Medicare expenditures for nursing home residents triaged to nursing home or hospital for acute infection

OBJECTIVES: To compare Medicare payments of nursing home residents triaged to nursing home with those of nursing home residents triaged to the hospital for acute infection care. DESIGN: Observational study with propensity score matching. SETTING: Fifty-nine nursing homes in Maryland. PARTICIPANTS: Two thousand two hundred eighty-five individuals admitted to the 59 nursing homes and followed between 1992 and 1997. MEASUREMENTS: Demographic and clinical data were obtained from interviews and medical record review and linked to Medicare payment records. Incident infection was ascertained according to medical record review for new infectious diagnoses or prescription of antibiotics. Hospital triage was defined as hospital transfer within 3 days of infection onset. Hospital triage patients were paired with similar nursing home triage patients using propensity score matching. Medicare expenditures for triage groups were compared in 1997 dollars. RESULTS: Of 3,618 infection cases, 28% were genitourinary infections, 20% skin, 14% upper respiratory, 12% lower respiratory, 4% gastrointestinal, and 2% bloodstream. Two hundred fifty-six pairs of hospital and nursing home triage cases fulfilled matching criteria. Mean Medicare payments +/- standard deviation were $5,202 +/- 7,310 and $996 +/- 2,475 per case in the hospital and nursing home triage groups, respectively, for a mean difference of $4,206 (95% confidence interval=$3,260-5,151). Mean payments per case in the hospital triage group were $3,628 higher in inpatient expenditures, $482 higher in physician visit expenditures, $161 higher in emergency department expenditures, and $147 higher in skilled nursing day expenditures. CONCLUSION: Per-case Medicare expenditures are higher with hospital triage than for nursing home triage for nursing home residents with acute infection. This result may be used to estimate cost savings to Medicare of interventions designed to reduce hospital use by nursing home residents.