical illness. However, our results suggest that additional measures to improve onsite management of ACSCs might prevent avoidable NH-to-acute care transfers among stable patients and/or decrease the severity of illness among patients destined to require acute care transfers. Both of these phenomena could have favorable effects on healthcare utilization and expenditures.

Previously successful strategies to reduce NH-to-ED transfers and hospitalizations have focused on improving access to care through innovative payment policies, improving care quality for specific diseases, and increasing referrals for hospice care.30-32 For example, Casarett and colleagues (2005) introduced a simple communication intervention to identify NH patients and families whose care preferences were congruent with palliative approaches to care.32 Patients randomized to this intervention had higher hospice enrollment rates, half as many acute hospitalizations, and fewer days spent in acute care hospitals. Kane and colleagues (2004) described the effects of an innovative Medicare payment program that increased the availability of NPs to NH residents.30,33 Intervention patients had half as many hospitalizations (2.43 per 100 patients per month vs 4.67 per 100 patients per month; P <.001) compared with control patients at other facilities, as well as 9% lower hazard for mortality compared with non-intervention patients at the same facilities. The program was estimated to save $103,000 per year per NP.

Regarding clinical management interventions, Loeb and colleagues (2006) demonstrated in a cluster-randomized trial that early initiation of a clinical pathway for onsite treatment of pneumonia resulted in a 12% absolute reduction in hospitalizations (95% CI, 5%-18%; P <.001) and a trend toward decreased mortality. This intervention was also evaluated to be cost-effective, estimated to save $1016 per resident (95% CI, $207-$1824).31

Unfortunately, the innovations described here have not been widely disseminated, and many NH professionals still regard access to timely, well-informed evaluations for acutely ill residents as a significant limitation in most nursing homes.13 Many have called for new and effective strategies to reduce NH transfers and hospitalizations given that prior efforts at NH regulation and market-based incentives have had only modest effects on quality metrics.34

Limitations and Strengths

This report should be evaluated in light of its limitations. First, our analysis involves a single state, South Carolina, and the observed frequencies and costs of acute care for ACSCs may not be generalizable nationally. However, based on 2006-2007 data from the Commonwealth Fund, South Carolina ranked 28th in the nation in Medicare hospital admissions per 100,000 beneficiaries, near the median national rate.35 Second, our data set did not include information on costs related to ambulance transportation. Grunier and colleagues reported that in 1 cohort of long-term care patients, more than 90% of patients transferred to the ED-required ambulance transport. 6 Thus, our results may underestimate total costs associated with ED and hospital transfers, especially for Medicare patients. We analyzed costs in aggregate without breaking them down into relevant cost centers. Thus, we are unable to comment on, for example, the relative contribution of radiographic tests versus laboratory testing or pharmacy costs. Finally, there were baseline differences in the prevalence of several chronic conditions between patients in the ACSC condition group and the non-ACSC condition group. It is possible that differences in severity of illness influenced patients’ clinical conditions and/or provider decision making during episodes of acute illness. Nevertheless, non-ACSC subjects had high levels of chronic disease, including heart disease, dementia, chronic kidney disease, depression, stroke, and cancer.

This study has relative strengths as well. We were able to examine a large cohort and to outline frequency and attributable costs for the acute care of ACSCs in Medicare. Our cost estimates include both ED and inpatient costs and represent actual payments received by Medicare, preferable to examining hospital charges as has been done in previous reports.26


Our findings have several implications for healthcare policy makers and intervention developers. CMS, in provisions related to the Affordable Care Act (ACA), has recently encouraged the development of community-based care transitions programs, as well as pilot initiatives, specifically focused on reducing avoidable NH transfers.36,37 Section 3025 of the ACA established penalties for hospitals with higher-than-expected risk-adjusted hospital readmission rates for congestive heart failure, an ACSC, and COPD was added to this list in 2014.38 Finally, several bundled care demonstration projects are under way for posthospital care that aim to improve care transitions for Medicare enrollees.39 All of these endeavors can benefit from reliable estimates of cost attributable to ACSCs among NH residents.

In considering potential interventions to reduce acute care transfers, it is plausible to hypothesize that real-time video teleconferencing might overcome barriers that restrict access to onsite physician and NP providers in NH settings. This redesign of the delivery system could be easily coupled with decision support similar to successful clinical management pathways for ACSC conditions as in prior clinical trials.31 Wade and colleagues (2010) reviewed 36 trials utilizing real-time video telehealth interventions in a variety of settings, and the majority of these interventions offered health outcomes superior or equivalent to those handled in person, and they were deemed cost-saving or cost-neutral.40 Real-time video telehealth has been used successfully in rural settings to increase subspecialty physician access, as well as in the home setting to improve chronic disease management.40,41 Daly and colleagues (2005) demonstrated the feasibility of establishing real-time videoconferencing in NHs, but no trial to date has assessed the effectiveness of this type of intervention.42 One barrier to implementation of telehealth and other interventions relates to expected cost outlays and estimating potential cost savings. Our analysis should prove useful to intervention developers in this respect.

In conclusion, we observed that a majority of Medicare patients transferred from NH to acute-care settings had at least 1 ACSC, and associated costs were substantial.

Author Affiliations: Ralph H. Johnson VA Medical Center, Health Equity and Rural Outreach Innovations Center (RNA), Charleston, NC; Division of General Internal Medicine and Geriatrics (RNA, JZ, PM, WPM) and Department of Public Health Services (MG), the Medical University of South Carolina, Charleston, SC; Clemson University School of Nursing, Clemson, SC, and Health Sciences South Carolina (JC), Columbia, SC.

Source of Funding: This project was supported by the South Carolina Clinical & Translational Research Institute, with an academic home at the Medical University of South Carolina, through NIH grant numbers UL1 RR029882 and UL1 TR000062.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (RNA, JC, MG, PM); acquisition of data (RNA, JC); analysis and interpretation of data (RNA, JC, MG, WPM, JZ); drafting of the manuscript (RNA, MG, JZ); critical revision of the manuscript for important intellectual content (RNA, MG, WPM, PM); statistical analysis (JC, MG, JZ); provision of study materials or patients (JC); obtaining funding (RNA, JC, WPM, PM); and supervision (RNA).

Address correspondence to: R. Neal Axon, MD, MSCR, Ralph H. Johnson VAMC, 109 Bee St, Charleston, SC 29401. E-mail:
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