Vitaland

HealthStatistics

Effects of the

Prospective Payment

System on Nursing

Homes

Series 13:

Data From the National Health Survey

No, 98

This report presents statistics on the utilization of non-Federal short-stay

hospitals and nursing homes by persons aged 65 years and over.

Estimates are based on data collected in the 1982-85 National

Hospital Discharge Surveys and the 1977 and 1985 National Nursing

Home Surveys, Measurements of hospital utilization are by frequency,

percent, and average length of stay from 1982 through 1985, Nursing

home use is examined by demographic characteristics, functional

status in the activities of daily living, and diagnosis.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service

Centers for Disease Control

National Center for Health Statistics

Hyaftsville, Maryland

March 1989

DHHS Publication No. (PHS) 89-1759
Copyright information

All material appearing In th,ls report IS In the public domalr) and may

be reproduced or copted wtthout permtsston, cltat!on as to source.

however, is appreciated

Suggested citation

Hing E. 1989. Effects of the prospectwe payment system on nursing

homes. National Center for Health Statistics. Vital Health Stat 13(98).

Library of Congress Cataloging-in-Publication Data

Hlng, Esther

Effects of the prospective payment system on nursing homes

(Vital & health statlsttcs Ser!es 13, Dala from

the Nat[onal Health Survey no 98} (DHHS publication

no [PHS) 89–1759)

Data from the National Hospttal Discharge Survey

and the National Nursing Home Survey conducted by the

National Center for Health Stat! stlcs

B, bl(ography: p.

Supt of Dots no HE 20.620913/98

1 Nursing homes—United States— Utlllzat!on —

Statistics 2 Nursing homes—United States— Prospectlve payment I National Hospital Discharge Survey

,

(U S.) II Nattonal Nurstng Home Survey (U. S.)

Ill National Center for Health Statlstlcs (U S )

IV Title V Series Wtal and health statistics

Series 13, Oata from the nat!onal health survey no 98

VI Series DHHS publlcat, on ; no (PHS) 89–1 759

[DNLM 1 Nursing Homes— Un!ted States 2 Prospective

Payment System—United States. W2 A N148vm no.98]

RA997 H565 1989 3621 ‘6’0973 88–600431

IS8N 0–8406–0404–1

For sale IJYthe Superintendent of Documents, U.S. Government Printing 05ce

\Vashington, D.(’, 20402
National Center for Health Statistics

Manning Feinleib, M.D., Dr.P.H., Director

Robert A. Israel, Deputy Director

Jacob J. Feldman, Ph.D., Associate Director for Analysis

and Epidemiology

Gail F. Fisher, Ph.D., Associate Directorfor Planning and

Extramural Programs

Peter L. Hurley, Associate Director for V2tal and Health

Statistics Systems

Stephen E. Nieberding, Associate Director for Management

Charles J. Rothwell, Associate Director for Data Processing

and Services

Monroe G. Sirken, Ph. D., Associate Director for Research

and Methodology

Sandra S. Smith, Public Affairs Oficer

Division of Health Care Statistics

W. Edward Bacon, Division Director

Joan F. Van Nostrand, Deputy Director

Evelyn S. Mathis, Chie$ Long-Term Care Statistics Brcmch
-. .

l.ntroductlon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Sources and limitations ofdata. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Hospital usebyelderly patients discharged to long-term care institutions: 1982-85 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Changes in nursing home use by elderly residents admitted in 1977 and 1985 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Hospital use by elderly residents admitted from hospitals in 1985 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Changes in case mix ofelderly residents admitted from hospitals in1985and 1977. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Medicare casemix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Case mixbyfacility certification.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Useofnursinghomes by discharged residents admitted from hospitals in 1976 andin 1985 . . . . . . . . . . . . . . . . . . . . . . .

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

List ofdetailed tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Appendixes

I. Sources of data . - -- . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . - - . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

IL Definitions ofterrns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

III. Notes on age-adjusted rates... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

IV. Notes on standard errors and statistical tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Listoftextfigures

1. Medicare-covered days per 1,000 beneficiaries in skilled nursing facilities, byyerm United States, 1977–84 . . . . .

2. Percent distribution of nursing home residents aged 65 years or over at admission by length of stay since

admission: United States, 1985 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

List of text tables

A.

B.

c.

D.

E.

Medicare short-stay hospital average length of stay in days, by year and waiver status: United States, 1982-85..

Average number ofdependencies in activities ofdaily livingbyagq and age-adjusted rate for residents 65years

of age and over at admission, admittedin 1977 andin 1985, by hospitalization statux United States, 1977and

1985 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Number,and percent distribution ofresidents 65 years ofage and over atadmission, transferred from short-stay

hospitaIsin 1985, bywaiver status, average hospital Iengthofstayin days, and average number ofdependencie%

United States, 1985 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Number ofresidents 65 years ofage and over at admission, transferred from short-stay hospitals in1985, and

percent distribution by selected characteristics, accordingto Medicare status atadmission, withaveragelength of

stay, average age, and percentof residents with selected diagnosex United States, 1985.. . . . . . . . . . . . . . . . . . . .

Percentofnursing home residents65 years ofage and over atadmission, transferred from short-stay hospitals in

1985, by type ofdependency in activities ofdaily living and Medicare status atadmission, percent distribution by

number of dependencies, and average number of dependencies, according to Medicare status at admissiom.

United States, 1985 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

1

1

3

6

9

10

10

13

14

17

18

20

28

31

34

35

4

6

5

8

9

11

12

...

Ill
F. Number of residents 65 years of age and over at admission, transferred from short-stay hospitals in 1977 and in

1985, average number of dependencies in activities of daily living, by age, and age-adjusted rate, by Medicare

status in month before interview United States, 1977 and 1985 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. !,... 12

G. Average number of dependencies in activities of daily living, by age; and age-adjusted rate for residents 65 years

of age and over at admission, transferred from short-stay hospitals in 1977 and in 1985, by facility certification:

United States, 1977 and 1985 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

H. Number and percent distribution of nursing home discharges 65 years of age and over at admission to nursing

homes in 1985 by discharge status, according to hospitalization status United States, 1985 . . . . . . . . . . . . . . .. . . . 14

J. Percent distribution of nursing home discharges 65 years of age and over at admission to nursing homes in 1985

by selected characteristics, according to hospitalization status; and percent of those residents by selected primary

diagnosis and type of dependency, with average length of stay in days and average agti United States, 1985,,... 15

K. Number of nursing home discharges 65 years of age and over at admission to nursing homes in 1985, and penxmt

distribution by length of stay and hospitalization status, according to Medicare status at discharge: United States,

1985 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . 15

L. Number of nursing home discharges 65 years of age and over using Medicare for primary or secondary payment

at the time of discharge and admitted in 1976 and 1985; percent distribution by selected patient characteristics,

and percent of discharges by selected primary diagnosis: United States, 1977 and 1985 . . . . . . . . . . . . . . . . ..,, . . . 16

Symbols

- - - Data not available

. . . Category not applicable

Quantity zero

0.0 Quantity more than zero but less than

0.05

z Quantity more than zero but less than

500 where numbers are rounded to

thousands

* Figure does not meet standard of

reliability or precision

# Figure suppressed to comply with

confidentiality requirements
Effects of the

Prospective Payment

System on Nursing

Homes

by Esther Hing, Division of Health Care

Statistics

Introduction

Background

Medicare is a federally administered health insurance

program for persons aged 65 years and over and for

disabled persons who are eligiile for benefits. Medicare’s

hospital insurance pays for medically necessary inpatient

hospital care and, after a hospital stay, for inpatient care in

a skilled nursing facility and for home care serviees in the

home. Implementation of the Medicare program in July

1966 provided greater access to inpatient care for the

majority of elderly individuals (Lubitz and Deacon, 1982).

Medicare costs for inpatient hospital cme have continued to increase since the onset of the program. In an

attempt to control the growth of Medicare hospital costs,

the Health Care Financing Administration (HCFA)

changed the basis of hospital reimbursement in 1983. Under the Tax Equity and Fiscal Responsibility Act of 1983,

hospitals were reimbursed for inpatient care for Medicare

patients based on a prospective payment system (PPS)

rather than retrospectively, as was done previously. Under

this system, hospitals are reimbursed a preestablished

amount based on the diagnosis-related group (DRG) to

which a patient’s illness is assigned. Diagnosis-related

groups are mutually exclusive categories of conditions and

treatments used to classify patients into groups that are

clinically coherent and homogeneous with respeet to resource use.

The PPS using DRG’s was implemented on October 1,

1983. Individual hospitals were started in the system beginning with their first fiscal year after this date. By the end of

September 1984, virtually 100 percent of hospitals subject

to this new payment system were operating under PPS.

Hospitals in Maryland, Massachusetts, New Jersey, and

New York were waived from inclusion in PPS from its

inception, because they were participating in demonstrations of other payment systems. Waivers for New York and

Massachusetts ended in fiscal year 1986, and Maryland and

New Jersey currently retain waiver status.

Under PPS, hospitals earn a profit when their costs fall

below the prospective payment per case or absorb a loss

when their costs exceed the prospective payment. Therefore, there are strong incentives for hospitals to limit costs

incurred by Medieare patients by controlling the amount of

services provided or by limiting the length of stay.

The effects of this new system were highly visible.

During the first year of PPS, the decrease in hospital length

of stay was more pronounced than had been projected,

while admission rates fell. Supply capacity was also affected: The number of short-stay hospital beds decreased,

and the occupancy rate decreased from 73.7 percent in

fiscal year 1983 to 67.7 percent in fiscal year 1984 (AHA,

1984). At the same time, hospital profits increased during

the first year of PPS, primarily beeause of the reduced

length of stay and associated cost reductions (Guterman

and Dobson, 1986).

Beeause PPS gives hospitals strong incentives to reduce

patient length of stay, an increase in the rate of transfers to

long-term care providers is expected (Guterman and

Dobscm, 1986; Lave, 1985). Another effect of interest to

researchers is the “sicker and quicker” issue. According to

E~ers (1987), “concerns have been raised that shorter

lengths of stay (quicker) will lead to patients being discharged in a less stable medical condition (sicker).” This

may also be manifested in changes in outcome measures,

such as mortality and rehospitalization rates.

This report examines the impact of PPS on nursing

home care by presenting estimates of the numbers of

elderly patients transferred from hospitals to nursing

homes and other long-term care institutions. Data presented are horn the National Hospital Discharge Survey

(NHDS) and the current resident and discharged resident

surveys of the National Nursing Home Survey (NNHS).

Viewed together, estimates horn these nationally representative surveys provide a more complete description of the

changes in nursing home utilization that have taken place

since the introduction of PPS than have previously been

available.

Sources and limitations of data

The NHDS and the current and discharged resident

surveys of the NNHS are nationwide sample surveys of

hospital discharges and nursing home patients, respectively,

conducted by the National Center for Health Statistics

(NCHS). The NHDS is a continuous survey of patients

discharged from noninstitutional general and specialty hospitals. The NHDS obtains its information directly from

hospital reeords of inpatients discharged from short-stay

1
hospitals, exclusive of Federal hospitals, located throughout

the 50 States and the District of Columbia. Information is

abstracted from the face sheets of a sample of inpatient

records in a sample of hospitals. For example, in 1985, 414

hospitals participated in the survey, submitting approximately 194,000 abstracts; and in 1982, 426 hospitals took

part in the survey, supplying about 214,000 abstracts. In this

report, data from the 1982–85 NHDS are presented for

patients 65 years of age and over–the patients most affected by changes in the Medicare system.

Data on nursing home residents are from the current

resident surveys of the 1977 and 1985 NNHS. The NNHS is

a nationwide sample survey of nursing homes and their

residents, discharges, and staff. The scope of the NNHS

encompasses all types of nursing homes, including personal

care and domiciliary care homes, in the conterminous

United States. The sample of current residents in the 1985

NNHS consisted of 5,243 residents in the 1,079 nursing

homes participating in the survey; the sample of current

residents in the 1977 NNHS consisted of 7,033 residents in

1,451 participating nursing homes. Residents included in

the 1985 and 1977 NNHS were those on the nursing home’s

roster the night before data collection began. Data were

collected by interviewing knowledgeable nursing home staff

members, who referred to the residents’ medical records

when necessary. In this report, data from the current

resident survey of the NNHS are presented on current

residents aged 65 years and over at admission entering

nursing homes in 1977 and 1985, according to whether or

not they were admitted from short-stay hospitals.

Data presented on nursing home discharges are from

the 1977 and 1985 NNHS. Estimates of discharges from the

1977 and 1985 NNHS are based on samples of 5,142 and

6,023 discharges, respectively, from participating nursing

homes. The 1985 survey covered all persons discharged

from 12 months prior to the survey date to the day immediately before the survey date. Thus the discharge sample

was composed of persons discharged from the sample

nursing homes from August 1984 through January 1986.

(The survey was conducted from August 1985 through

January 1986.) The reference period for discharges in the

1977 NNHS was calendar year 1976. For both survey years,

data were collected by interviewing nursing home staff, who

referred to the discharged resident’s medical record. For

convenience, the terms “discharges” and “discharged residents” are used interchangeably in this report. Estimates

from the 1985 discharged resident survey are comparable

to the 1985 current resident estimates in that all discharges

aged 65 years and over transferred from short-stay hospitals in 1985 or later are examined. Data from these two

NNHS patient samples, together with data from the NHDS,

give a more complete description of the population aged 65

years and over moving horn hospitals to nursing homes

than if only one of these surveys is examined.

A primary difference between the NHDS and NNHS

discharge data and the current resident data from the

NNHS is that the discharge data reflect annual discharge

events (hospital or nursing home discharges) rather than

cross-sectional (point) estimates of the number af patients

in nursing homes on any given day during the survey period.

Sampled patients who were discharged more than once

during a calendar year were included in the discharge

samples as multiple discharges. In contrast, the current

resident sample from the NNHS reflects patients concurrently (at the time of the survey) residing in the nursing

home. Because the current resident sample is selected from

all patients on the facility roster the night before t!hesurvey,

however, the data tend to over-represent residents with

long nursing home stays and to under-represent residents

with short stays. More details on the survey methc~dology of

the NHDS and the NNHS are presented in appendix I.

In appendix II, definitions of terms used in this report

are presented. Reference to definitions is essential to the

interpretation of the data.

In this report, two types of morbidity rate are presented: crude rates and age-adjusted rates. The method of

computing age-adjusted rates is found in appendix 11~

appendix IV contains a brief discussion of sampling errors

for estimates that were not age-adjusted.

For the rates that were not age-adjusted, termnssuch as

“similar” and “the same” mean that there is no statistically

significant difference between the rates being compared.

Terms such as “greater than” or “less than” indicate that

the difference is statistically significant. Lack of comment

regarding the difference between any two statistics does not

mean that the difference was tested and found not to be

significant. For more details on statistical tests performed,

see appendix IV.

Because the age distribution of nursing home residents

in 1985 differs from that of nursing home residents in 1977,

this report contains some age-adjusted rates. For example,

the proportion of residents aged 85 years andl over increased from 35 percent in 1977 to 40 percent in 1985

(NCHS, 1989). Use of age-adjusted rates assumes identical

age distrl%utions of all groups, making age-adjusted rates

useful when examining relationships among groups with

divergent age distributions. The unadjusted (crude) rates,

however, should be quoted rather than the age-adjusted

ones. References to rates in this report are to the unadjusted ones unless otherwise stated.
Hospital use by elderly

patients discharged to

long-term care

institutions: 1982-85

Between 1982 and 1985, there were nationwide declines in hospital discharge rates and length of stay according to data from two surveys conducted by NCHS: the

National Health Interview Survey (NHIS) and the NHDS

(NCHS, 1987a). Declines in the hospital discharge rate

ocmmred for all four major age groups and both sexes.

Hospital discharge rates for the elderly decreased 10 to 12

percent between 1983 and 1985, and the average length of

stay for the elderly decreased 11 to 14 percent behveen

1982 and 1985, according to data from the NHIS and the

NHDS (NCHS, 1987a).

