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Relative contributions of hospital versus skilled nursing facility quality on patient outcomes
  1. Paula Chatterjee1,2,3,
  2. Mingyu Qi1,
  3. Rachel Werner1,2
  1. 1 Department of Medicine, Division of General Internal Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
  2. 2 Leonard Davis Institute for Health Economics, Philadelphia, Pennsylvania, USA
  3. 3 Penn Presbyterian Hospital, Philadelphia, Pennsylvania, USA
  1. Correspondence to Dr Paula Chatterjee, Department of Medicine, Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; pchat{at}


Background Hospitals and health systems worldwide have adopted value-based payment to improve quality and reduce costs. In the USA, skilled nursing facilities (SNFs) are now financially penalised for higher-than-expected readmission rates. However, the extent to which SNFs contribute to, and should thus be held accountable for, readmission rates is unknown. To compare the relative contributions of hospital and SNF quality on readmission rates while controlling for unobserved patient characteristics.

Methods Retrospective cohort study of Medicare beneficiaries, 2010–2016. Acute care hospitals and SNFs in the USA. Medicare beneficiaries with two hospitalisations followed by SNF admissions, divided into two groups: (1) patients who went to different hospitals but were discharged to the same SNF after both hospitalisations and (2) patients who went to the same hospital but were discharged to different SNFs. Hospital-level and SNF-level quality, using a lagged measure of 30-day risk-standardised readmission rates (RSRRs). Readmission within 30 days of hospital discharge.

Results There were 140 583 patients who changed hospitals but not SNFs, and 183 232 who changed SNFs but not hospitals. Patients who went to the lowest-performing hospitals (highest RSRR) had a 0.9% higher likelihood of readmission (p=0.005) compared with patients who went to the highest-performing hospitals (lowest RSRR). In contrast, patients who went to the lowest-performing SNFs had a 2% higher likelihood of readmission (p<0.001) compared with patients to went to the highest-performing SNFs.

Conclusions The association between SNF quality and patient outcomes was larger than the association between hospital quality and patient outcomes among postacute care patients. Holding postacute care providers accountable for their quality may be an effective strategy to improve SNF quality.

  • health policy
  • health services research
  • quality improvement

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  • Contributors The authors give permission as the rights holder to include the images/tables in this article.

  • Funding This research was supported by a grant from the Agency for Healthcare Research and Quality (R01-HS024266). RW was supported in part by K24-AG047908 from the National Institute on Aging.

  • Disclaimer PC and MQ have no disclosures.

  • Competing interests RW is paid as a consultant by CarePort Health.

  • Patient consent for publication Not required.

  • Ethics approval This study was approved by the university’s institutional review board.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement No data are available. No data are available.