Postacute care outcomes and medicare payments for patients treated by physicians and advanced practitioners who specialize in nursing home practice

Clinicians Who Practice Primarily in Nursing Homes and the Quality of End-of-Life Care Among Residents

Importance

Clinician specialization in the care of nursing home (NH) residents or patients in skilled nursing facilities (SNFs) has become increasingly common. It is not known whether clinicians focused on NH care, often referred to as SNFists (ie, physicians, nurse practitioners, and physician assistants concentrating their practice in the NH or SNF setting), are associated with a reduced likelihood of burdensome transitions in the last 90 days of life for residents, which are a marker of poor-quality end-of-life (EOL) care.

Objective

To quantify the association between receipt of care from an SNFist and quality of EOL care for NH residents.

Design, Setting, and Participants

This cohort study analyzed Medicare fee-for-service claims for a nationally representative 20% sample of beneficiaries to examine burdensome transitions among NH decedents at the EOL from January 1, 2013, through December 31, 2019. Statistical analyses were conducted from December 2022 to June 2023.

Exposure

Receipt of care from an SNFist, defined as physicians and advanced practitioners who provided 80% or more of their evaluation and management visits in NHs annually.

Main Outcomes and Measures

This study used augmented inverse probability weighting in analyses of Medicare fee-for-service claims for a nationally representative 20% sample of beneficiaries. Main outcomes included 4 measures of burdensome transitions: (1) hospital transfer in the last 3 days of life; (2) lack of continuity in NHs after hospitalization in the last 90 days of life; (3) multiple hospitalizations in the last 90 days of life for any reason or any hospitalization for pneumonia, urinary tract infection, dehydration, or sepsis; and (4) any hospitalization in the last 90 days of life for an ambulatory care-sensitive condition.

Results

Of the 2 091 954 NH decedents studied (mean [SD] age, 85.4 [8.5] years; 1 470 724 women [70.3%]), 953 722 (45.6%) received care from SNFists and 1 138 232 (54.4%) received care from non-SNFists; 422 575 of all decedents (20.2%) experienced a burdensome transition at the EOL. Receipt of care by an SNFist was associated with a reduced risk of (1) hospital transfer in the last 3 days of life (-1.6% [95% CI, -2.5% to -0.8%]), (2) lack of continuity in NHs after hospitalization (-4.8% [95% CI, -6.7% to -3.0%]), and (3) decedents experiencing multiple hospitalizations for any reason or any hospitalization for pneumonia, urinary tract infection, dehydration, or sepsis (-5.8% [95% CI, -10.1% to -1.7%]). There was not a statistically significant association with the risk of hospitalization for an ambulatory care-sensitive condition in the last 90 days of life (0.0% [95% CI, -14.7% to 131.7%]).

Conclusions and Relevance

This study suggests that SNFists may be an important resource to improve the quality of EOL care for NH residents.

Clinicians who primarily practice in nursing homes and outcomes among residents with urinary tract infection or pneumonia

Objective

Assess the association between clinicians who primarily practice in nursing homes (NHs) and 14-day resident outcomes following initial antibiotic dispensing for pneumonia or urinary tract infection (UTI).

Design

Retrospective cohort.

Setting

U.S. NHs.

Participants

NH residents aged ≥65 years who were prescribed antibiotics for pneumonia or UTI between 1 January 2016 and 30 November 2018.

Methods

Medicare fee-for-service claims were linked to Minimum Data Set data. Clinicians who primarily practiced in NHs prescribed ≥90% of Part D dispensings to NH residents. Outcomes included death, all-cause and infection-specific hospitalization, and subsequent antibiotic dispensing. Adjusted risk ratios were estimated using inverse-probability-of-treatment-weighted (IPTW) modified Poisson regression models adjusting for 53 covariates.

Results

The study population included 28,826 resident-years who were prescribed antibiotics for pneumonia and 106,354 resident-years who were prescribed antibiotics for UTI. Among the pneumonia group, clinicians who primarily practiced in NHs were associated with a greater risk of death (RR 1.3; 95%CLs 1.0, 1.6), lower risks of all-cause (RR 0.9; 95%CLs 0.8, 0.9) and infection-specific hospitalization (RR 0.8; 95%CLs 0.7, 0.9), and similar risk of subsequent antibiotic dispensing (RR 1.0; 95%CLs 1.0, 1.1) after IPTW. No meaningful associations were observed between clinicians who primarily practiced in NHs and outcomes among the UTI group.