Table 1 shows that between 1982 and 1985, the number of elderly discharges from hospitals remained constant

at about 11 million. The number of elderly patients discharged to long-term care institutions, however, increased

36 percent belsveen 1982 and 1985, and the percent of

elderly discharges transferred to long-term care institutions

also increased significantly during the same period (from

8 percent in 1982 to 11 percent in 1985). Medicare program statistics show similar trends. Belsveen 1981 and 1985

admissions to skilled nursing facilities (SNF’S) per 1,000

Medicare enrollees increased from 9.6 to 11.8 (Guterman

et al., 1988). The number of SNF days per 1,000 enrollees

also increased between 1982 and 1984 (figure 1). These

findings confirm a tendency under PPS for the demand for

long-term care services to increase as had been predicted

(Meiners and Coffey, 1985; Guterman and Dobson, 1986

Lave, 1985).

With the exception of the discharge status categories of

“Alive, disposition not stated” and “Transferred to another

short-stay hospital:’ the percent of elderly discharges in the

remaining discharge status categories remained the same

between 1982 and 1985. The percent of elderly patients

discharged alive with unknown dispositions decreased

60 percent between 1982 and 1985. Although it is possible

that the change in percent transferred to long-term care

institutions after the start of PPS is merely a reflection of

better reporting of discharge status by hospitals, Medicare

statistics suggest that the increase is real. Furthermore, the

reduction in percent of elderly live discharges with unknown disposition may reflect built-in incentives for hospital management efficiency under PPS. According to

Guterman and Dobson (1986), and Alsofrom (1983),

improvements in hospital management and hospital administrative data systems are some of the expected outcomes of

PPS. The percent of elderly patients transferred to another

short-stay hospital increased from 2 percent in 1982 to

3 percent in 1985.

Table 1 also shows the average length of stay for elderly

patients, by discharge status, between 1982 and 1985. Overall, the average length of stay declined 14 percent during

this time for elderly patients discharged horn hospitals.

This decline primarily reflects the reduction in length of

stay for elderly patients routinely discharged home, transferred to long-term care institutions, or discharged dead.

Differences in average lengths of stay for the remaining

discharge status categories between 1982 and 1985 were

not statistically significant. The length of stay for elderly

patients routinely discharged home decreased 22 percent

between 1982 and 1985, and the declines in length of stay

for elderly patients transferred to a long-term care institution and for those discharged dead were 18 and 12 percent,

respectively. Despite the dramatic decline in length of

hospital stay between 1982 and 1985, elderly patients transferred to long-term care institutions tended to have the

longest hospital stays of the discharge status categories

shown in table 1. In 1985, the average length of stay for

elderly patients transferred to long-term care institutions

was 12.9 days, compared with 5.8 to 11.5 days for the

remaining discharge status categories. Elderly residents

discharged dead (11.5 days) and those transferred to another short-stay hospital (10.2 days) had relatively long

stays on the average, but not as long as for those transferred

to long-term care institutions. Elderly patients who left

against medical advice (5.8 days) and those routinely discharged home (7.8 days) tended to have the shortest average hospital stays.

The tendency of elderly patients transferred to longterm care institutions to have longer hospital stays than

other patients was ako noted by Meiners and Coffey

(1985). In their study of discharges from Maryland hospitals, they found that patients referred to long-term care

services tended to stay longer than other patients within the

same DRG category.

Table 2 shows the number of discharges, percent distrl%ution, and average lengfh of stay for the 20 most

frequent DRG’s for elderly patients transferred to longterm care institutions in 1985. The most common DRG for

elderly patients transferred to long-term care institutions

was “specific cerebrovascular disorders except transient

ischemic attack~’ followed by “simple pneumonia and pleurisy, age 70 or over, and/or substantial comorbidity and

3
370 -

360

350

w

.-s!

.-z

.s?

%

5 340

n

o

0

0-

k

Q

~ 330

G

-a

Y

a

$

: 320

z

u

5

#

;

310

300

/

o A

1977 1978 1979 1980 1981 1982 1983 7984

Calendar year

SOURCE: Health Care Financing Administration, Bureau of Data Management and Strategy. Unpublished data from the Medicare Statistical Svstem.

Figure 1. Medicare-coverad days per 1,000 beneficiaries in skilled nursing facilities by year: United States. 1977-S4

complication, “ “hip and femur procedures except major

joint, age 70 or over, and/or substantial comorbidity and

complication,” and “heart failure and shock.” These top

four DRG’s were also among the top four DRG’s for

discharges to nursing homes in Maryland noted by Meiners

and Coffey. Together, the 20 DRG’s presented in table 2

account for 56 percent of all DRG’s for the 1.2 million

elderly patients discharged to long-term care institutions in

1985.

For purposes of comparison, table 3 presents the 20

most frequent DRG’s for elderly patients routinely discharged home. Although many of the DRG’s for elderly

patients discharged home also were common to elderly

patients transferred to long-term care institutions, the rankings varied for these two types of discharges. For example,

the top three DRG’s for elderly patients transferred to

long-term care institutions—’’specific cerebrovascular dis4

orders except transient ischemic attack,” “simple pneumo- -.

nia and pleurisy, age 70 or over, and/or substantial

comorbidity and complication,” arid “hip and femur procedures, except major joint, age 70 or over, and/or substantial

comorbidity and complication’’-were ranked 7tlh, 4th, and

31st, respectively, for elderly patients discharged home

(table 4). Other differences in DRG’s between these two

types of discharges are the presence among long-term care

transferees of DRG categories that reflect mental disorders

and behavioral problem~ “organic disturbances and mental

retardation” and “psychoses.” These two DRG’s were absent from the top 20 DRG’s for elderly patients discharged

home. Another difference in DRG’s for these two types of

discharges is the greater diversity of DRG’s amcmg elderly

patients discharged home. Although the top 20 IDRG’s for

elderly patients discharged to long-term care institutions

applied to 56 percent of all these patients, the
top 20 DRG’s for elderly patients discharged home accounted for only 43 percent.

Table 4 shows the average lengths of stay for elderly

patientstransferredto long-term care institutionsand for

those dischargedhome, according to the top 15 DRG’s for

elderly patientstransferredto long-term care institutions.

With the exceptionof the DRG categories “hip and femur

procedures, except major joint, age 70 or over, and/or

substantialcomorbidity and complication,” “major joint

procedures: “septicemi~ age 18 or over;’ and “gastrointestinal hemorrhage, age 70 or over, and/or substantial

comorbidityand complication,” the average length of stay

waslonger for elderlypatientsdischargedto long-termcare

institutions than for elderly patients discharged home

withinthe same DRG category. For example, stroke patientswithin the DRG catego~ “specific cerebrovascular

disorders except transientischemic attack” transferredto

long-term care institutionshad longer average hospital

stays (15.0 days) than did stroke patientswith the same

DRG who were dischargedhome (11.6 days). Similarly,for

elderlypatientswithintheDRG category “heartfailureand

shoc~ there was a difference of 4.5 days in the average

lengthof staybetween elderly patientsdischargedto longtermcare institutionsand elderlypatientsdischargedhome.

These findings are similar to those reported earlier for

Marylandhospitaldischargesby Meinersand Coffey.

The difference in lengthof staybetween dischargesto

long-term care institutionsand discharges home may be

influencedby the seriousnessof the patient’smedical conditionthatis not reflected in the assignedDRG categoryor

by the rate of supply (specifically, undersupply) of longterm care services. If the undersupply of long-term care

servicesis in fact responsiblefor thebackloggingof hospital

patientsand the difference in length of stayfor these two

types of discharges, it is a problem that preceded the

introductionof PPS (Feder and ScanIon,1982; Comor and

Green, 1983).

The datapresentedthus far are nationalestimatesthat

mask certain differences by reimbursementsystems.During the period 1982to 1985, not all Medicare-participating

hospitals were operating under PPS. Hospitals in four

States (Matyland, Massachusetts,New Jersey, and New

York) were waived from PPSbecause theywere participating in other payment systemsduring that time. To show

how hospitalsoperatingunder PPS differed from hospitals

operating under other payment systems,table A presents

the Medicare average length of stayfor waiverStates (the

Table A. Medicare short-stey hospitel ●verage length of stsy in

days, by yew ●nd waiver status: United Ststes, 1982-85

Yesr

WatverSmfus 198.2 1983 1984 1985

Average length of stay in days

All States . . . . . . . . . . . . . . . . . . 10.3 10.0 9.1 8.4

WaMer Stafes . . . . . . . . . . . . . . . . 13.6 13.2 127 11.9

Prospectke payment system States. . 9.8 9.5 8.5 7.9

SOU~ K. Seebe, W. Calla!mn,andA. MarkuKI.1958. Medicareskrt-stay Fcspitdlength

of -Y, fkal yews 19S1-18@5.Mh Cam?l%snc@ReWW7(S~l19-125.

four States mentioned above) and PPS States (all other

States) for 1982 through 1985. During this period, the

Medicare average len@h of staywas insistently longer in

thewaiverStates(11.9 to 13.6 dayson theaverage)thanin

the PPS States (7.9 to 9.8 days on the average). This is in

part due to the historically longer hospital stays in the

Northeast-which incIudes three of the waiver States

(Massachusetts,New Jersey,and New York)–than in the

rest of the country. Between 1983 and 1985, however,the

percent decline in average length of stay for Medicare

patientswas greater in PPS States(17 percent) thanin the

four waiverStates(10 percent) (K. Beebe, W. Callahan,and

A. Mariano, 1986). And although the Medicare hospital

discharge rate in PPS Statesdeclined 3.5 percent between

1983 and 1984, the discharge rate in waiver States increased 1 percent during the same time (Eggers, 1987).

There was, however, a slower rate of growth in the waiver

Statesbetween 1983 and 1984thanbefore PPS. According

to E~ers, the slower rate of growth in dischargerateand

the decline in lengthof stayinwaiverStatesmay “represent

a spillover effect of PPS.” Apparently, providers in the

waiver States “were reacting to the PPS changes in ways

similar to providers in PPS States” (Eggers, 1987). The

same phenomenon was also observed for non-Medicare

patients.For example, declines in hospitzdutilizationrates

for childrenafter the introductionof PPSwere reportedby

Kozak et al. (1987) and NCHS (1987a).

In the remainderof thisreport, dataiiom the National

NursingHome Surveyare presented.The NHDS provided

annual estimates of elderly patients transferred to longtermcare institutions(primarilynursinghomes); datafrom

the NNHS in the next section of the report show the

characteristicsof the patientpopulation residingin nursing

homes on any given day of the surveyperiod.

5
Changes in nursing

home use by elderly

residents admitted in

1977 and 1985

In 1985, an estimated 1,491,400 residents lived in

19,100 nursing homes nationwide (NCHS, 1987b). Of these

residents, 1,266,300, or 85 percent, were aged 65 years or

over at the time of admission. In the remainder of this

report, the term “elderly” refers to residents 65 years or

older at the time of admission. This subset of the nursing

home +population is examined to mimimize age differences

between current residents from the NNHS admitted from

hospitals and persons transferred from hospitals to longterm care institutions as reported in the NHDS. Of these

elderly nursing home residents, 39 percent had been admitted from short-stay hospitals. This proportion was significantly higher than the proportion in 1977 (table 5).

At the time of the survey, most elderly nursing home

residents had long stays in the facili~, 63 percent had

resided in the facility 1 year or more (figure 2). About

23 percent of elderly residents had been in the facility less

than 6 months, and 13 percent had been in the facility less

than 3 months. The mean length of stay since admission for

elderly residents, which is influenced by the range of cases,

was significantly longer (2.8 years) than the median length

of stay for elderly residents (1.7 years). The median length

of stay is the point in the distribution at which half of the

residents have shorter stays and half have longer stays.

Because of the generally long stays of the nursing home

resident population, a relatively small proportion were

directly affected by the changes brought about by PPS.

Table 5 shows that only 189,900 elderly residents had been

transferred tlom hospitals in 1985, the first full year in

which all designated hospitals were participating in PPS.

50

40

I 33.3

c

0

.- 30

;

g

.

~

-0

E

m

2 20

2

10

0 Less than 3 to less 6 to less 1 to I ess 3 to less 5 years

3 months than than than than or

6 months 12 months 3 years 5 years more

Length of stay

Figure 2, Percent distribution of nursing home residemts aged 65 yeare or over at admission by length of stay since admission:

United States, 1985

6
The difference between this NNHS estimate of elderly

residents admitted from short-stay hospitals in 1985 and the

NHDS estimate of elderly patients transferred to long-term

care institutions in 1985 (table 1) is primarily due to

methodologic differences in the surveys. The 1985 NNHS

estimate of elderly residents admitted from hospitals in

1985 is a point estimate of residents on any given day

during the survey period. Excluded horn this estimate are

residents admitted in 1985 but discharged before the survey

date (including those discharged dead), as well as residents

admitted in 1985 after the survey date. The NHDS estimate

of elderly patients transferred to long-term care institutions, in contrast, is an annual estimate of all discharges to

these institutions during calendar year 1985, including multiple discharges of the same patient to nursing homes. The

NHDS estimate also includes elderly patients going to

long-term care institutions other than nursing homes, such

as chronic disease hospitals and hospices.

Despite the inherent biases of the current resident

data, the strength of looking at the NNHS current resident

data in conjunction with the NHDS data is that the NNHS

current resident survey provides further information, not

available from hospital records, about nursing home use by

a definable subset of elderly patients transferred to longterm care institutions.

In this section of the report, elderly residents admitted

in 1985 are compared with a similar population of elderly

residents from the 1977 NNHS. Included in the 1977 study

population are all residents aged 65 years or over at

admission whose length of stay since admission was 357

days or less (the maximum length of stay for the 1985 study

population). The 1977 and 1985 data are compared to see

whether there was an increase in nursing home use by those

admitted horn hospitals after 1977. The benefits of limiting

the comparison to elderly residents (65 years and over at

admission) with lengths of stay of 357 days or less are as

follows

. The difference between the number of activities of

daily living (ADL) dependencies at the time of admission and the number at the time of the survey is

minimized, because of the short length of stay of the

study populations. The number of ADL dependencies

at the time of the survey is the main case-mix variable

examined in this report.

. Case-mix differences by length of nursing home stay

are controlled (the care needs of those recently admitted to the nursing home maybe different from those of

longer-staying patients, whose conditions may have

stabilized); and

. The under-representation of short-stay nursing home

patients, a bias inherent to the survey, should affect the

1977 and 1985 data equally, because the data cover

similar time frames.

Table 5 shows that 410,500 elderly residents were

admitted in 1985, the year of the survey. The comparable

estimate from the 1977 survey was 406,500. The estimate of

elderly residents admitted in 1985 includes a small number

of residents admitted in January 1986. (The data collection

period of the 1985 NNHS was August 1985 through January 1986.) These residents were included because their

average length of stay is more similar to that of residents

admitted in 1985 than of residents admitted before 1985.

Between 1977 and 1985 there was a slight, although not

statistically significant, increase in the percent of the study

populations transferred from short-stay hospitals-from

44 percent in 1977 to 46 percent in 1985. The lack of

change shown by these dat~ in contrast to the increased

long-term care use shown by the NHDS data, maybe an

indication of biases in the current resident data toward

long-stay residents. For example, suppose that the increased use of nursing homes is primarily by residents with

short nursing home stays. Their under-representation in the

current resident data might then preclude this phenomenon

from being measured. Later in this report, characteristics of

short-stay nursing home patients likely to be missed in the

current resident survey are examined using data from the

discharged resident survey of the 1985 NNHS. The discharged resident survey is more representative of nursing

home patients with short durations of stay than is the

current resident survey.

To show changes in patient characteristics betsveen the

1977 and 1985 study populations, table 6 presents demographic and diagnostic information. The average age of the

1985 study population is higher than that of the 1977 study

population, regardless of hospitalization status (whether

admitted from a short-stay hospital or not). In general, the

average nursing home stay was shorter for residents admitted tlom hospitals than for residents not admitted from

hospitals. Thk difference between average nursing home

stays by hospitalization status, however, was significant only

in 1977. A shorter average nursing home stay was also

found for the 1985 study population not admitted from

short-stay hospitals (133.2 days in 1985, compared with

149.3 days in 1977). The average nursing home stays for

residents admitted from short-stay hospitals in 1977 and in

1985 were similar.

Study residents admitted from short-stay hospitals in

1985 were more likely to be female than were 1977 study

residents. There were also changes in the ranking of the

most current primary diagnoses for residents not admitted

from short-stay hospitals. In 1985, residents not admitted

from hospitals were less likely (34 percent) to have primary

diagnoses involving diseases of the circulatory system than

were their 1977 counterparts (43 percent), but they were

more likely to have primary diagnoses involving mental

disorders (20 percent in 1985 compared with 13 percent in

1977).