Conclusions

Clinicians who primarily practiced in NHs were associated with a lower risk of hospitalization but greater risk of mortality for NH residents with pneumonia. Further examination is needed to better understand drivers of differences in infection-related outcomes based on clinicians' training and primary practice setting.

Potentially Harmful Medication Prescribing by the Degree of Physician Specialization in Nursing Home Practice: An Observational Study

OBJECTIVES

The use of anticholinergics, antipsychotics, benzodiazepines, and other potentially harmful medications (PHMs) is associated with particularly poor outcomes in nursing home (NH) residents with Alzheimer's disease and related dementias (ADRD). Our objective was to compare PHM prescribing by NH physicians and advanced practitioners who focus their practice on NH residents (NH specialists) vs non-NH specialists.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

We included a 20% random sample of Medicare beneficiaries with ADRD who resided in 12,278 US NHs in 2017. Long-stay NH residents with ADRD were identified using MDS, Medicare Parts A and B claims. Residents <65 years old or without continuous Part D coverage were excluded.

METHODS

Physicians in generalist specialties and advanced practitioners with ≥90% of Part B claims for NH care were considered NH specialists. Residents were assigned to NH specialists vs non-NH specialists based on plurality of Part D claims submitted for that resident. Any PHM use (defined using the Beers Criteria) and the proportion of NH days on a PHM were modeled using generalized estimating equations. Models included resident demographics, clinical characteristics, cognitive and functional status, behavioral assessments, and facility characteristics.

RESULTS

Of the 54,713 residents in the sample, 27.9% were managed by an NH specialist and 72.1% by a non-NH specialist. There was no statistically significant difference in any PHM use [odds ratio (OR) 0.97, 95% CI 0.93-1.02, P = .23]. There were lower odds of prolonged PHM use (OR 0.87, 95% CI 0.81-0.94, P < .001, for PHM use on >75% vs >0%-<25% of NH days) for NH specialists vs non-NH specialists.

CONCLUSIONS AND IMPLICATIONS

Although the use of PHMs among NH residents with ADRD managed by NH specialists was not lower, they were less likely to receive PHMs over longer periods of time. Future work should evaluate the underlying causes of these differences to inform interventions to improve prescribing for NH residents.

Prediction of rehospitalization and mortality risks for skilled nursing facilities using a dimension reduction approach

BACKGROUND

Hospitals are incentivized to reduce rehospitalization rates, creating an emphasis on skilled nursing facilities (SNFs) for post-hospital discharge. How rehospitalization rates vary depending on patient and SNF characteristics is not well understood, in part because these characteristics are high-dimensional. We sought to estimate rehospitalization and mortality risks by patient and skilled nursing facility (SNF) leveraging high-dimensional characteristics.

METHODS

Using 1,060,337 discharges from 13,708 SNFs of Medicare patients residing or visiting a provider in Wisconsin, Iowa, and Illinois, factor analysis was performed to reduce the number of patient and SNF characteristics. K-means clustering was applied to SNF factors to categorize SNFs into groups. Rehospitalization and mortality risks within 60 days of discharge was estimated by SNF group for various values of patient factors.

RESULTS

Patient and SNF characteristics (616 in total) were reduced to 12 patient factors and 4 SNF groups. Patient factors reflected broad conditions. SNF groups differed in beds and staff capacity, off-site services, and physical and occupational therapy capacity; and in mortality and rehospitalization rates for some patients. Patients with cardiac, orthopedic, and neuropsychiatric conditions are associated with better outcomes when assigned to SNFs with greater on-site capacity (i.e. beds, staff, physical and occupational therapy), whereas patients with conditions related to cancer or chronic renal failure are associated with better outcomes when assigned to SNFs with less on-site capacity.

CONCLUSIONS

Risks of rehospitalization and mortality appear to vary significantly by patient and SNF, with certain SNFs being better suited for some patient conditions over others.

Physician Practice Characteristics Influencing Nurse Practitioner and Physician Assistant Care in Nursing Homes: A Scoping Review

OBJECTIVES

Physicians, nurse practitioners (NPs), and physician assistants (PAs) are key to the effective delivery of medical care in nursing homes (NHs). Although several studies have reported on the relationship between the care delivered by a given discipline and specific clinical outcomes, the mediating effect of physician practice characteristics is unknown. A scoping review was conducted to determine whether studies examining the impact of NP and PA care in NHs have accounted for both the collaborative relationship between themselves and physicians as well as physician practice size and type.