Table 7 presents the functional status of the 1977 and

1985 study populations. Functional status is defined by the

need for assistance in performing the activities of daily

living. The ADL’s used in this report are bathing, dressing,

using the toilet room, mobility, continence, and eating.

(Mobility is used in place of transferring into or out of a

chair or bed, because transferring data were not available in

7
the 1977 survey.) The activities of daily living have been

found to begood predictors of resource use in long-term

care settings (Stassen and Bishop, 1983) and cost of care

(Cameron and Knauf, 1982).

Overall, the 1985 study population admitted from

short-stay hospitals were more dependent in ADL than

were their 1977 counterparts. For example, a greater proportion of 1985 than of 1977 residents admitted from

hospitals required assistance in bathing, dressing, using the

toilet room, and eating. In addition, a larger proportion of

1985 residents admitted from hospitals were incontinent of

bowels, bladder, or both (57 percent in 1985, compared

with 50 percent in 1977). The percents of hospitalized

residents who were dependent in mobility were similar for

1977 and 1985. In general, residents not admitted from

hospitals were less dependent than were residents admitted

from hospitals. However, in only two activities did residents

not admitted from hospitals require more assistance in

1985 than in 1977.

The six activities of daily living maybe summarized into

a single measure of ADL dependency by summing the

number of activities in which a resident receives assistance

(Katz and Akpom, 1976). The 1985 study population

tended to be more dependent in individual activities than

did the 1977 study population: The average number of

ADL dependencies for residents admitted from hospitals

was 4.5 in 1985 compared with 4.0 in 1977. Similarly, the

average number of ADL dependencies for residents not

admitted from short-stay hospitals was higher in 1985 than

in 1977 (3.6 in 1985 compared with 3.4 in 1977).

Because residents admitted in 1985 were older than

their 1977 counterparts, regardless of hospitalization status,

the number of ADL dependencies for the 1985 and 1977

study populations was age-adjusted (table B). After ageadjusting, the average numbers of ADL dependencies for

those admitted from short-stay hospitals in 1985 and 1977

were 4.5 and 4.1, respectively. Therefore, the greater dependency level of these 1985 residents cannot be accounted

for by their age structure. This was not the case, however,

for residents not admitted from short-stay hospitals. After

age-adjusting the average number of ADL dependencies,

the difference in this measure between 1977 and 1985

narrowed for those not admitted from hospitals.

Because PPS affects only nursing home residents admitted from short-stay hospitals, the remainder of this

section of the report focuses on this group only.

Table B. Average number of dependencies in activitiesof daily living by age; and age-adjusted rate for residents 65 years c)fage and

over at admission, admitted in 1977 and in 1985, by hospitalization status: United States, 1977 and 1985

Admitted from a shor$stay hospttal Not admitted from a shoti-stay hospital

Age and age-adjusted rate 19771 19852 19771 Ig&Jz

Avsrage number of dependencies

65yeare andover . . . . . . . . . . . . . . . . . 4.0 4.5 3.4 3.6

6&74years . . . . . . . . . . . . . . . . . . . . . 3.9 4.3 3.0 3.2

7$64years . . . . . . . . . . . . . . . . . . . . . 4.0 4.3 3.4 3.4

65-69 years . . . . . . . . . . . . . . . . . . . . 4.3 4.5 3.6 4.0

90years orover . . . . . . . . . . . . . . . . . . . 4.2 4.9 3.8 4.0

Age-adjusted rate s . . . . . . . . . . . . . . . 4.1 4.5 3.5 3.6

1 Matched with 1985 data on age and length d stay since admission.

2 Includes a small rwmber of residents admitted In January 1986.

3 ~e.adj@ed by t~ direct ~et~d to the 1985 resident ppdatlon agec 65 years and over In nursing homes, using 4 age grcups. Nursing tmme reslde~ population fi9ur= are from ~~ 1985

National Nursing Home Suwey.
Hospital use by elderly

residents admitted

from hospitals in 1985

Prospective payment was implemented in 1983-84;

therefore, DRG estimates for elderly residents admitted

from short-stay hospitals are available only for the 1985

study population. Table 8 presents the top 10 DRG’s for

elderly residents admitted from short-stay hospitals in 1985.

The top 10 DRG’s for nursing home residents are similar

to those presented earlier for hospital discharges. For

example, the top four DRG’s for nursing home residents

were the top four DRG’s for hospital discharge “specific

cerebrovascular disorders except transient ischemic

attack” “hip and femur proceckres except major joint, age

70 or over, and/or substantial comorbidity and complication: “simple pneumonia and pleurisy, age 70 or over,

and/or substantial comorbidity and complication,” and

“heart failure and shock.” Chronic conditions reflected in

the DRG categories— “degenerative nervous system disorders” and “diabetes, age 36 and over’’-however, were

ranked higher among nursing home residents than were

hospital discharges. These two DRGs were ranked 5th and

9th among nursing home residents admitted from hospitals

but were ranked 15th and 19th among hospital discharges

to long-term care institutions. Altogether, the 10 DRG’s

presented in table 8 accounted for 43 percent of the DRG’s

for elderly residents admitted from hospitals in 1985.

Table 8 also presents the average hospital length of stay

for the 1985 study population as reported by nursing home

staff. In six of the seven DRG’s common to table 8 and

table 2 (NHDS data), the average hospital lengths of stay

were statistically similar. The overall hospital length of stay

reported by nursing home staff, however, was longer than

that reported by NHDS (15.9 days for residents, compared

with 12.9 days from NHDS). The difference between these

two estimates may be due to methodologic differences

between the surveys. Because the current resident estimates tend to underestimate the number of short-stay

nursing home residents, the estimate of hospital length of

stay may also be affected. That is, it may be that residents

with longer nursing home stays also have longer hospital

stays.

As with the Medicare data, the overall hospital length

of stay masks differences by waiver status. Table C shows

that the hospital stays for residents transferred from hospitals in 1985 were higher for residents in the waiver States

(33.5 days, on the average) than for those in the PPS States

(12.4 days). Table C ako shows that the average numbers

of ADL dependencies were statistically similar for hospitalized residents in the waiver States (4.6 dependencies) and

for those in PPS States (4.4 dependencies). Based on the

assumption that the waiver status of the State of residence

had no effect on the fi.mctional status of the 1985 study

population, the analysis of case mix that follows includes

data for residents in the waiver States.

Table C. Number and percent distribution of residents 65 years of age and over at admission, transferred from short-stay hospitals in

1985, by waiver status, average hospital length of stay in days, and average number of dependencies United States, 1985

WuVerskdus

Prospectivepayment

Total Wa~er States systemStates

Averagehospftallengthof stayIn days and Percent Percent Percent

averagenumber of deparrdencles Number dislrlbtrllon Number dlstriwtion Number distritwtion

Allresldentsl . . . . . . . . . . . . . . . . . . . . . . 189,900 100.0 30,600 16.2 159,100 83.8

Average hospital length of stay in days. . . . . . . 15.9 33.5 124

Average number of dependencies. . . . . . . . . .

. . . . . .

4.4

. . .

. . . 4.6 . . . 4.4 . . .

i Includes a small rumbar or rasidents admltkd In Jmwary 1986.

9
Changes in case mix of

elderly residents

admitted from

hospitals in 1985 and

1977

The previous section on nursing home utilization

showed that the declines in hospital length of stay that

followed the introduction of PPS also affected patients

transferred to nursing homes. Between 1982 and 1985, the

average hospital stay for patients transferred to long-term

care institutions declined from 15.8 days to 12.9 days

(table 1). With shorter hospital stays, elderly patients transferred to nursing homes in 1985 tended to have greater

care needs (more ADL dependencies) than their 1977

counterparts had. To examine this change in case mix, this

section compares characteristics of elderly residents transferred from short-stay hospitals by Medicare status and

facility certification. Medicare status is examined because

residents using Medicare for payment of nursing home care

must be transferees from a hospital and thus are directly

affected by changes brought about by PPS. “Medicare

status in the month before interview” is examined for

changes in case mix of Medicare beneficiaries since 1977.

Medicare statistics have already shown increased utilization

of the Medicare skilled nursing facility (SNF) benefit since

the start of PPS.

Facility certification is examined for differences in case

mix between residents in facilities certified as skilled nursing facilities (including facilities dually certified as SNF and

intermediate care facilities) and facilities not certified as

SNF. The latter category includes facilities certified for

intermediate care only and those not certified (that is, not

participating in either the Medicare or Medicaid program).

Given the greater care needs of elderly residents transferred from hospitals in 1985, it maybe that skilled nursing

facilities (SNF) rather than those that are not so classified

are meeting the changing needs of the elderly transferred

from short-stay hospitals.

Medicare case mix

Medicare’s skilled nursing facility benefit was not designed to provide long-term care; rather, it was designed to

provide a less costly alternative to extended hospital stays,

where medically appropriate. Thus, Medicare’s coverage of

SNF services for up to 100 days is limited to patients who

have had 3 days of hospital care and need daily skilled

or rehabilitation services. For the first 20 covered days in an

SNF, the beneficiary pays no coinsurance. For days 21

through 100, however, the beneficiary is subject to a daily

coinsurance payment of one-eighth of the hospital

deductible ($50.00 in 1985). In 1985, the average per diem

rate for Medicare patients was $62.02” (NCHS, 1987b).

Thus, for Medicare beneficiaries using the SNF benefit,

out-of-pocket copayments during the 21st throu~gh 100th

day of their stay exceeded Medicare’s payment for care.

Medicare’s SNF coverage is limited, and the coverage

requirements are stringent. To qualify for Medicare’s SNF

benefit, the patient must have been certified by a physician

as needing daily skilled nursing care or related rehabilitative services, which as a practical matter can only be

provided on an inpatient basis in a skilled nursing facility. In

addition, the patient must have been admitted for further

treatment of a condition for which he or she was hospitalized, within 30 days of the previous discharge from the

hospital, with a stay of at least 3 days. In addition, coverage

of SNF benefits applies only as long as these level-of-care

requirements are met. Thus many patients admitted under

Medicare may have to switch to other payment sources

during their stays in nursing homes, because Medicare

coverage terminates when Medicare coverage requirements

are not met. In 1980, the average time in an SNF covered

by Medicare was only 30 days (HCFA, 1985). In contrast,

the average stay for all nursing home residents in 1985 was

2.9 years (NCHS, 1989).

Because of the limited coverage of SNF Medicare

benefits and the stringent level-of-care requirements necessary to qualify for coverage, utilization of Medicare in

nursing homes in 1985 was low. In 1985, Meclicare accounted for only 1.7 percent of nursing home expenditures,

but Medicaid accounted for 42 percent (Waldo, Levh, and

Lazenby, 1986). Medicaid is a joint Federal-State program

providing medical benefits to persons who qualify for welfare and to some of the “medically needy” (those who

would be on welfare if their incomes were a littlle lower).

The State-set criteria for Medicaid eligibility vary from

State to State but cover most poor people in thle United

States (Davis and Schoen, 1978). Data from the 1985

NNHS show similar trends. At the time of the survey, in

1985, 1.4 percent of nursing home residents used Medicare

as the primary source of payment; 50.4 percent c~fnursing

home residents relied on Medicaid as their primarily source

of payment (NCHS, 1989).

Of the 1985 study population admitted from hospitals,

the proportion using Medicare as a primary or secondary

payment source at admission (19 percent) is higher than for

all nursing home residents because of the relatively shorter

10
stays of the study population (Table D). However, even for

the 1985 study population transferred horn hospitals, the

majority (81percent) used payment sources other than

Medicare.

Table D compares selected patient characteristics for

residents admitted horn hospitals in 1985 by Medicare

status at admission. With the exception of shorter stays for

Medicare residents, the profiles of Medicare and nonMedicare residents are similar. For example, although it

appears that Medicare residents had more severe medical

problems, such as cancer, stroke, and hip fractures, the

difference between the percents of the Medicare and nonMedicare residents having these conditions was not statistically significant. The average nursing home stay for

Medicare residents (106.3 days) was significantly shorter

than that for residents using payment sources other than

Medicare (130.8 days). The average stay for Medicare

residents is more than 100 days (the maximum number of

days in an SNF that Medicare covers) because this figure

includes residents who used Medicare at admission but

later switched to another payment source.

Because Medicare residents, by definition of the SNF

benefi~ require intensive skilled nursing and rehabilitative

care, their care needs tend to be greater than those of

residents using other payment sources. Table E shows that

Medicare residents required assistance in activities of daily

living more often than did non-Medicare residents in four

of the six activities. There was no difference in the percent

requiring assistance in bathing or eating between Medicare

and non-Medicare residents. As a result of the generally

more dependent functional status of Medicare residents,

the average number of ADL dependencies for Medicare

residents (5.0) was greater than that for non-Medicare

residents (4.3).

Table F compares the case mix of Medicare and nonMedicare residents in 1977 and 1985. In comparing 1977

and 1985 current resident data, it should be noted that the

time frame for Medicare resident data changes from “at

admission” to “last month.” The “last month” time frame

was necessary for comparability, because information on

payment sources at admission is available only from the

1985 survey. It should also be noted that the estimate of

Table D. Number of residents 65 years of age and over at admission, transferred from shoti-stay hospitals in 1985, and percent

distribution by seiected characteristics, according to Medicare status at admission, with average iength of stay, average age, and

percent of residents with seiected diagnoses: United Ststes, 1985

MedJcem siWus etarlmissbn

Madkximpr’knmycr

All Sacondarypeyment Noh4edkamus6Kl

Characfwistk residents at admlss.km al admlssbrr

Number

Reskfenis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189,900 35,600 154,30)

Age Percent dtsfributbn

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.0 100.0 100.0

65-74 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.0 21.7 18.4

75-84 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39.5 40.0 39.3

85yeemand over . . . . . . . . . . . . . . . . . . . . . . . . . 41.5 36.3 422

6ex

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24.5 26.1 24.1

Female . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75.5 73.9 75.9

Race

White . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91.4 e2.5 91.1

Black and other . . . . . . . . . . . . . . . . . . . . . . . . . . 8.6 7.5 8.9

Current marttel status

Married . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18.7 20.4 18.3

Not married . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81.3 79.6 61.7

Days

Average length ofstayl . . . . . . . . . . . . . . . . . . . . . 126.2 106.3 130.8

Yearn

Averege age . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82.3 81.4 62.5

Selected current primary diagnosLs

end ICO-9-CM code Percent

Malignant neoplaems . . . . . . . . . . . . . . ...140-208 4.1 9.0 3.0

Mental dlsordere . . . . . . . . . . . . . . . . . ...290-319 10.4 5.2 11.6

Diseases of the circulatory system . . . . . . . . .3H59 34.1 41.4 32.5

Cerebrovascular disease . . . . . . . . . . ...430-486 13.1 22.1 11.1

Fracture ofnackoffemur . . . . . . . . . . . . . . ...820 4.0 4.5 3.8

1~ ~mge day ~r Medlwe ~~jd~~ j$ ~re th 100 clays because this figure Includes reskkmts Wha used Medicare at adni=l~ ~t l~er ~~~ to ~ Pm ~~.

11
Table E. Percent of nursing home residents 65 years of age and over at admission, transferred from shor%stsy hospitals in 1985, by

type of dependency in activities of daily fiving and Medicare status at admission, percent distribution by number of dependencies, and

average number of dependencies, according to Medicare status at admission: United States, 1985

Medicare shtus et admission

Medicareprtmaiy or

All ewondarypayment No Medkare

Functional stetus reskterrts sourca at admbebn used al admtseion

Type of dependency

Requires assistance In bathing. . . . . . . . . . . .

Requires assistance in dressing . . . . . . . . . . . . . . .

Requires assistance in using toilet room . . . . . . . . .

MobilItY-walks with assistance or

ischairfael or bedfeet . . . . . . . . . . . . . . . . . . . .

Contmence–d~culty with bowel

and/or bladder control . . . . . . . . . . . . . . . . . . . . .

Requiresesslstancelneating. . . . . . . . . . . . . . . . . .

Average number of dependencies. . . . . . . . .

95.8

85.8

76.5

84.0

57.4

47.7

100.0

2.7

5.0

7.8

7.6

18.4

21.2

37.4

4.5

98.6

92.7

91.4

94.6

69.1

57.1

Percent distribution

100.0

2.3

3.8

4.0

15.5

27.0

47.5

Average number

5.0

95.1

84.2

73.1

81.5

54.7

45.6

100.0

3.3

5.6

8.7

8.4

19.1

19.9

35.0

4.3

NOTE Figures may not add to totals bacause of rounding,

residents using Medicare in the last month for primary or

secondary payment for care is likely to underestimate the

actual number using Medicare because of the time frame

(the last month) and because of sample biases. The “last

month” time frame excludes residents who used Medicare

at the time of admission but who had switched to other

payment sources by the time of the survey. Thus, the

number of Medicare residents transferred from hospitals in

1985 decreases from 35,600 at admission (table D) to

22,000 in the last month (table F). And to the extent

that the current resident data underestimate the number of

short-stay nursing home residents, the number of residents

using Medicare is affected, beeause the average Medicareeovered skilled nursing facility stay (30 days, in 1980)

is much shorter than the average stay for all nursing home

patients (HCFA, 1985).

As was found previously for elderly residents transferred from hospitals, table F shows an apparent change in

case mix among Medicare and non-Medieare residents

between 1977 and 1985. The difference in average number

of ADL dependencies for Medicare residents in 1977

versus 1985, however, was not statistically significant. This

lack of significance is probably due to the small number of

sample cases involved. Residents using payment sources

Table F. Number of residents 65 yeara of age and over at admission, transferred from short-stay hospitals in 1977 and in 198!5, average

number of dependencies in activities of daily living, by age, and age-adjusted rate, by Medicare status in month before interview

United States, 1977 and 1985

Medicare prlmfvy or .semrrdary

payment source in rrvnth before interview No Medi&ve used h month before interview

Age and age-adjusted tate 19771 19852 19771 ,:~z

Number of residents . . . . . . . . . . . . . . . . . . . . . . . 25,900 22,000 152,400 167,900

Average number of dependencies

65yeers and over . . . . . . . . . . . . . . . . . . . . . . . . . 4.6 4.9 4.0 4.4

6S74 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.4 *4.7 3.7

75-64 years . . . . . . . . . . . . . . . . . . . . . . . . . .

4.3

4.4 5.0 3.9

6W39years . . . . . . . . . . . . . . . . . . . . .

4.2

5.1 *4.8 4.2

90yeam orover, . . . . . . . . . . . . . . . . . . . . . . . . .

4.4

*4.6 *5.2 4.1 4.8

Age-adjusted rate3 . . . . . . . . . . . . . 4.6 5.0 4.0 4.4

1 Matched with 19s5 data on age and length of stay since admission.

2 Includes a small rumber or residents sdmitted In January 1986.

3 Age.adjusted by 1~ direct methOd tO the 19s5 reslde”t ppuktio” 65 years of age and over in nursing homes, using 4 age groups. Nursing home resident poWatiOn figures are fmm t~ 1~

Natiom.i Nursing Home Swvey.

12
other than Medicare required assistance in performing

more ADL activities in 1985 (4.4 dependencies, on the

average) than in 1977 (4.0 dependencies), a difference that

persists even after age-adjusting. Thus, the case mix of

Medicare residents did not change between 1977 and 1985

but that of residents using payment sources other than

Medicare worsened in the same time period. Although no

change was found in the case mix of Medicare residents in

this analysis, it should be noted that in other studies,

greater care needs have been found among Medicare nursing home patients in the period following PPS. A study of

nursing homes in 10 States, for example, indicated that the

“subacute care needs of patients increased in the post-PPS

period” in homes serving a large number of Medicare

patients (Guterman et al., 1988).

Case mix by facility certification

Table 9 shows selected patient characteristics of the

1977 and 1985study populations transferred from hospitals

by facility certification. The average nursing home stays for

the 1985 study population were similar to those for the

1977 study population, regardless of facility certification.

The 1985 study population of patients admitted to SNF’S

were also older (on the average, 82.5 years) than their 1977

counteqmrts (80.7 years). Other differences between the

1977 and 1985 study populations transferred to SNF’S were

a larger proportion in 1985 who were aged 85 years and

older and a larger proportion in 1985 who were female. The

patient profiles of residents transferred in 1985 to facilities

not certified as WIT% showed that more of them had

mental disorders and that they were older than was true for

their 1977 counterparts.

Table 10 presents the functional status of hospitalized

elderly residents in 1977 and 1985 by facility certification.

As might be expected, residents with greater care needs

(more ADL dependencies) tended to be admitted to skilled

nursing facilities. For example, 61 percent of SNF residents

in 1985, compared with 42 percent of residents in non-SNF

facilities, were incontinent of bowels, bladder, or both. In

1985, 51 percent of SNF residents, compared with

35 percent of non-SNF residents, required assistance in

eating, and 40 percent of SNF residents, compared with

24 percent of non-SNF residents, required assistance in all

6 activities of daily living. Reflecting the generally more

dependent functional status of residents in SNFS, the

average number of ADL dependencies among these residents (4.6) was significantly greater than that for residents

in facilities not certified as SNF’S (3.7).

Table 10 also shows a change in the case mix of elderly

residents transferred horn hospitals to SNF’S after” 1977.

The average number of ADL dependencies among SNF

residents increased from 4.2 in 1977 to 4.6 in 1985. Eightyone percent of SNF residents in 1985 had 4 to 6 ADL

dependencies, compared with 69 percent in 1977. This

difference cannot be accounted for on the basis of age,

because the difference remains even after the data are

age-adjusted (table G). In contrast to the greater care

needs of SNF residents in 1985, there was no difference in

the average number of ADL dependencies for residents of

facilities not certified as SNF’S in 1977 or 1985 (3.5 dependencies in 1977 and 3.7 dependencies in 1985).

Table G. Average number of dependencies in activities of daily living, by age; and age-adjusted rate for residents 65 years of age and

over at admission, transferred from short-stay hospitals in 1977 and in 1985, by facility certification: United States, 1977 and 1985

Skllladnursingfaclliiy~ Not carfhd m a skikd nurshg fmffi(v

Aga and age-aojustedrare 19i72 7g&7.53 19772 j~3

Average number of dependencies

65years andover . . . . . . . . . . . . . . . . . . . . . . . . . 4.2 4,6 3.5 3.7

65-74 year3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.0 4.6 3.3 3.4

7H34years . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1 4.6 3.6 3.3

8S-69years . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.4 4.6 3.6 4.0

90yea.rs orover . . . . . . . . . . . . . . . . . . . . . . . . . . 4.3 4.9 *3.7 4.7

Age-adjusted rate4 . . . . . . . . . . . . . . . . . . . . . . . . 4.2 4.7 3.6 3.8

i,mlu~~ ~mS dually~fifled ss s~lled rf.jralngfacilitiesandInterrnedaiec~e f=lries.

‘Matchedwith 1985 data on age ard length C4stay since Amission.

31nCIUC& a small twmbsr of residents admitisd in Jarwary 19M

4Age-zdjusted by the direct rnstlwd 10 ths 13S5 resident populatbn 65 years of age ard over in rursing kmss, usicg 4 age grcups. Nursing lmme resident pqxlation figures are from the 191?5

Natlofw.1 Nursing Wane Survey.

13
Use of nursing homes

by discharged

residents admitted

from hospitals in 1976

and in 1985

As already shown, using data from the current resident

sample of the NNHS, elderly residents transferred from

short-stay hospitaJs in 1985 were more dependent in activities of daily living than were their 1977 counterparts. These

estimates, however, do not reflect the functional status of

all patients transferred from hospitals in 1985–only of

those still residing in nursing homes at the time of the

survey. They do not apply to residents transferred from

hospitals in 1985 but discharged in 1985 before the date of

the survey or to residents transferred from hospitals in 1985

after the date of the survey. In this section, characteristics

of the former group are examined to identi& characteristics

of short-stay nursing home residents likely to be missed in

the current resident sample. Data from the discharged

resident sample of the 1985 NNHS cover all persons discharged from nursing homes in the 12 months prior to the

survey date.

It should be noted that by focusing on the subset of the

discharged resident sample comparable to the 1985 current

resident study population (aged 65 years and over at admission, transferred from short-stay hospitals in 1985 or later),

the estimate of discharges will not reflect a full l-year time

period. (Only use of all discharge data will include discharges during a calendar year.) This is due to the fact that

the 12-month discharge reference period could have fallen

anywhere from the beginning of August 1984 through

January 1986.

Data from the 1985 discharged resident survey show

that of an estimated 1,223,500 persons discharged from

nursing homes during 1984–85 (NCHS, 1987c), 1,070,600

were aged 65 years or over at admission. Of this total,

451,100 (42 percent) were admitted and discharged in

1985. Table H shows that of the 451,100 persons admitted

and discharged in 1985, 291,400 (65 percent) were transferred from short-stay hospitals. Whether the percent of

discharges transferred from hospitals in 1985 represents an

increase over that for 1977 cannot be determined from -

discharge data from the 1977 NNHS, because information

on living arrangements prior to admission was not, collected

for discharges in 1977.

In general, elderly discharges transferred from shortstay hospitals in 1985 may have had more serious medical

conditions than other elderly discharges admitted from

places other than short-stay hospitals, because 28 percent

of previously hospitalized discharges had died in their

nursing home and 34 percent had to be readmitted to

short-stay hospitals at the end of their stays (table H). In

comparison, elderly discharges admitted from places other

than short-stay hospital were less likely (22 percent) to be

discharged dead and were less likely (27 percent) to be

readmitted to hospitals for further treatment.

Table J compares other differences between elderly

discharges from nursing homes in 1985 by hospitalization

status. Overall, the demographic profiles of discharges

admitted and those not admitted from hospitals were similar. There were no significant differences between these

two groups in age, sex, race, or marital status. There were

differences, however, in diagnosis and functional status. At

the time of admission, discharges transferred from shortstay hospitals were more likely (8 percent) to be admitted

Table H. Number and percent distribution of nursing home discharges 65 years of age and over at admission to nursing homes in 1985

by discharge status, according to hospitalization status: United States, 1985

Dlacharge status

Discharged Discharged

Dlsstrarged alive to Discharged alive to

All Discharged alive to a another All Discharged alfVe to a another

Hospltalizetion status statuses dead hospital bcatkwri statuses dead hospital Iocatiorrl

Number Percentdistrilwtion

Total . . . . . . . . . . . . . . . . . . . . 451,100 116,600 140,300 194,2C0 100.0 25.8 31.1

Admitted from a short-stay

43.0

hospital . . . . . . . . . . . . . . . . . . 291,400 81,700 97,700 112,000 100.0 28.0 33.5

Not admitted from a short-stay

38.4

hospital . . . . . . . . . . . . . . . . . . . 159,700 34,900 42,600 82,200 100.0 21.8 28.7 51.5

1Includes a small rumber of discharges for wbm it was udmown whether they were discharged dive.

14
Table J. Percent distribution of nursing home discharges 65

years of age and over at admisaion to nursing homes in 1985 by

selected characteristics, according to hospitalization statwq and

percent of those residents by selected primary diagnosis and

type of dependency, with average length of stay in days and

average age: United States, 1965

Hosplf.Mzathm status

Not adrn#tad

Admitted from from a

a short-stay shorkstay

CharaCf8/lStk hospital hospital

Total . . . . . . . . . . . . . . . . . . . . .

Age 1

65-74 years . . . . . . . . . . . . . . . .

7S64years . . . . . . . . . . . . . . . .

65yeats andover . . . . . . . . . . . . .

sex

Male . . . . . . . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . . . . . . . .

pace

White . . . . . . . . . . . . . . . . . . . . .

Black and other . . . . . . . . . . . . . .

Current marital status 1

Married . . . . . . . . . . . . . . . . . . .

Nolmarrled . . . . . . . . . . . . . . . . .

Partial index of dependency

Not dependent In mobillty or

continence . . . . . . . . . . . . . . . .

Dependent lnmobillty only. . . . . . .

Depanderd incontinence only. . . . .

Dependent In mobilily

andcontinence . . . . . . . . . . . . . .

Medicare status atadmkslon

Medlcareprimary orsecondary

paymentsotircaat admiselon . . . . .

NoMadkareueadatadmbeion. . . .

Selected prirr!ay diagnosis at

admission and ICD-9-CM code

Met@wrntnaoplasms . . ...140-206

Mental dkorders . . . . . ...290-319

Diseases of the circulatory

system . . . . . . . . . . ...390-459

Cerebrovascular disease. .430-436

Fraclure ofneckoffemur . . . ..620

Typs of dependkyl

Chalrfast. . . . . . . . . . . . . . . . . . .

Bedfast . . . . . . . . . . . . . . . . . . .

Continence-difficulty with bowel

and/or bladder controI . . . . . . . . .

Average length of stay . . . . . . . . .

Average age . . . . . . . . . . . . . . . .

Percent dtstributton

100.0

16.6

49.2

32.0

34.3

65.7

93.5

6.5

27.5

72.5

27.8

16.9

8.0

47.3

40.3

59.7

8.8

5.3

34.6

14.1

8.3

27.2

36.9

55.3

Percent

Days2

42.5

Years 1

81.1

100.0

20.2

43.9

35.9

40.1

59.9

93.2

6.8

28.4

71.6

36.4

12.9

9.9

36.9

13.1

88.9

9.4

8.6

34.2

12.5

3.8

21.7

30.0

48.8

47.8

81.4

f wer~e period for discharge data is at time cl dkcharga.

‘Length ofsfayfordkchsrges kthetotal cumbarcf days inrurslng txmmfrom day of

admission Ihrcugh day of discharge,

for hip fractures than were discharges admitted from other

locations (4 percent). The latter were, however, more likely

to be admitted with diagnoses involving mental disorders

(9 percent) than were those transferred from hospitals

(5 percent). Higher proportions of discharges transferred

born hospitals than of others were bedfast (37 versus

30 percent) and incontinent (55 versus 49 percent). Differences in mobility and continence are summarized in the

partial index of dependency in table J. Overall, more discharges admitted horn short-stay hospitals (47 percent)

than discharges not admitted from hospitals (39 percent)

were dependent in both mobility and continence.

As was discussed previously, short-stay nursing home

patients using Medicare as a primary or secondary payment

source are likely to be under-represented in the current

resident survey. Because of the signii-lcantly shorter lengths

of stay of discharged residents in the study population,

Medicare residents were twice as likely to be included

among discharges as were residents. In 1985, 40 percent of

elderly discharges transferred from hospitals were using

Medicare as their primary or secondary source of payment

at the time of admission. The comparable rate for residents

was only 19 percent (table D).

As was mentioned earlier, rmmparisons between discharges admitted from hospitals in the 1977 versus the 1985

NNHS are not poss]%le because information on living

arrangements prior to admission was not collected for

discharges in the 1977 swey. Discharged residents who

used Medicare as a primary or secondary SNF payment

source, however, had by definition been admitted after a

hospital stay of 3 days or more. Table K shows that in 1985,

113,300 discharged residents used Medicare as the primary

or secondary payment source at the time of discharge.

About 83 percent of these discharges had been directly

transferred from short-stay hospitals, and most (71 percent) had only recently been transferred with stays of less

than 1 month; therefore, by comparing 1977 and 1985

discharges using Medicare for primary or secondary payment, it may be determined whether there was a change in

case mix similar to that found for current residents using

Medicare.

Table K. Number of nursing home discharges 65 years of age

and over at admlsslon to nursing homes In 1985, and percent

distribution by length of stay and hospitalization status,

according to Medicare status at discharge: United States, 1985

kfecfkam statusat discharge

Medhxre @nary

Length ofstayand or Sawldsry No

hospMtL?at&rr status paJmlailt source h4edbati9 used

Number

Dkcharges . . . . . . . . . . . . . . . 113,300 337,800

Percent distribution

ToteI . . . . . . . . . . . . . . . . . . . 100.0 100.0

Length of stay

Leesthan l month . . . . . . . . . . 70.5 49.2

Imonthormore . . . . . . . . . . . 29.5 !70.8

Hospitaliratbn status

Admilted from a shoit-stay

hospiteI . . . . . . . . . . . . . . . . 63.1 56.4

Not admiltad from a

shofl-stay hospital. . . . . . . . . . 16.9 41.6

15
In comparing 1976 and 1985 data for discharges using

Medicare for primary or secondary payment for care, the

time reference used was “at time of discharge” rather that

“at admission,” as shown in table J. The change in time

reference was necessary for comparability, because information on payment sources at admission is available only

from the 1985 survey. Again, because information on living

arrangements prior to admission was not collected in the

1977 NNI-IS survey of discharges, Medicare discharges

from both the 1977 and 1985 surveys are compared without

regard to whether or not they were admitted from a

hospital.