DESIGN

Scoping review.

SETTINGS AND PARTICIPANTS

NH and NH residents.

METHODS

Papers eligible for review included peer-reviewed studies written in English and that were quantitative in nature. Inclusion criteria required that more than 1 NH and more than a single NP or PA be included for the analysis. Further, the size of the NH studied must have equaled or exceeded 100 residents and more than 1 clinical outcome reported. Databases searched included Ovid MEDLINE, Cochrane Library, Web of Science; CINAHL, and AgeLine.

RESULTS

A total of 1878 studies underwent abstract review of which 1719 were excluded. A full-text review of the remaining articles was completed (n = 157, as 2 articles could not be retrieved), of which 16 met eligibility criteria. The study designs were generally retrospective and quasi-experimental in nature. No randomized controlled studies were identified. Physician practice variables such as number of physicians, total practice case load, case mix, and the nature of the collaborative practice between NP/PA and MD were infrequently specified. In no reports was the type of physician practice characterized and no physician practice variables were adjusted for with regard to outcomes.

CONCLUSIONS

None of the studies included in the review were found to have incorporated any physician variables into their outcome analyses. Before purporting equivalency between medical provider disciplines in NHs, future studies must, at the very least, consider the mediating effect of physician practice characteristics.

Physician Practice in Ontario Nursing Homes: Defining Physician Commitment

OBJECTIVES

To characterize the practice profile of nursing home (NH) physicians in Ontario, Canada.

DESIGN

Population-based cross-sectional study.

SETTING AND PARTICIPANTS

A total of 1527 most responsible physicians (MRPs) across 626 NHs in Ontario, Canada, for the calendar year, 2017.

METHODS

We examined physician services within all publicly regulated and funded NH facilities. Descriptive summaries were generated to characterize MRPs and their practice patterns by the physician's primary practice location, the NH facility size, and the proportion of physician billings that occurred within NHs. Community sizes were classified into quintiles based on population size and assigned as urban or rural. The number of ministry-designated NH beds were assessed by quintiles to examine physician services by facility size. We also assessed the proportion of physician billings within NHs by quintiles.

RESULTS

MRPs tended to be older, male, and practice family medicine. The majority of MRPs practiced in communities with populations exceeding 100,000 residents, although physicians with greater NH billings tended to practice in rural locations. The mean number of NH residents that a physician was MRP for was positively associated with the community size. Physicians provided care for more NH residents than they were assigned most responsible. Fifty-one percent of physicians were MRP for 90% of all NH residents.

CONCLUSIONS AND IMPLICATIONS

Our work provides an exemplar for characterizing physician commitment in NHs, using 2 approaches, according to the NH specialist model. We demonstrated the medical practice characteristics, locations, and billing patterns of physicians within Ontario NHs. Future work can investigate the association between physician commitment and the quality of care provided to NH residents. A greater understanding of physician commitment may lead to the development of quality metrics based on physician practice patterns.

US Generalist Physicians and Groups That Focused Practice in a Single Care Setting: 2014-2017

BACKGROUND

Some generalist physicians whose training prepared them for primary care practice increasingly practice in a facility (eg, hospitals, nursing homes); however, whether this trend was accompanied by a complimentary rise in generalist physicians who focused their practice on office-based care is unknown.

OBJECTIVES

Our objective in this study was to examine trends in the prevalence of generalist physicians and physician groups that practice in a single setting.

RESEARCH DESIGN

This was a retrospective cross-sectional study of generalist physicians trained in family medicine, internal medicine, or geriatrics. We used 2014-2017 billing data for Medicare fee-for-service beneficiaries to measure the proportion of all patient visits made by physicians in the following care settings: office, outpatient hospital department, inpatient hospital, and other sites.

RESULTS

From 2014 to 2017, the proportion of generalist physicians who narrowed their practice to a single setting increased by 6.69% (from 62.80% to 67.00%, p for trend <0.001). In 2017, 4.63% of physician groups included more than 1 type of setting-based physicians.

CONCLUSIONS

Generalist physicians treating older adults increasingly narrowed their practice focus to a single type of health care setting. This trend was not accompanied by growth among physician groups that included different types of setting-based physicians. Further evaluation of the consequences of these trends on the fragmentation of primary care delivery across different health care settings and primary care outcomes is needed.