Table L shows that, between 1976 and 1985, there was

an increase in percent of Medicare discharges with nursing

home stays of less then 1 month: from 56 percent in 1976 to

71 percent in 1985. This finding is similar to that noted by

Guterman et al. of increased use of WWF’Sby Medicare

beneficiaries with nursing home stays of 7 days or less

between 1981 and 1984-85 (Guterman et al., 1988).

Table L also reveals a change in the partial index of dependency. In 1985, Medicare discharges were more dependent

on mobility and continence than were their 1976 counterparts–50 percent of Medicare discharges were dependent

in both mobility and continence in 1985, compared with

37 percent in 1976. Similarly, a smaller proportion of Medicare discharges in 1985 were independent in mobility and

continence (28 percent ) than in 1977 (37 percent). These

tindings corroborate findings reported earlier of a worsening of the Medicare patients case mix after the introduction

of PPS (Guterman et al., 1988).

Although there were observable differences by primary

diagnosis at admission between 1976 and 1985, the only

statistically significant difference between these two data

years was a decline in percent of Medicare discharges

admitted with tlacture of neck of femur (14 percent in

1976, compared with 9 percent in 1985). Further research

is needed to investigate the reasons for the decline in

Medicare discharges admitted with this diagnosis.

Table L. Number of nursing home discharges 65 yeairs of age

and over using Medicare for primary or seeondary payment at

the time of discharge and admitted in 1976 and 1985; percent

distribution by selected patient characteristics, and percent of

discharges by selected primary diagnosis: United Stntes, 1976

and 1985

Charac$erMc 1976 Ig&ljl

Numbar

Discharges . . . . . . . . . . . . . . . . . 192,200 113,300

Percent dislllbutiin

Total . . . . . . . . . . . . . . . . . . . . . 100.0 100.0

Length of stay

Lesslhan l month . . . . . . . . . . . . !56.1 70.5

Imonth ormore . . . . . . . . . . . . . 43.9 29.5

Partial index of dependency

Not dependent In mobility

orcontinence . . . . . . . . . . . . . . . 36.6 27.7

Dependent In mobility only . . . . . . 14.9 16.1

Dependent In continence only . . . . . 11.3 4.3

Dependent in mobility and

continence . . . . . . . . . . . . . . . . . 37.2 49.9

3elected primary dlagnosle

at admission and ICD-9-CM code

Malignant neoplesms . . ...140-208 10.8 8.0

Mental disorders . . . . . . ..290-319 3.7 2.1

Dkeasas of the circulatory

syetem . . . . . . . . . . . . ..3e0-459 41.3 35.5

Cerebrovascular dieease. .430-436 15.4 20.1

Fracture of neck of femur. . . . . .620 14.2 8.8

1Includes a srmdl rumba of pstlents admitted in JamJaiy 19se.

z~br~e period for discharge data is at the of discharge.

16
Conclusions

Data from the NHDS and NNHS provide a more

complete description of changes in nursing home utilization

under PPS when viewed together than when seen separately. Data from the NHDS show a decreased hospital

length of stay for elderly patients transferred to long-term

care institutions and increased utilization of long-term care

institutions (nursing homes, for the most part). Using the

1977 NNHS data as a surrogate for the pre-PPS period, the

NNHS current resident data show a slight although not

statistically significant increase in the percent of residents

transferred horn short-stay hospitals and a change in the

case-mix of residents transferred from short-stay hospitals

since the start of PPS. The resident population transferred

from hospitals in 1985 are more dependent in ADL than

are their 1977 counterparts. The functional status of elderly

residents not admitted from hospitals also worsened during

the same period. Much of the change in ADL function for

elderly residents not admitted from hospitals is accounted

for by their age. After age-adjustment, the average number

of ADL dependencies for elderly residents not admitted

from hospitals in 1985 more closely resembled the average

in 1977.

This study has also revealed that the greater care needs

of residents admitted from short-stay hospitals in 1985 are

being served by skilled nursing facilities. The age-adjusted

number of ADL dependencies for residents in skilled nursing facilities was 4.2 in 1977 and 4.7 in 1985. There was no

difference between 1977 and 1985 in the number of ADL

dependencies of residents of facilities not certified as skilled

nursing facilities. This study also revealed no difference

between 1977 and 1985 in the case mix of residents relying

on Medicare for primary or secondary source of payment in

the month before interview, the case mix of residents who

did not use Medicare for payment in the month before the

interview, however, worsened.

Data horn the current resident survey of the NNHS,

however, have limitations, both because of the small number of sample cases involved and because of inherent biases

that tend to under-represent short-stay residents. Examination of the discharge resident survey from the 1985 NNHS,

for example, revealed that of a study population of discharges 65 years of age and over and admitted in 1985 or

later, those admitted from short-stay hospitals had. an

average nursing home stay of 43 days and those not admitted from hospitals had an average stay of 48 days. Because

of the shorter nursing home stays of discharged residents in

the study population, Medicare residents were twice as

likeIy to be included in the discharge study population as in

the resident study population. Comparison of Medicine

discharges between 1976 and 1985 revealed increases in

both of the percent of discharges with nursing home stays

of less than 1 month and of the percent dependent in both

mobility and continence.

Findings from this study are consistent with Medicare

program statistics as reported by Guterman et al. (1988)

and in several studies based on small area samples.

Lewis et al. (1987), for example, found increased SNF utilization by Medicare beneficiaries between 1980 and 1984

in the San Bernardino-Riverside Standard Metropolitan

Statistical Area in Southern California, and Guterman et al.

(1988) found increased SNF utilization among Medicare

beneficiaries nationwide. Small area studies of Medicare

hospital discharges also showed greater care needs for

Medicare patients after the implementation of PPS

(Guterman et al., 1988). This report also revealed that PPS

affects not only persons using Medicare for payment but

also those not relying on Medicare. Between 1977 and

1985, the average number of ADL dependencies for residents in the study populations not relying on Medicare for

payment increased from 4.0 to 4.4.

17
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PHS Pub. No. 1000. Public Health SeMce. Washington: U.S.

Government Printing Office.

National Center for Health Statistics, M. J. Witkirm 1967b.

Utilization of short-stay hospitals by characteristics of discharged

patients, United States, 1965. Mtal and Health Statistics.%ries 13,

No. 3. PHS Pub. No. 1000. Public Health Service. Washington

U.S. Government Printing Office.

National Center for Health Statistics. 1967c. Eighth Revision

International Classification of Diseases, Adapted for Vie in the

United States. PHS Pub. No. 1693. Public Health Service. Washington: U.S. Government Printing Office.

National Center for Health Statistic, P. J. McCarthy. 1969.

Pseudoreplication, further evaluation and application of the balanced half-sample technique. P7taland Healfh Statistics.Series 2,

No. 31. DHEW Pub. No. (HSM) 73-1270. Health Services and

Mental Health Administration. Washington: U.S. Government

Printing Office.

National Center for Health Statistics, J. Van Nostrand, A. Zappolo, E. Hing, et al. 1979. The National Nursing Home Swvey,

1977 summary for the United States. Vifal and Healfh Statistics.

Series 13, No. 43. DHHS Pub. No. (PHS) 79-1794. Public Health

Service. Washington: U.S. Government Printing Office.

National Center for Health Statistics, E. Hing. 1981. Characteristics of nursing home residents, health status, and care received,

National Nursing Home Smvey, United States, 1977. Vital and

Health Statistics. Series 13, No. 51. DHHS Pub. No. (PHS)

81-1712. Public Health Service. Washington: U.S. Government

Printing Office.

National Center for Health Statistics, A. Moss and M. Moien.

1987a. Recent declines in hospitalization: United States, 1982-

1986, data from the National Health Interview Survey and the

18
National Hospital Discharge Survey. Advance Data From V7tal

and Health Stti”stics. No. 140. DHHS Pub. No. (PHS) 87–1250.

Public Health S&vice. Hyattsville, Md.

National Center for Health Statistics, G. Strahan. 1987b. Nursing

home characteristics, preliminmy data tim the 1985 National

Nursing Home Survey. Advance Data From I&l and Health

Statistics. No. 131. DHHS Pub. No. (PHS) 87–1250. Public Health

Service. Hyattsville, Md.

National Center for Health Statistics, E. Sekscenski. 1987c. Discharges from nursing homes, preliminary data from the 1985

National Nursing Home Survey. Advance Data From fital and

Health Statistics. No. 142. DHHS Pub. No. (PHS) 87–1250. Public

Health Service. Hyattsville, Md.

National Center for Health Statistics, E. Hing, E. Sekscenski, and

G. Strahan. 1989. The National Nursing Home Survey 1985

Summmy for the United States. Wal and Heahh Statistics. Series

13, No. 97. DHHS Pub. No. (PHS) 89-1758. Public Health

Service. Washington: U.S. Government Printing Office.

Shimizu, I. 1987. The 1985 National Nursing Home Survey design.

Proceedings of Section on Survey Reseamh Methods, 1986 Amu&l

Meeting of the Amaican Statistical Asssoci&”on. Chicago: American Statistical Association.

Stassen, M., and C. E. Bishop. 1983. Incorporating case-mix in

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Medicare critical review of relevant research. Background paper.

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U.S. Public Health Service and Health Care Financing Administration. 1980. Intem&”onal Ciassi@ztion of Dkeases, 9th Revisioq

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Waldo, D., K Levit, and H. Lazenby. 1986. National health

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Woodruff, R. 1971. Simple method for approximating variance for

a complicated estimate. Jou.mal of the Ameri”can Statistical

Association 66:411-14.

19
List of detailed tables

1.

2.

3.

4.

5.

6.

Number, percent distribution, and average length of

stay of patients 65 years of age and over discharged

from short-stay hospitals by discharge status:

United States, 1982–1985 .......... ............ ................

Number, percent, and average length of stay of patients

65 years of age and over discharged from short-stay

hospitals to long-term care institutions, by selected

diagnosis-related groups: United States, 1985 .......... ..

Number, percent, and average length of stay of patients

65 years of age and over routinely discharged home

from short-stay hospitals, by selected diagnosis-related

groups: United States, 1985 ........................ ....... ....

Rankings and average lengjh of stay of patients 65 years

of age and over discharged from short-stay hospitals, by

discharge status and selected diagnosis-related groups:

United States, 1985 ........................ ............ ....... ..

Number and percent distribution of nursing home residents 65 years of age and over at admission by hospitalization status, according to year of admission:

United States, 1977 and 1985 ...................... ....... ....

Percent distribution of nursing home residents 65 years

of age and over at admission to nursing homes in 1977

and in 1985 by selected characteristics, according to

hospitalization status, and percent by selected primzuy

diagnosis, with average length of stay and average age

by hospitalization status: United States, 1977

and 198~.............. ............... .... ..........................

21

21

22

22

23

23

7. Percent of nursing home residents 65 years of age ~and

over at admission to nursing homes in 1977 and 1985,

by type of dependency in activities of daily living and

hospitalization status, percent distribution by number

of dependencies, and average number of dependencies,

according to hospitalization status: United States, 1977

and 1985. ...... ..... ................... .............. ..............

8. Number, percent, and average hospital length of stay

for nursing home residents 65 years of age and over

transferred from short-stay hospitals in 1985, by selected diagnosis-related groups: United States, 1985 ....

9. Number of residents 65 years of age and over at

admission, transferred from short-stay hospitals in 1977

and in 1985, and percent distribution by selected characteristics, according to facility certification, with average length of stay, average age, and percent of

residents with selected diagnoses: United States, 1977

and 1985. .... ....... .............. ..... ............................

10. Percent ofnursing home residents 65yeamof age and

over at admission, transferred from short-stay hospitals

in 1977 andin 1985jby type of dependency in activities

of daily living and facility certification, percent distribution by number of dependencies, and average number

of dependencies, according to facility certification:

United States, 1977 and 1985 ...... ..... ....... ..............

24

24

25

26

20
Table 1. Number, percent distdbutfon, and average length of stay of patients 65 years of age and over discharged from short-stay

hospitals by discharge status: United States, 1982-85

Discharge status 1982 1983 1984 1985 198.? 1983 1954 1985 1982 ISW3 IW l=

Number of dischargesinthousands Percentdistribution Average lengthof stay indays

Alld&oharge stafus6s . . . . . . . . . . 10,697 11,302 11,226 10,506 100.0 100.0 Im.o 100.0 10.1 9.7 8.9 8.7

Routinedfsohargeto home. . . . . . . 8,164 8,740 8,690 7,997 76.3 77.3 77.4 76.1 9.2

Laffagainstmedicaladvise . . . . . . . 34 33 25

8.8 8.1

33 0.3

7.8

0.3 0.2 0.3

Tmnsfermdto enothershort-term

6.0 5.4 4.1 5.8

hospital. . . . . . . . . . . . . . . . . . . 218 224 260 279 2.0

Trensfems-dto long-termcare

2.0 2.3 2.7 10.4 8.5 9.0 10.2

institufbn . . . . . . . . . . . . . . . . . 662 1,019 1,100 1,202 8.2 9.0 9.8 11.4

Alive,dispos~bnnot stated. . . . . . . 543 437

15.8 15.6

336 212

13.3 12.9

5.1

Dead. . . . . . . . . . . . . . . . . . . . . 721

3.9 3.0 2.0 9.7

726

9.8 8.9 9.8

669 66e 6.7 6.4 6.1 6.4

Statusnotstefed . . . . . . . . . . . . . 135

13.1

124

13.0

125 116

12.5 11.5

1.3 1.1 1.1 1.1 10.2 10.3 10.1 9.6

Table 2. Number, percent and average length of stay of patients 65 years of age and over discharged from short-stay hospitals to

long-term care Institutions, by selected diagnosis-related groups: United States, 1985

Diegnosis-relafed group

Alldisgnosis-relafedgroups. . . . . . . . . . . . . . . . . . . . . . . . . .

SpactficcerebrovssoulerdlsordereexceptWenslant

Ischemkatfac k . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Simple pneumoniaand pleurlsy,age 70 or over, snd/or substantial

comorbidtlysndcomplkstbn . . . . . . . . . . . . . . . . . . . . . . . .

Hipand femur proceduresexcept majorJoint,age 70 or over,

and/or substantialcomorbldityand complkatbn . . . . . . . . . . . .

Heartfailureandshoclc . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Nulritloneland mkcellaneous metabolicdtsorders,age 70 or over,

end/or substantialcomorbkfityend complication. . . . . . . . . . . .

Kidneyand urhary tract Infacfbns,age 70 w over, end/or

substantialcomorbWyendcomplketIon.. . . . . . . . . . . . . . . .

Meforjoint prweduree . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Unrelatedoparstingroom procedures. . . . . . . . . . . . . . . . . . .

Esophagltls,gastroentertfis,and miscailaneousd@stive disorders,

age 70 or over, and/or substanlleicomorbidkyand complkafbn . .

Chronk obstructivepulmonarydisease. . . . . . . . . . . . . . . . . . .

Transientts.chembattacl(. . . . . . . . . . . . . . . . . . . . . . . . . . .

Septicemle,age180rover . . . . . . . . . . . . . . . . . . . . . . . . . .

Gaslrointesfinalhemonhage, age 70 or over, end/or substantial

Comorbklllyandcomplkatbn . . . . . . . . . . . . . . . . . . . . . . . .

Cardiacarrhylhmleand conductbn d!sorder,age 70 or over,

SKf/Orsubstantialcomorbidllyend complketbn . . . . . . . . . . . .

Degenerativenetvoussystemdlsordere . . . . . . . . . . . . . . . . . .

Circulatorydisorderswilh acute myocardialInfsrofbnand

cardbvascularcomplkstbns, dischargedallve . . . . . . . . . . . . .

Organicdlsturbencaeand mentalretardatbn . . . . . . . . . . . . . . .

Respiratorykrfectbnsend Inflammatbnrage 70 or over, and/or

substantialcomorbidltyand complication. . . . . . . . . . . . . . . . .

Psychoses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Diabetes,age360rover . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Number of discharges

Average length of

stay in days

1,201,700 100.0 129

64,900 7.1 15.0

73,600 6.1

5.5

4.9

11.6

66,200

56,WJ

14.0

11.6

50,603 4.2 9.0

44,500

35,600

29,700

3.7

3.0

25

9.2

14.8

21.8

25,100

23,400

21,%30

20,400

21

1.9

1.8

1.7

8.0

11.4

9.3

74.8

19,500 1.6 7.7

18,800

17,300

1.6

1.4

10.1

23.6

16,600

16,300

1.4

1.4

13.5

18.1

15,900

14,900

14,600

1.3

1.2

1.2

12.9

16.4

11.0

21
Table 3. Number, percentj and average length of stay of patfenta 65 years of age and over routinely discharged home from short-stay

hoapftals, by selected diagnosis-related groupa: United States, 1985

Average length of

Disgnos/e-re/ated group Number of discharges Percent stay in days

Alldiagnosk-related groups . . . . . . . . . . . . . . . . . . . . . . . . . .

Hearffaliure and shock . . . . . . . . . . . . . . . . . . .

Anglnapecforis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Esophagifis, gastroenter~k, and mkcellaneous digesthfe disorders,

age 70 or over, and/or substantial comorbldity and complication .

Simple pneumonia and pleurky, age 70 or over, and/or substantial

comorbidity andcompllcation. . . . . . . . . . . . . . . . . . . . . . .

Chronic obstructive pulmonary dsease. . . . . . . . . . . . . . . . . .

Carchac amhylhmia and conduction dkorder, age 70 or over,

and/or substantial comorbidity and complication . . . . . . . . .

.$@roifk oerebrovaecular disorders except translant

Ischeml catfack . . . . . . . . . . . . . . . . . . . . . . . . . .

Bronchttie and asthma, age 70 or over, and/or substantial

comorbldity and complication . . . . . . . . . . . . . . . . . . . . . . .

Transurethrai prostatectomy, age 70 or over, snd/or subskmtiil

comorbidtty and complication . . . . . . . . . . . . . . . . . . . . . . . .

Transient lschemk attack . . . . . . . . . . . . . . . . . . . . . . . . . .

Circulatory disorders wlh acute myocardial infarction without

cardiovascular complications, dischergedaltve . . . . . . . . .

Atherosclerosis, age 70 or over, and/or substantial comorbldify

and complication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Unrelated operating room procedures . . . . . . . . . . . . .

Medkal back problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Nutritional and miscellaneous metabolk disorders, age 70 or over,

and/or substantial comorbicl~ and complication . . . . . . . . . . .

Lansprocaduras. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Gaetroinlestinal hemorrhage, age 70 or over, and/or

substantial comorbidtiy andcompiicatlon. . . . . . . . . . . . . . . .

Major Joint procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Diabetes, age360rover . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Kidney and urinary tract infections, age 70 or over, and/or

substantial comorbldity andcomplkation. . . . . . . . . . . .

7,997,100

343,300

275,000

100.0

4.3

3.4

7.8

7.1

5.1

252,900 3.2 5.6

216,000

207.000

2.7

2.6

8.4

7.2

205,000 2.6 5.6

174,900 2.2 11.6

162,1CQ 2.0 6.8

157,200

150,600

2.0

1.9

6.7

5.2

143,400 1.8 9.2

143,300

139,000

137.300

1.8

1.7

1.7

6.5

12.9

6.9

137,200

126,600

1.7

1.6

6.6

1.4

116,100

116,0131

109,500

1.5

1.5

1.4

6.6

14.4

7.2

1.4 6.8

Table4. Rankinga and average length of stay of patients65 years of ageandover discharged from short-stay hospitals, by discharge

atatusand selected diagnosis-related groups: United States, 1985

Dlecharged to Discharged to

long-term care Discharged long-term care Discharged

D.fagrrosk-related group /nstitut/ons home instifutfons home

Ranking 1 Average length of stay In days

S@citlc cerebrovaecular disorders except transient

kchemkaftack . . . . . . . . . . . . . . . . . . . . . . . . . .

Simple pneumonia and pleurisy, age 70 or over, and/or

substantial comorbidtty andcornplkation. . . . . . . . .

Hip and femur procedures except major Joint, age 70 or

over, and/or substantial comorbldii andcomplicatlon .

Heart failure and shock . . . . . . . . . . . . . . . . . . . . .

NutrRional and miscellaneous metabolic disorders, age

70 or over, and/or substantial comorbidify and

complkation . . . . . . . . . . . . . . . . . . . . . . . . . . .

Kidney and urinary tracl infections, age 70 or over,

and/or substantial comorbidity andcompilcsflon . . . .

Major joint procaduree . . . . . . . . . . . . . . . . . . . . . .

Unrelated operaflng room prMedures . . . . .

Esophagifls, gastroanteritls, and miscellaneous digestive

disorders, age 70 or over, and/or substanfkd

comorbid~and compikatlon. . . . . . . . .

Chronic obstructive pulmona~dieeaea

Transient ischemk attack . . . . . . . . . . . . . . . . . . . .

Septicemia, age180rover . . . . . . . . . . . . . . . . . . .

Gastrointestinal hemorrhage, age 70 or over, and/or

substantial comorbidity and complication. . . . . .

Cardiac arrhythmia and conduction disorder, age 70

or over, and/or substantial comorbidity and

complication . .. . . . . . . . . . . . . . . . . . . . . . . . . .

Degenerative nervous system dlsordere. . . . . .

1 7 15.0 11.6

2 4 8.4

3

4

31

1

14.0

11.6

16.1

7.1

r

5 15 9.0 6.8

6

7

8

20

18

13

9.2

14.6

21.8

6.8

14.4

12.9

9

10

11

12

3

5

10

50

&o

11.4

9.3

14.8

5.6

7.2

5.2

11.4

13 17 7.7 6.6

14

15

6

38

10.1

23.6

5.6

14.4

'%kl~&patletis bypropotilon towtich each diagWs-related gHpappli-, tithl being mxtcommom

22
Table 5. Number and percent distribution of nursing home residents 65 years of age and over at admission by hospitalization status,

according to year of admission: United States, 1977 and 1965

1977 survey 1965 Survay

Yeer of i?dmissbn Y-of admiswon

All Atl

Hosptta/&Wn status raskfents Bafom 1977 197 rasidants Bati3m 1985 IW5’

Total . . . . . . . . . . . . . . . . . . . .

Admitted from a short-stay

hospital. . . . . . . . . . . . . . . . . . .

Not admitted from a short-stay

hospital. . . . . . . . . . . . . . . . . . .

Total . . . . . . . . . . . . . . . . . . . . .

Admltfed from a short-stay

hospital. . . . . . . . . . . . . . . . . . .

Not admfled from a short-stay

hospital. . . . . . . . . . . . . . . . . . .

Number

1,084,800 6~8,100 406,500 1,266,300 855,600 410,500

367,s00 189,600 178,30Q 499,100 308,-2C0 168,W0

716,700 488,5Q0 228,200 767,200 546,600 220,600

Percent dletributii

100.0 100.0 lm.o lIXLO 100.0 100.0

33.9 28.0 43.9 39.4 38.1 46.3

66.1 720 !%.1 80.6 63.9 53.7

‘ Inchdesa smallIwmberof residentsadmittedInJarwaiy 1W8.

NOT& Datafor residentsadmittedin 1977 matchedwith 1585 data on We and lengthC4.sSayafteradmission.

Table 6. Percent distribution of nursing home residents 65 years of age and over at admission to nursing homes in 1977 and in 1865 by

selected characteristics, according to hospitalization status, and percent by selected primary diagnosis, with average length of stay and

average age by hospitalization status: United States, 1977 and 1985

19771 19352

HospitalPethnr status f-bspMl&@cri status

Adm#fed Not adm#ksd Adm#tad Not edmlbd

fnn-na rlvma

All

thma ha

shoWstay shcvt-stay AIl

Chamctarktk

Shwhtay shor-stay

raskfarrts hospnal hospnet tBsk7ants haspht twspnet

Average length of stay shine

admksion in lays . . . . . . . . . . . . 140.0 128.0 149.3 130.0

Average age . . . . . . . . . . . . . . . . 80.9 80.5

126.2 133.2

81.2 822 823 820

Percent distrt+xsfion

Total . . . . . . . . . . . . . . . . . . . . . 100.0 100.0 100.0 100.0 100.0 100.0

Age

65-74 yeats . . . . . . . . . . . . . . . . 21.6 23.7

76-84 yeare . . . . . . . . . . . . . . . . 44.3 44.1

65years andover . . . . . . . . . . . . . 34.0 32.2

20.0

44.5

35.5

78.4 19.0

40.5 39.5

41.1 41.5

17.9

41.3

40.8

sex

Male . . . . . . . . . . . . . . . . . . . . . 30.9 31.2 30.7 27.3

Female . . . . . . . . . . . . . . . . . . . 69.1 68.6

24.5 29.7

88.3 727 75.5 70.3

Race

White . . . . . . . . . . . . . . . . . . . . . 93.7 93.9 83.5 %?.5

Black andolher . . . . . . . . . . . . . . 6.3 6.1

91.4 93.5

6.4 7.5 8.6 6.5

Current marttal status

Married . . . . . . . . . . . . . . . . . . . 17.1 16.0 18.1 18.5

Notmarrled . . . . . . . . . . . . . . . . . 82.9 84.0

18.7 18.3

81.9 81.5 81.3 81.7

Seleofedcumentprimary

diagnosis and ICD-8-CM code

Malignant neoplasms . . ...140-208 4.1 6.4 23 3.3

Menlaldlsordere . . . . . . . .280-319 11.0 8.8

4.1 2.6

127 15.4

Diseases of the circulatory

10.4 19.6

system . . . . . . . . . . . ...390-459 41.5 39.6 43.0 33.8

Cerebrovascular disease. .430-436 9.9 12.8

34.1 33.5

7.6 11.6

Fracture ofneck of femur. . . . ..820 4.4

13.1

6.6

10.2

2.7 29 4.0 1.9

1~atcM ~~h 19s5 data onaW ad lengthof say tier Sdmi=lon.

‘Irchdes a smallrumber of reddenteadmittedInJarwary 1ss8.

NOW Figuresmay rat add to totalsbecauseof rounding.

23
Table7. Percent of nursing home reaidents65 years of age and over atadmission to nursing homesin 1977 and in 1985, by type of

dependency in activities of daily living and hospitalization status, percent distribution by number of dependencies, and averaga number

of dependencies, according to hospitalization status: United States, 1977 and 1985

19771 19852

Hosprtallzatb’r status Hospitalization status

Admitted Not admitted Admitted Not admitted

from a from a from a from a

All shori-stay short-stay All shod-stay shoti-stay

Functbnal status reskfents ho.sprial hospital rashlents hospital hospttal

Dependency in actlviiiae

of daily living Percent

Requires assistance In bathing. . 89.6 92.2 87.6 91.8 95.8 66.4

Requires assistance in dressing . . . 72.8 79.0 66.0 79.8 85.8 74.6

Requires assistance in using

toilet room . . . . . . . . . . . . . . . . . 57.0 65.2

Mobili–walks with assistance or is

50.6 66.0 76.5 57.0

chairfast or bedfast . . . . . . . . . . . 71.1 80.5 63.7

Ccmfinence-diffiiulfy with bowel

74.4 64.0 66.1

and/or bladder control . . . . . . . . 44.2 60.0 39.7 60.2 57.4 44.0

Requires assistance in eating. . . . . . 32.6 37.3 29.0 39.5 47.7 32.5

Number of dependencies Percent distribution

Total . . . . . . . . . . . . . . . . . . . . . 1Ca.o 100.0 100.0 100.0 100.0 100.0

None . . . . . . . . . . . . . . . . . . . . . 6.0 3.7 7.8 6.0 2.7 6.6

l . . . . . . . . . . . . . . . . . . . . . . . 11.6 7.8 14.6 7.5 5.0 9.7

2 13.0 12.6 13.2 10.1 7,6 12.0

3::::::::::::::::::::: :: 11.4 9.0 13.3 9.6 7.6 11.3

4 16.3 17.6 15.3 17.3 18.4 16.4

5::::::::::::::::::::: :: 19.7 22.0 18.0 21.1 21.2 21.0

6 . . . . . . . . . . . . . . . . . . . . . . . 21.9 27.3 17.8 28.4 37.4 20.7

Average number

Averaae number ofdeDendencles. . . 3.7 4.0 3.4 4.0 4.5 3.6

‘Matchedwith1w data on age and lengthof stayafteradmission.

‘Includesa smallrrumber of residents admitted In January19B6.

Table 8. Number, percent, and average hospital length of stay for nursing home residents 65 years of age andover transferred from

short-stay hospitalsin 1985, byselected diagnosis-related groups: United States, 1985

Average hoepiial

Number of /en@r of stay

Diagnosis-related group residents Percent In days

Alldiagnosls-related groups . . . . . . . . . . . . 189,900 100.0

Spectic cerebrovascular disorders except transient

ischemlc aftack . . . . . . . . . . . . . . . . . . . . . . . . . . 16,400 8.6

tip and femur procedures except major joint, age 70 or

over, and/or substantial comorbidity

andcomplicatlon . . . . . . . . . . . . . . . . . . . . . . . . . 13,200 6.9

Simple pneumonia and pleurisy, age 70 or over, and/or

substantial comorbldify andcompllcafion. . . . . 9,300 4.9

Heart failure andshcck . . . . . . . . . . . . . . . . . . . . . 7,400 3.9

Degenerative nervous system disorders . . . . . . 6,500 3.4

Fracture ofhipand pelvis . . . . . . . . . . . . . . . . . . . . 6,500 3.4

Nutritional and miscellaneous metabolic disorders, age

70 or over, and/or substantial comorbid”~

and complication . . . . . . . . . . . . . . . . . . . . . . . . . 6,500 3.4

Kidney and urinary tract Infecfiins, age 70 or over,

and/or substantial comorbidlfy and complication . . . . ●5,600 *2.9

Diabetes, age360r over. . . . . . . . . . . . . . . . . . . . . ●4,900 ●2.6

Atherosclerosis, age 70 or over, and/or substantial

comorbidity and complication. . . . . . . . . . . . *4,600 *2.4

NOTE Includesa smallnumberof residentsadmittedinJammry 19B6.

15.9

18.6

14.2

12.4

6.5

15.6

11.9

12.1

7.6

*22.O

26.3

24
Table 9. Number of residents 65 years of age and over at admission, transferred from short-stay hospitels In 19~ and In 1985, and

percent distribution by selected characteristics, according to facility certification, with average length of stay, average age, and percent

of residents with selected diagnoses: United States, 1977 and 1985

1977 1s2?51

Cerflfkatkm Certifbatiorr

Skilled Not certrYii Skilled

All

Not certifkxl

nursing as a skilled AII nursing

Characterfsfb

as a skilled

rasldents facwtyz nursing facility residents faciliiyz nursing facility

Number ofreskients . . . . . . . . . . . . . . . 178,300

Average length of stay since

admission in lays . . . . . . . . . . . . . . . . T28.O

Average age . . . . . . . . . . . . . . . . . . . . 80.5

147,100 31 ,2Q0 189,900 153,600 36,300

125.6

80.7

139.7 126.2

79.8 82.3

123.1

82.5

139.1

81.7

Percent distribufiin

Total . . . . . . . . . . . . . . . . . . . . . . . . . 100.0 IcK).o 100.0 100.0 100.0 100.0

Age

65-74 years . . . . . . . . . . . . . . . . . . . .

7E-84yeafs . . . . . . . . . . . . . . . . . . . .

B5years andover . . . . . . . . . . . . . . . .

23.7

44.1

32.2

228

43.6

33.6

28.0 19.0

46.2 39.5

25.6 41.5

16.6

39.2

42.2

20.8

40.7

36.5

Sex

Male. . . . . . . . . . . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . . . . . . . . . . . .

31.2

66.8

25.6

74.4

31.0

69.0

32.4 24.5

67.6 75.5

24.2

75.6

Race

Whit e . . . . . . . . . . . . . . . . . . . . . . .

Blackandother . . . . . . . . . . . . . . . . . .

93.9

6.1

93.3

6.7

96.8 91.4

3.2 8.6

91.6

8.4

90.6

9.4

Cufrentmarltalstal us

Married . . . . . . . . . . . . . . . . . . . . . . .

Nolmarried . . . . . . . . . . . . . . . . . . . .