Successful Community Discharge Among Older Adults With Traumatic Brain Injury Admitted to Inpatient Rehabilitation Facilities

Objective

To identify admission characteristics that predict a successful community discharge from an inpatient rehabilitation facility (IRF) among older adults with traumatic brain injury (TBI).

Design

In a retrospective cohort study, we leveraged probabilistically linked Medicare Administrative, IRF-Patient Assessment Instrument, and National Trauma Data Bank data to build a parsimonious logistic model to identify characteristics associated with successful discharge. Multiple imputation methods were used to estimate effects across linked datasets to account for potential data linkage errors.

Setting

Inpatient Rehabilitation Facilities in the U.S.

Participants

The sample included a mean of 1060 community-dwelling adults aged 66 years and older across 30 linked datasets (N=1060). All were hospitalized after TBI between 2011 and 2015 and then admitted to an IRF. The mean age of the sample was 79.7 years, and 44.3% of the sample was women.

Interventions

Not applicable.

Main Outcome Measures

Successful discharge home.

Results

Overall, 64.6% of the sample was successfully discharged home. A logistic model including 4 predictor variables: Functional Independence Measure motor (FIM-M) and cognitive (FIM-C) scores, pre-injury chronic conditions, and pre-injury living arrangement, that were significantly associated with successful discharge, resulted in acceptable discrimination (area under the curve: 0.76, 95% confidence interval [CI]: 0.72-0.81). Higher scores on the FIM-M (odds ratio [OR]:1.07, 95% CI: 1.05-1.09) and FIM-C (OR: 1.05, 95% CI: 1.02-1.08) were associated with greater odds of successful discharge, whereas living alone vs with others (OR: 0.46, 95% CI: 0.30-0.71) and a greater number of chronic conditions (OR: 0.94, 95% CI: 0.90-0.99) were associated with lower odds of successful discharge.

Conclusions

The results provide a parsimonious model for predicting successful discharge among older adults admitted to an IRF after a TBI-related hospitalization and provide clinically useful information to inform discharge planning.

Successful Discharge of Short Stay Veterans from VA Community Living Centers

The Veterans Health Administration (VHA) long-term care rebalancing initiative encouraged VA Community Living Centers (CLCs) to shift from long-stay custodial-focused care to short-stay skilled and rehabilitative care. Using all VA CLC admissions during 2007-2010 categorized as needing short-stay rehabilitation or skilled nursing care, we assessed the patient and facility rates of successful discharge to the community (SDC) of these short-stay Veterans. We found large variation in inter- as well as intra- facility SDC rates across the rehabilitation and skilled nursing short-stay cohorts. We discuss how our results can help guide VHA policy directed at delivering high-quality short-stay CLC care for Veterans.

Growth of Physicians and Nurse Practitioners Practicing Full Time in Nursing Homes

OBJECTIVES

The objective was to describe the growth of physicians, nurse practitioners (NPs), and physician assistants (PAs) who practice full time in nursing homes, to assess resident and nursing home characteristics associated with receiving care from full-time providers, and describe variation among nursing homes in use of full-time providers.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

A 20% national sample Medicare data on long-term care residents in 2008 to 2018 and the physicians, NPs, and PAs who submitted charges to Medicare for their care.

METHODS

We measured the percentage of provider charges for services rendered in nursing homes, in addition to resident and facility characteristics.

RESULTS

Full-time nursing home providers increased from 26.0% of all nursing home providers in 2008 to 44.6% in 2017. The largest increase was in NPs: from 1986 in 2008 to 4479 in 2017. Resident age, sex, Medicaid eligibility, and race/ethnicity had minimal association with the odds of having a full-time provider, whereas residents with an NP primary care provider were 23.0 times more likely (95% confidence interval = 21.6, 24.6) to have a full-time provider. Residents who received care from both a physician and an NP or PA increased from 33.6% in 2008 to 62.5% in 2018. There was large variation among facilities in the percentage of residents with full-time providers, from 5.72% of residents with full-time providers in the bottom quintile of facilities to 91.44% in the top quintile. Individual nursing homes accounted for 59% of the variation in whether a resident had a full-time provider.

CONCLUSIONS AND IMPLICATIONS

The percentage of nursing home residents with full-time providers continues to grow, with very large variation among nursing homes.