16.0

64.0

16.7

63.3

126 18.7

87.4 61.3

18.5

81.5

19.8

60.2

Selected current primary diagnosis

andlCD-9-CMccde

Malignantnacplasms . . . . . . . . .14CWX18

Mentaldkordefs.. . . . . . . . . . .290-319

Disaasasoflheclrculatory

system . . . . . . . . . . . . . . . ..330-459

Cerebrwasculardkaese... . ..430—436

Fracfureofneokoffemur . . . . . . ...620

6.4

6.6

7.5

9.3

*0.8 4.1

*6.2 10.4

5.0

6.6

0.4

18.0

39.6

12.8

6.6

39.2

13.2

6.7

41.3 34.1

*10.8 13.1

*6. 1 4.0

34.9

14.2

3.5

30.9

8.6

6.0

1 l~l”daastilwmbr ofmsldanfssdmitfed lnJsnuaryWS6.

2 Inciudes homm dusdly certified as sklled rurslr-tg fsclliiies ard Irterrnedlafe care facilities.

NOTR Figures msy rmt sdd to totsls because of ramdhg.

25
Table 10. Percent of nursing home residents 65years ofageand over atadmission, transferred from shoti-sWy hospitala in1977 andin

1985, by type of dependency in activities of daily living and facility certification; percent distribution by number of dependencies, and

average number of dependencies, according to facility certification: United States, 1977 and 1985

1977 19851

Certtfiiat/on Certir%atkm

SWled Not certified Skilled Not Certitii

All nursing sea skilled All nursing as a skilled

Functional status reskients facWty2 nursing facility residents facililyz nwrslng facility

Type of dependency Percent

Requires assistance in bathing . . . . . . 92.2 92.9 88.5 95.8 96.9 eo.9

Requires aeeiekmce in dressing. . . . . . 79.0 81.7 66.4 85.8 88.5 74.5

Requires assistance in using toilet room. . . 65.2

Mobility-walks with assistance or IS

66.9 57.1 76.5 80.9 57.9

chairfeet or bedfast . . . . . . . . . . . . . . . 80.5 82.0 73.6 64.0 86.6 73.0

Continence-difficulty wtih bowei and/or

bladder controi . . . . . . . . . . . . . . . . . 50.0 51.9 40.9 57.4 60.9

Requires assistance In eating . . . . .

42.4

37.3 40.1 24.2 47.7 50.8 34.9

Number of dependencies

Totat. . . . . . . . . . . . . . . . . . . . . . . . .

None . . . . . . . . . . . . . . . . . . . . . . .

l . . . . . . . . . . . . . . . . . . . . . . . . . . .

2

3::::::::::::::::::::: ::::::

4 . . . . . . . . . . . . . . . . . . . . . .

5

6::::::::::::::::::::: ::::::

Average number of dependencies . . . . .

100.0

3.7

7.8

12.6

9.0

17.6

22.0

27.3

4.0

100.0

3.3

6.2

12.0

9.9

17.2

21.6

29.8

4.2

Percent distribution

100.0 100.0

5.3 2.7

15.4 5.0

15.9 7.8

4.7 7.6

19.4 18.4

23.9 21.2

15.4 37.4

Average numbar

3.5 4.5

100.0

1.9

3.4

7.3

6.4

17.6

22.7

40.4

4.6

100.0

6.0

11.4

9.6

12.5

21.0

14.9

24.4

3.7

‘ Ihchides a smallrumber of residents admitted In January 1986.

‘Inshdes homes dJally certified as skilled m.trslng facilities and Internwdlate care facilities.

26
Appendixes

Contents

I. Sources of data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

National Hospital Discharge Survey methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

National Nursing Home Survey methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

II. Definitions of terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Diagnosis-related groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

National Hospital Discharge Survey-terms relating to hospitalization.. . . . . . . . . . . . . . .

National Nursing Home Survey-terms relating to nursing homes

. . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

National Nursing Home Survey-terms relating to residents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

National Nursing Home Survey-terms relating to discharges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... .

III. Notes on age-adjusted rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

IV. Notes onstandard errors and statistical tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standard errors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Statistical tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

List of appendix figures

L Relative standard errors of estimated number of discharges horn short-stay hospitals 1982 and 1985 National

Hospital Discharge Surveys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

II. Relative standard errors of estimated number of residents in 1977 and 1985 and of number of discharges in 1976

and 1984-85:1977 and 1985 National Nursing Home Surveys.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

List of appendix tables

I. Average age-adjusted number of dependencies in activities of daily living for elderly residents admitted from

short-stay hospitals by year of admission, distribution, and age United States, 1977 and 1985 . . . . . . . . . . . . . . . .

IL Approximate standard errors of average length of stay by number of discharges: 1982 and 1985 National Hospital

Discharge Surveys . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

III. Standard errors of average number of dependencies in activities of daily living for elderly residents entering

nursing homes, by year and selected characteristics: 1977 and 1985 NationaI Nursing Home Surveys. . . . . . . . . .

28

28

29

31

31

31

31

32

32

34

35

35

35

37

38

34

35

36

27
Appendix I

Sources of data

National Hospital Discharge Survey

methodology

Source and description

The National Hospital Discharge Survey samples the

records of inpatients discharged from noninstitutional hospitals, exclusive of military and Veterans Administration

hospitals, located in the 50 States and the District of

Columbia. Only hospitals with six beds or more for patient

use and those in which the average length of stay for all

patients is less than 30 days are included in the survey.

Discharges from Federal hospitals are excluded.

The National Master Facility Inventory of Hospitals

(NMFI) is the universe from which the NHDS sample is

drawn. The original universe for the survey consisted of

6,965 short-stay hospitals contained in the 1963 NMFI.

New hospitals were sampled for inclusion in the survey in

1972, 1975, 1977, 1979, 1981, 1983, and 1985.

The number of hospitals participating in the survey

varies from year to year, as do the number of abstracts of

medical records provided by participating hospitals. This is

because each year some of the sampled hospitals refuse to

participate in the survey or are found to be out of scope,

either because they have gone out of business or fail to

meet the definition of a short-stay hospital. In all, 558

hospitals were sampled in 1985. Of these hospitals, 82

refused to participate and 62 were out of scope. The 414

participating hospitals provided approximately 194,000 abstracts of medical records.

The medical record data consist of items relating to the

personal characteristics of the patient, including birth date,

sex, race, and marital status (but not name and address);

administrative information, including admission and discharge dates, discharge status, and medical record number;

and medical information, including diagnoses and surgical

and nonsurgical operations or procedures. Since 1977,

patient ZIP Code, expected source of payment, and dates

of surgery have also been collected.

Sample design

All hospitals with 1,000 beds or more in the universe of

short-stay hospitals are selected with certainty in the

sample. All hospitals with fewer than 1,000 beds are stratified, the primary strata being 24 size-by-region classes.

Within each primary stratum, allocation of the hospitals in

the sample is made through a controlled selection technique, so that h~spitals in the sample are properly distrl%-

uted with regard to type of ownership and geographic

division. Sample hospitals are drawn with probabilities

ranging from certainty for the largest hospitals to 1 in 40 for

the smallest hospitals.

Until 1985, all sample discharges were selected using

the daily listing sheet of discharges as the sampling frame.

These discharges were selected using a random technique,

usually on the basis of the terminal digit or digits of the

patient’s medical record number. The within-hospital sampling ratio for selecting sample discharges varied inversely

with the probability of selection of the hospital. Sample

selection and abstraction of data from the face sheet and

discharge summa~ of the medical records were performed

by the hospital staff or by representatives of the National

Center for Health Statistics, after which the completed

forms were forwarded to NCHS for coding, editing, and

weighting.

In 1985, two data collection procedures were used in

the NHDS. The first was the traditional manual system of

sample selection and data abstraction previously described.

The second was an automated method used in approximately 17 percent of the sample hospitals, which involved

the purchase of data tapes from commercial abstracting

services. For the automated hospitals, tapes containing

machine-readable medical record data are subjected to

NCHS sampling, editing, and weighting procedures. A

detailed description of the automated process is to be

published.

Presentation of estimates

Statistics from NHDS are derived using a (complex

estimating procedure. The basic unit of estimation is the

sample inpatient discharge abstract. The estimating procedure used to produce essentially unbiased national estimates in NHDS has three principal components: inflation

by reciprocals of the probabilities of sample selection,

adjustment for nonresponse, and ratio adjustment to fixed

totals. These components of estimation are described in

appendix I of two earlier publications (NCHS, 1967a and

1967b).

As in any survey, results are subject to nonsampling or

measurement errors, which include errors resulting from

NOTE: A list of references follows the text.

28
hospital nonresponse, missing abstracts, information incompletely or inaccurately recorded on the abstract forms,

and processing errors. For example, the age and sex of the

patient are not stated on the hospital records for about

one-half of 1 percent of the discharges. Imputations of

these missing items are made by assigning the patient an

age or sex consistent with the age or sex of other patients

with the same diagnostic code.

If the dates of admission or discharge are not given and

cannot be obtained from the monthly sample listing sheet

transmitted by the sample hospital, a length of stay is

imputed by assigning the patient a length of stay characteristic of those of other patients of the same age. About

one-tenth of 1 percent of the records are missing the date of

admission or discharge.

National Nursing Home Survey

methodology

Source and description of data

The National Nursing Home Survey (NNHS) is a

cross-sectional nationwide survey of nursing homes, their

residents, discharges, and staff conducted by the National

Center for Health Statistics. The most recent survey, which

was conducted from August 1985 through January 1986,

was the third of a continuing series of nursing home

surveys. The first survey was conducted from August 1973

through April 1974, and the second was conducted from

May through December 1977.

In this report only data from the current and discharged resident surveys of the 1977 and 1985 NNHS are

presented. The NNHS, however, involved not only data on

residents and discharges but also on nursing homes and

staff. Resident data were collected in personal interviews

with a nurse familar with the care provided to the resident.

The nurse relied on the medical record and personal

knowledge of the resident. Discharge data were collected

by personal interview with nursing home staff, who based

their response on information recorded in the medical

record. Additional data about current and discharged residents were obtained by telephone interviews with next of

kin in the 1985 survey only.

The scope of the 1977 NNHS encompassed all types of

nursing homes, including personal care and domiciliary

care homes. The sample of 1,698 facilities was selected

from 23,105 nursing homes in the sampling frame, which

consisted of all homes listed in the 1973 NMFI and those

opening for business between 1973 and December 1976.

Data were obtained from 1,451 facilities, 13,634 staff providing direct services to residents, 7,033 residents, and

5,142 discharged residents. Response rates were 95 percent

for facilities, 85 percent for expenses, 81 percent for staff,

99 percent for residents, and 97 percent for discharges.

The scope of the 1985 NNHS was similar in that it

included all types of nursing homes. The sample of 1,220

homes was selected from a sampling frame of 20,479

nursing and related care homes. The frame consisted of aU

homes in the 1982 NMFI, homes identified in the 1982

Complement Survey of the NNIFI as “missing” horn the

1982 NMFI, fadities that opened for business from 1982

through June 1984, and hospital-based nursing homes identified in the records of the Health Care Financing Administration. Data were obtained from 1,079 facilities, 2,763

registered nurses, 5,243 residents, and 6,023 discharges.

Response rates were 93 percent for facilities, 68 percent for

expenses, 80 percent for registered nurses, 97 percent for

residents, 95 percent for discharges, and !?0percent for next

of kin.

Sample design

The sampling was basically a stratified two-stage probability design. The first stage was the selection of facilities,

and the second stage was a selection of residents, discharges, and staff fkom the sample facilities. In the 1977

survey, 24 primary types of service-size strata were employed in the selection of facilities. Homes of originally

unknown bed size were also included in the sample. (For a

more detailed description of the survey design of the 1977

NNHS, see NCHS, 1979.) In the 1985 NNHS, 20

certification-size primary strata were used in the selection

of facilities. (For a more detailed description of the survey

design of the 1985 NNHS, see Shimizu, 1987.)

The second stage sampling of residents and discharges

was carried out by the interviewers at the time of their visits

to facilities, in accordance with specific instructions given

for each sample facility. The sample frame for residents was

the total number of residents on the register of the facility

on the evening prior to the day of the survey. Residents who

were physically absent from the facility because of overnight leave or a hospital visit but who had a bed maintained

for them at the facility were included in the sample frame.

In the 1977 survey, an average of five residents per facility

were selected. In the 1985 survey, a sample of five or fewer

residents per facility were selected.

The sampling frame for discharges in the 1985 NNHS

was the total number of persons discharged alive or dead

during the 12 months prior to the survey date. The sampling frame for discharges in the 1977 NNHS was the total

number of persons discharged alive or dead during calendar year 1976. Persons who were discharged more than

once during these 12-month periods were listed for each

discharge. In 1985, 91 of the sampled discharges were listed

more than once in the same home. It is ako possible that

some current residents were included in the discharge

sampling frame who were discharged during the 12 months

prior to the survey and then readmitted to the sample

nursing home. In 1985, 45 sampled discharges were ako

included in the current resident sample. In the 1977 survey,

an average of five discharges per facility were selected. In

the 1985 survey, a sample of six or fewer discharges per

facility were selected.

NOTE A list of references follows the tek

29
Presentation of estimates

Because the design of the NNHS is a complex, multistage probability sample, it is necessary to reflect these

complex procedures in the derivation of estimates. The

NNHS estimates presented in this report are based upon

sample person counts weighted to produce national estimates. The estimating procedure used to produce these

estimates has three principal components: inflation by reciprocals of the probabilities of sample selection, adjustment for nonresponse, and ratio adjustment to fixed totals.

Because NNHS estimates are based on a sample, they

may differ somewhat from the figures that would have been

obtained had a complete census been taken using the same

survey and processing procedures. To the extent possible,

sampling and nonsarnpling errors were kept to a minimum

by methods built into the survey procedures.

Descriptive material on data collection, field procedures, and questionnaire development in the NNHS have

been published, as well as a detailed description of the

sample design, estimation procedure, and qualifications of

the data (NCHS, 1979 and NCHS, 1989).

NOTE A list of references follows the text.

30
Appendix II

Definitions of terms

Diagnosis-related groups

The DRG’s referred to in this report were produced

using the DRG program available in the summer of 1983

and are identical to those in the August 31, 1984, issue of

the Federal Register. This is a computer program that

groups patients into DRG’s based on diagnostic, surgical,

and patient information. The program is maintained and is

commercially available at Health Systems International

(DRG Support Group, 100 Broadway, New Haven, Corm.

06511). However, the actual program used to produce

estimates in this report was obtained from the Health Care

Financing Administration. For NHDS estimates, the entire

NHDS file was used to produce estimates, including outliers. No data were excluded or trimmed because of an

abnormal length of stay. This was akm true for NNHS

estimates of residents by DRG categories.

National Hospital Discharge

Survey-terms relating to

hospitalization

Hospitals-Short-stay specialty and general hospitals

have six beds or more for inpatient use and an average

length of stay of less than 30 days. Federal hospitals and

hospital units of institutions are not included.

Padent—A person who is formally admitted to the

inpatient service of a short-stay hospital for observation,

care, diagnosis, or treatment is considered a patient. In this

‘ report, the number of patients refers to the number of

discharges during the year, including any multiple discharges of the same individual from one short-stay hospital

or more. The terms “patient” and “inpatient” are used

synonymously.

Dischznge-Discharge is the formal release of a patient

by a hospital; that is, the termination of a period of

hospitalization by death or by disposition to place of residence, nursing home, or another hospital. The terms “discharge” and “patient discharge” are used synonymously.

Average length of stay-The average length of stay is the

total number of patient days accumulated at the time of

discharge by patients discharged during the year divided by

the number of patients discharged.

Age—The patient’s age refers to age at the last birthday

prior to admission to the hospital inpatient service. To

approximate the Medicare population, estimates of patients

age 65 years and over only are presented in this report.

Wm.verstatus-Waiver status refers to whether or not

the State in which the hospital is located has a waiver from

participation in the Medicare prospective payment system.

During 1982-85, four States had waivers from PPS participation because they were participating in demonstrations

of other payment systems. These four States were Maryland, Massachusetts, New Jersey, and New York. All remaining States are included in the “PPS States” category.

Dkharge status-The discharge status of a patient

upon the termination of a period of hospitalization is

classified according to one of seven categories in this

report. The “routinely discharged home” category consists

of patients who returned to their previous place of residence after discharge, including patients discharged to

private homes and those discharged to nonmedical residential facilities, such as prisons, orphanages, and other nonmedical custodial care facilities. The “left against medical

advice” category comprises patients who refused further

medical care and left the hospital, whether or not a release

of responsibility statement was signed, and patients who left

without informing any members of the medicaJ staff. The

“disch~gd, tra.nsferrd to another short-term hospital”

category refers to patients who were transferred to another

short-term hospital for short-term care. The “discharged,

transferred to long-term care institution” category consists

of patients transferred to a nursing home, chronic disease

hospital, or other long-term care facility. Deaths refers to

patients who died during an inpatient stay.