Medical Staffing Organization and Quality of Care Outcomes in Post-acute Care Settings

BACKGROUND AND OBJECTIVES

Medical providers are significant drivers of care in post-acute long-term care (PALTC) settings, yet little research has examined the medical provider workforce and its role in ensuring quality of care.

RESEARCH DESIGN AND METHODS

This study examined the impact of nursing home medical staffing organization (NHMSO) dimensions on the quality of care in U.S. nursing homes. The principal data source was a survey specifically designed to study medical staff organization for post-acute care. Respondents were medical directors and attending physicians providing PALTC. We linked a number of medical provider and nursing home characteristics to the Centers for Medicaid and Medicare Services Nursing Home Compare quality measures hypothesized to be sensitive to input by medical providers.

RESULTS

From the sample of nursing home medical providers surveyed (n = 1,511), 560 responses were received, yielding a 37% response rate; 425 medical provider responses contained sufficient data for analysis. The results of the impact of NHMSO dimensions were mixed, with many domains not having any significance or having negative relationships between provider characteristics and quality measures. Respondents who reported having a formal process for granting privileges and nursing homes with direct employment of physicians reported significantly fewer emergency visits.

DISCUSSION AND IMPLICATIONS

Further research is needed regarding what quality measures are sensitive to both medical provider characteristics and NHMSO characteristics.

Medical Care Delivery in U.S. Nursing Homes: Current and Future Practice

The delivery of medical care services in U.S. nursing homes (NHs) is dependent on a workforce that comprises physicians, nurse practitioners, and physician assistants. Each of these disciplines operates under a unique regulatory framework while adhering to common standards of care. NH provider characteristics and their roles in NH care can illuminate potential links to clinical outcomes and overall quality of care with important policy and cost implications. This perspective provides an overview of what is currently known about medical provider practice in NH and organizational models of practice. Links to quality, both conceptual and established, are presented as is a research and policy agenda that addresses the gaps in the evidence base within the context of our ever-changing health care landscape.

Expectations and experiences with physician care among patients receiving post-acute care in US skilled nursing facilities

BACKGROUND

In the US, post-acute care in skilled nursing facilities (SNFs) is common and outcomes vary greatly across facilities. Little is known about the expectations of patients and their caregivers about physician care during the hospital to SNF transition. Our objectives were to (1) describe the experiences and expectations of patients and their caregivers with SNF physicians in SNFs, and (2) identify patterns that differed between patients with vs. without cognitive impairment.

METHODS

This qualitative study used grounded theory approach to analyze data collected from semi-structured interviews at five SNFs in January-August 2018. Patients admitted for short-term SNF care 5-10 days prior were eligible to participate. Thematic analysis was performed to detect recurrent themes with a focus on modifiable aspects of physician care. Analysis was stratified by patient cognitive impairment (measured by the Montreal Cognitive Assessment at the time of the interview).

RESULTS

Fifty patients and six caregivers were interviewed. Major themes were: (1) patients had poor awareness of the physician in charge of their care; (2) they were dissatisfied with the frequency of interaction with the physician; and (3) participants valued the perception of receiving individualized care from the physician. Less cognitively impaired patients were more concerned about limited interactions with the physicians and were more likely to report attempts to seek out the physician.

CONCLUSION

Patient and caregiver expectations of SNF physicians were not well aligned with their experiences. SNFs aiming to improve satisfaction with care may focus efforts in this area, such as facilitating frequent communication between physicians, patients and caregivers.

Trends In Hospitals And Skilled Nursing Facilities Sharing Medical Providers, 2008-16

Hospitals and skilled nursing facilities (SNFs) face increasing pressure to improve care coordination and reduce unnecessary readmissions. One strategy to accomplish this is to share physicians and advanced practice clinicians, so that the same providers see patients in both settings. Using 2008-16 Medicare claims, we found that as SNFs moved increasingly toward using SNF specialists, there was a steady decline in the number of facilities sharing medical providers and in the proportion of SNF primary care delivered by provider practices with both hospital and SNF clinicians (hospital-SNF practices). In SNF fixed effects analyses, we found that SNFs that increased primary care visits by hospital-SNF practices had slightly fewer readmissions, shorter lengths-of-stay, and increased successful community discharges. These findings suggest that SNFs that share medical providers with hospitals may see some benefit from that linkage, although the magnitude of the benefit may be small.

Long-Term Care, Residential Facilities, and COVID-19: An Overview of Federal and State Policy Responses

The COVID-19 pandemic has disproportionately affected residents and staff at long-term care (LTC) and other residential facilities in the United States. The high morbidity and mortality at these facilities has been attributed to a combination of a particularly vulnerable population and a lack of resources to mitigate the risk. During the first wave of the pandemic, the federal and state governments received urgent calls for help from LTC and residential care facilities; between March and early June of 2020, policymakers responded with dozens of regulatory and policy changes. In this article, we provide an overview of these responses by first summarizing federal regulatory changes and then reviewing state-level executive orders. The policy and regulatory changes implemented at the federal and state levels can be categorized into the following 4 classes: (1) preventing virus transmission, which includes policies relating to visitation restrictions, personal protective equipment guidance, and testing requirements; (2) expanding facilities' capacities, which includes both the expansion of physical space for isolation purposes and the expansion of workforce to combat COVID-19; (3) relaxing administrative requirements, which includes measures enacted to shift the attention of caretakers and administrators from administrative requirements to residents' care; and (4) reporting COVID-19 data, which includes the reporting of cases and deaths to residents, families, and administrative bodies (such as state health departments). These policies represent a snapshot of the initial efforts to mitigate damage inflicted by the pandemic. Looking ahead, empirical evaluation of the consequences of these policies-including potential unintended effects-is urgently needed. The recent availability of publicly reported COVID-19 LTC data can be used to inform the development of evidence-based regulations, though there are concerns of reporting inaccuracies. Importantly, these data should also be used to systematically identify hot spots and help direct resources to struggling facilities.

Patient and Caregiver Perceptions of Nursing Home Physicians: Insight from Yelp Reviews, 2009-2018

OBJECTIVES

To describe the content of reviews submitted on Yelp that pertain to nursing home (NH) physicians.

DESIGN

Retrospective qualitative study.

SETTING

NHs in the United States reviewed on Yelp from 2009 to 2018 with reviews that discussed NH physicians.

PARTICIPANTS

Physicians in 375 NHs in 31 states.

MEASUREMENTS

Content analysis was performed to detect recurrent themes and divergent ideas about NH physicians perceived by reviewers.

RESULTS

Average rating among NHs with physician reviews was 2.0 (standard deviation = 1.5; range = 1-5). The major themes from content analysis of reviews that discussed physicians were perceived attitudes of clinicians toward patients and caregivers, physician communication with patients or caregivers, and perceived clinical expertise of the physicians.

CONCLUSION

Unsolicited online reviews of NHs that comment on patient and caregiver perceptions of physician care represent a small but growing number of online comments about NHs. These reviews contain important information about aspects of physician care valued by NH patients and caregivers. However, the sample of comments about physicians represents a small proportion of online reviews and is not representative of all NHs. As online reviews grow in number and become more representative, these data could be used by physicians to improve perceptions of their care by NH patients and their families, and by NHs to inform expectations of their medical director and attending physicians.

Postacute care outcomes and medicare payments for patients treated by physicians and advanced practitioners who specialize in nursing home practice

OBJECTIVE

To measure the association between clinician specialization in nursing home (NH) practice and outcomes of patients who received postacute care in skilled nursing facilities (SNFs).

DATA SOURCES

Medicare claims and NH assessments for 2 118 941 hospital discharges to 14 526 SNFs in January 2012-October 2014 and MD-PPAS data for 52 379 clinicians.

STUDY DESIGN

Generalist physicians and advanced practitioners with ≥ 90 percent of claims for NH-based care were considered NH specialists. The primary clinician during each SNF stay was determined based on plurality of claims during that stay. We estimated the effect of being treated by a NH specialist on 30-day rehospitalizations, successful discharge to community, and 60-day episode-of-care Medicare payments (Parts A and B). All models included patient demographics, clinical variables, and SNF fixed effects.

PRINCIPAL FINDINGS

Nursing home specialists' patients were less likely to be rehospitalized (14.71 percent vs 16.23 percent; adjusted difference, -1.51 percent, 95% CI -1.78 to -1.24), more likely to be successfully discharged to community (56.33 percent vs 55.49 percent; adjusted difference, 0.84 percent, 95% CI 0.54 to 1.14), but had higher 60-day Medicare payments ($31 628 vs $31 292; adjusted difference, $335; 95% CI $242 to $429).

CONCLUSIONS

Clinicians who specialize in NH practice may achieve better postacute care outcomes at slightly higher costs.