National Nursing Home Survey–

terms relating to nursing homes

l%cWy-A.11 types of nursing and related care homes,

including personal care and domiciliary care homes, in the

ccmterminous United States were included in the 1977 and

1985 National Nursing Home Surveys. A nursing home

must have three beds or more set up for use by residents

and may be either free-standing or a distinct unit of a huger

facility.

Wtiver status-see National Hospital Discharge Survey—terms relating to hospitalization: Waiver status.

Certification —Certification refers to the facility certification under Medicare andfor Medicaid.

Medicare-Medicare refers to the medical assistance provided in title XVIII of the Social Security Act.

Medicare is a health insurance program administered

31
by the Social Security Administration for persons aged

65 years and over and for disabled persons who are

eligible for benefits.

Medicaid-Medicaid refers to the medical assistance provided in title XIX of the Social Security Act.

Medicaid is a State-administered program for the medically indigent.

Skilled nursing faciIi&Skilled nursing facility refers to certification as a skilled nursing facility under

Medicare, under Medicaid, or under both programs.

Intermediate carefacility-Intermediate care facility refers to certification as an intermediate care facility

under Medicaid.

Not certified-Not certified refers to facilities that

are not certified as providers of care under either

Medicare or Medicaid.

National Nursing Home Survey–

terms relating to residents

Resh’ent-A resident is a person on the roster of the

nursing home as of the night before the survey. All residents for whom beds are maintained are included, even

those on overnight leave or in a hospital.

Hospitalization status-Hospitalization status refers to

whether or not the resident was admitted to the nursing

home from a short-stay hospital.

Medicare status last month —Medicare status last

month refers to whether Medicare funds were the primmy

or the secondary source of payment for care in the last

completed calendar month prior to the survey. Persons who

did not use Medicare funds in the last completed calendar

month before the survey are in the “No Medicare used last

month” category. This category describes residents who

used the following payment sources in the last month: own

income or family support, Medicaid, other government

assistance or welfare, religious organizations, foundations,

volunteer agencies, Veterans Administration contracts, initial payment arrangements, life care arrangements, miscellaneous sources, and no-charge arrangements.

Length of stay since admission —Length of stay since

admission refers to the resident’s period of stay, from the

date of the most recent admission to the facility to the date

of the survey interview.

Demographic items

Age—The age of the resident is age on the day of

the survey, as calculated from the date of birth.

Race—Race refers to the racial background as

reported by the nursing home staff respondent.

Functional status

Activities of daiZy fiving—In this report, the activities of daily living are six everyday activities (bathing,

continence, dressing, eating, mobility, and using the

toilet room) for which the nursing home staff

respondent reported the resident’s current performance in terms of need for the help of special equipment or another person.

Number of dependencies in activities of dai& living—The number of dependencies in activities of daily

living, based on the work of Dr. Sidney Katz (Katz and

Akpom, 1976), is a measure that summarizes the level

of dependency in performing the six activities of daily

living. The following criteria are used in classifying a

resident as dependent:

Bathing-Resident requires assistance.

Dressing—Resident requires assistance or does

not dress.

Using the toilet room —Resident requires assistance or does not use toilet room.

Mobi/i&—Resident requires assistance, is chairfast, or is bedfast.

Continence-Resident has difficulty controlling

bowels, bladder, or both or has an ostomy.

Eating-Resident requires assistance, including

tube or intravenous feeding.

Diagnoses— One or more diseases or injuries (or some

factor that influences health status and leads to contact with

health services that is not itself a current illness or injury)

were listed by the attending physician on the resident’s

medical record. In 1977, the primary diagnosis was the one

condition reported by the nursing home staff respondent as

the major diagnosis noted at the resident’s last examination.

The list of conditions corresponded to that in the Eighth

Revision International Classification of Diseases, Adapted

for Use in the United States (NCHS, 1967). The respondent reported the information based on the resident’s

medical record. In 1985, diagnoses were those recorded at

the time of the survey. All diagnoses were transcribed in the

order listed. Each sample resident was assigned a maximum of eight 5-digit codes according to the International

Classification of Diseases, 9th Revision, Clinical Modification (USPHS and HCFA, 1980). The primary diagnosis is

the coded diagnosis identified as the prima~ diagnosis or

first listed on the medical record.

Hospital length ofstqy-The average hospital length of

stay is the total number of nights spent in a hospital during

the stay preceding nursing home admission for residents as

reported by nursing home staff, divided by the number of

residents admitted from hospitals. The average hospital

length of stay excludes cases for which the number of nights

spent in a hospital is missing.

National Nursing Home Survey–

terms relating to discharges

Discharge-A discharge is a person who was formally

discharged from a nursing home during the appropriate

discharge reference period. Both live and dead discharges

NOTE: A list of references follows the text.

32
are included. Theoretically, the same person can be

counted more than once if discharged more than once from

a nursing home during the discharge reference period.

Dischczge status-The discharge status of a resident

upon the termination of a stay is classified into one of three

categories in this report. “Discharged dead” refers to discharges who died during the sampled nursing home stay.

The category “Discharged alive to a hospital” refers to

discharges who were transferred to a short-stay hospital for

short-term care. All remaining discharges were classified in

the “Discharged alive to another location” category, including those for whom it was unknown whether they were

discharged alive.

Hospitalization status— see National Nursing Home

Survey-terms relating to residents: Hospitalization status.

Medicare status at dkchqe – see National Nursing

Home Sunwy-te?ms relathg to residents-Medicare status

last month. The time frame for Medicare status for discharges in 1976 and 1985 was at the time of discharge

rather than last month (for current residents).

Health status

Activities of dai~ living—Data on activities of daily

living were collected for discharges in the areas of corttinence and mobility only, based on information in the

medical record or on performance at the time of discharge.

Continence

No difficul~ controlling bowels or biadder-The

discharge did not have any difficulty in controlling

either bowels or bladder at the time of discharge.

Difficulty controlling bowels—The discharge had

difficulty controlling bowels at the time of discharge.

Diflcul~ controlling bladder-The discharge had

difficulty controlling bladder at the time of discharge.

(2rtomy in either bowels or bIadder-The discharge had undergone a surgical procedure that

resulted in the creation of an artificial opening for the

elimination of waste.

Mobility

Widks with or without asszktance-The discharge

was able to walk at the time of discharge, either with or

without assistance of special equipment or another

person. This excludes those discharges who were chairfast or bedfast or whose status was unknown.

Chairjiit-The discharge was confined to a chair

at the time of discharge.

Bedfzst-The discharge was confined to a bed at

the time of discharge.

Pcntial index of dependency in activities of daily living–

The partial index is modeled after the seven-level hierarchy

of dependence developed by Dr. Sidney Katz (Katz et al.,

1963). The partial index is a measure that permits overall

classification of individuals according to their dependency

at the time of discharge in performing the two activities of

daily living just described. The resident index covers six

activities; the partial index covers only two, because information on the others was not available in the medical

records of discharges. The partial index has four categories,

with categories 2 and 3 approximating the category “dependent in only one activity” in the resident index. Two

activities, ordered in hierarchy sequence, are the criteria for

classi~ing a discharge as dependent:

ikfobi/ity-Discharge was chairfast or bedfast.

Continence—Discharge had difficulty controlling

bowels, bladder, or both or had an ostomy.

Diagnoses —see National Nursing Home Sunwy— terms

relating to residents: Diagnoses. The time frame for primary

diagnosis of discharges in 1976 and 1985 was at admission

rather than currently (for current residents).

NOTE: A list of references follows the text.

33
Appendix 111

Notes on age-adjusted

rates

The age-adjusted rates presented in this report were

computed by the direct method; that is, by applying the

age-specific rates to the standard population distributed by

age (Fleiss, 1981). To age-adjust data by this method, tsvo

basic pieces of information are needed:

● Age-specific rates for the population being studied, say

c1,C2,...,Cn.

● The distribution across the same age groups for a

selected standard population, say P~l, P*2, . . . . P,n. For

this report, the standard population chosen was the

total resident population aged 65 years or over in

nursing homes of the United States, as enumerated in

1985 in the National Nursing Home Survey.

The direct adjusted rate is then simply

n

~ direct = z c,. Pa.

i=l

NOTE: A list of references follows the text.

As an example, the age distribution of the standard

population (total 1985 resident population aged 65 years or

over in nursing homes in the United States) and the 1985

age-specific number of ADL dependencies for hospitalized

residents in 1977 and 1985 are shown in table I.

The conclusion drawn from the comparison of these

age-adjusted rates is that the average number of ADL

dependencies for the 1985 study population admitted from

short-stay hospitals (4.5) is greater than that for their 1977

counterparts (4.2).

Standard errors were not computed for the

age-adjusted statistics. However, the standard error for an

adjusted rate may be approximated using the standard

error of the nonadjusted statistics, presented in

appendix IV.

Table L Average age-adjuated number of dependencies In activities of daily living for elderly residents admitted from short-stay

hospitals by year of admission, distribution, and age: United States, 1977 and 1985

Di.str\butlon 19?7 1985

for standard

Age population P,l G q P*I G c1P.l

65years And over . . . . . . . . . . . . . . . . . . . . . . . . 1,000000 . . . 4.096940 . . . 4.482171

65-74 years . . . . . . . . . . . . . . . . . . . . . . . . . . 0.160861 3.9 0.627356 4.3 0.691702

75-64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.386103 4.0 1.544412 4.3 1.660243

6S-$9years . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.224139 4.3 0.963798 4.5 1.008626

90years and over . . . . . . . . . . . . . . . . . . . . . . . . . 0.228898 4.2 0.961372 4.9 1.121600

34
Appendix IV

Notes on standard

errors and statistical

tests

Standard errors

The three surveys used as primary sources for data

contained in this report are all based on multistage probability samples. The sampling errors for each survey were

calculated taking their complex sample designs into account.

For the National Hospital Discharge Survey, estimates

of sampling variability were calculated directly. For the

1985 National Nursing Home Survey, estimates of sampling

variability were calculated using half-sample replication. A

description of the development and evaluation of the replication technique for error estimation has been published

(NCHS, 1966 and 1969). Estimates of sampling variability

for the 1977 NNI-IS were calculated using Taylor series

Iinearizations. Descriptions of this method for obtaining

approximations of standard errors in large samples have

been published (Kendal and Stuart, 1963; Woodruff, 1971;

and Folsom, Bayless, and Shah, 1971).

To derive error estimates that would be applicable to a

wide variety of statistics and could be prepared at a moderate cost, several approximations were required.

Rather than calculate standard errors for particular

estimates S’.,the calculated variances for a wide variety of

estimates for each of these surveys were fitted into curves

using the empirically determined relationship between the

size of an estimate X and its relative variance (rel var X).

This relationship is expressed as

rel var X =

s 2X b

=a+—

X2 x

where a and b are regression estimates determined in an

iterative procedure.

The relative standard error is then derived by calculating the square root of the relative variance curve. The

relative standard error estimates used for this report were

read directly from these curves. Because of the relationship

between the relative standard error of an estimate and the

estimate itself, the standard error SXcan be derived from its

relative standard error by multiplying the relative standard

error of the estimate by the estimate itself.

General relative standard error curves for NHDS estimates of discharges in 1982 and 1985 are presented in

NOTE A list of references follows the text,

figure I. General relative standard error curves for NNHS

estimates of current residents in 1977 and 1985 are presented in figure II, as are the general relative standard

error curves for NNHS estimates of discharges in 1976 and

in 1985. An example of the use of these figures follows.

In 1985, 189,900 residents aged 65 years and over were

transferred from short-stay hospitals (table 5). In curve C

of figure II, the estimate of 189,900 residents has a relative

standard error of 5.2 percent or a standard error of 9,875.

Figure I can be used in a similar manner to calculate the

relative standard error and standard error for hospital

discharges.

Table II presents the standard errors of average length

of stay for hospital discharges in 1982 and 1985 from the

NHDS. Table III presents the standard errors of the average number of ADL dependencies for residents presented

in this report.

Statistical tests

In this report, the determination of statistical inference

of rates (those that were not age-adjusted) and proportions

is based on the two-tailed t-test with 20 degrees of freedom.

At the 0.05 (5 percent) level, the critical value for the t-test

is 2.09. For more details on hypothesis testing performed

for NHDS and NNHS, see NCHS, 1989, and Shimizu,

1987.

Table IL Approximate standard errors of average length of stay

by number of discharges: 1982 and 1985 National Hospitai

Discharge Surveys

Average length of stay

Yaar and numbar ofdbcherges 4 days 6 days 8 days 10 days

19s2 Standard error In days

mc@oo .. . . . . . . . . . . . . . . . . . 0.2 0.3 0.3 0.4

1,000,030. . . . . . . . . . . . . . . . . . 0.2 0.2 0.3 0.4

5,0C0,0C0 . . . . . . . . . . . . . . . . . . 0.1 0.2 0.2 0.3

lo,ooo,ooo . . . . . . . . . . . . . . . . . 0.1 0.2 0.2 0.3

30,000,W0. . . . . . . . . . . . . . . . . 0.1 0.1 0.2 0.2

19s5

600,000 . . . . . . . . . . . . . . . . . . . 0.1 0.2 0.3 0.3

I,ooo,ooo . . . . . . . . . . . . . . . . . . 0.1 0.2 0.2 0.3

5,000,000 . . . . . . . . . . . . . . . . . . 0.1 0.1 0.2 0.3

Io,ooo,ooo . . . . . . . . . . . . . . . . . 0.1 0.1 0.2 0.2

30.000,000 . . . . . . . . . . . . . . . . . 0.1 0.1 0.1 0.2

35
Table Ill. Standard errors of average number of dependencies In

activities of daily iiving for elderly residents entering nursing

homes, by year and selected characteristics: 1977 and 1985

National Nursing Home Surveys

Characferistk 1977 19851

Standarderroreof average

number of dependencies

All elderly residents entering nursing

homes inyearof survey . . . . . . . . . . . . 0.05 0.04

Hospifalizdion status

Admitted from a short-stay hospital. . . . . . 0.07 0.06

Not admitted from a short-stay hospital . . . 0.06 0.07

Admitted from a shorl-stay hospital

Medicare status In month before Intewiew

Medicare primary or secondary source . 0.13 0.17

No Medicare used . . . . . . . . . . . . . . . . 0.07 0.07

Facility cerllflcatlon:

Skilied nursing facilityz 0.07 0.07

Not certified es a skilled nursing facility. . . 0.16 0.20

Waiver status

WaMer State............,.. . . . . . . . . 0.15

Prospective payment system Stste. . . . . . . 0.07

1Irwiudesa smallnumber of residents admitted In January 19s6.

‘Inchdes facilities dually cettified as skilled nursing facilities and htermedlate care facilities.

36
‘j

60

50

40

30

20

‘I

7

6

6

4

3

2

81

0s7

0.6

0.5

0.4

0.3

0.2

0,1

1 10 100 1,000 10,000 100J

Size of estimate (in thousands)

60

50

40

30

20

5

4

3

2

ii

0.7

0.6

0.5

0.4

0,3

0.2

0.1

Figure 1, Relative standard errors of estimated number of discharges from shorbatay hospitals: 1982 and 1986 National Hospital Discharge Surveys
c!.)

m

,4: 1976 discharges _tii iii

R 1984-I35 discharges I 1 I

C: 1985 residents

Ll 1977 residents

.

I 1 I I 111111++. 1

.I I I t I I I 1 IN

1 I I I I I , , , , ,,

i I I I Illllllltlt

I a I , ,

I

I 1 1 ,

1 1 1 I II

, 1

+!! I I I I I I IIIH+

I 1

i tiHttttMl

–.

60

50

40

30

20

6

5

4

3

2

0.5

0.4

0.3

0.2

0.1 -.

A 2 3 456789A 2 3 456789A 2 3 456789A 2 3 456789A 2 3 456789A

100 1,000 10,000 100,000 1,000,000 1O,ooo,ocm

Size of estimate (in thousends)

——

Fiaura ..e—.—.Il. Relative – stendard errors of estimated number of residents in 1977 and 1985 and of number of discharges in 1976 and 1984-85:

1977 end 1985 Netional Nureing Home Surveys
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