Panel A. Risk-adjusted Rate of Hospitalization Panel B. Risk-adjusted Rate of Any Emergency Department Visit
Panel C. Risk-adjusted Rate of Emergency Department Visits without Hospitalization or Observation Stay
Panel D. Risk-adjusted Rate of Potentially Avoidable Emergency Department Visits
Supplemental Figure 1. Distribution of Risk-adjusted Rates of Hospitalization and Emergency Department Visits Pooled 2011 Q2-2013 Q3
Notes: Risk-adjusted rates > 50% were not presented to better show the distributions.
Supplemental Table 1. Resident-level Multinomial Logit Regression on Hospitalization in 2012 Q3 (N=708,682) Hospitalization vs Alive
without Hospitalization
Death vs Alive without Hospitalization
Variables OR 95% CI OR 95% CI
Sociodemographic and enrollment characteristics
Age 0.99 0.99 0.99 1.05 1.04 1.05
Female 0.85 0.83 0.87 0.63 0.59 0.68
Non-Hispanic White 0.73 0.70 0.75 2.06 1.88 2.27
Married 0.92 0.89 0.94 0.88 0.82 0.95
Medicare Disability Insurance Benefits 0.83 0.76 0.91 N/A N/A N/A
Medicare end-stage renal disease coverage 2.52 2.38 2.68 1.77 1.35 2.30
Medicaid dual-eligible status 1.13 1.09 1.16 0.92* 0.86 0.99
Comorbidities
Anxiety 1.12 1.10 1.14 1.06† 1.00 1.12
Cardiovascular 1.30 1.25 1.35 1.08† 0.99 1.17
Gastrointestinal 1.14 1.11 1.17 0.96† 0.88 1.04
Infections 2.43 2.37 2.49 1.06† 0.98 1.14
Neurological 0.91 0.89 0.94 0.90 0.83 0.97
Other endocrine 1.06 1.04 1.08 0.89 0.84 0.94
Pulmonary 1.10 1.08 1.13 1.11 1.03 1.19
Severe mental illness 1.28 1.25 1.31 0.94† 0.87 1.02
Clinical conditions and treatments
Admitted from acute hospital 2.53 2.43 2.63 0.91 0.85 0.97
Any pressure ulcers of class ≥2 1.62 1.56 1.67 1.57 1.43 1.72
Daily use of any restraint 1.11 1.06 1.16 0.89* 0.79 1.00
Dehydrated 1.37 1.17 1.60 2.09 1.55 2.82
Fall History
Last 30 Days 1.48 1.41 1.56 0.93† 0.80 1.09
Last 31-180 Days 2.69 2.56 2.82 0.96† 0.82 1.13
Since admission or Prior Assessment 1.28 1.25 1.31 1.23 1.16 1.31
Fever 3.05 2.90 3.20 1.40 1.22 1.62
Indwelling catheter 1.23 1.19 1.28 1.24 1.11 1.38
Nursing home episode days 1.00 1.00 1.00 1.00 1.00 1.00
Obesity (BMI > 31.15) 1.12 1.10 1.15 0.69 0.63 0.74
Pain in last 5 days 1.18 1.16 1.21 1.04† 0.98 1.10
Rejection of care ≥ 4 days per week 1.32 1.26 1.37 1.23 1.10 1.38
Shortness of breath
Sitting 2.44 2.33 2.56 1.78 1.57 2.03
With exertion 1.27 1.22 1.32 1.23 1.11 1.37
Lying flat 1.16 1.11 1.21 1.13* 1.01 1.27
Surgical wound 2.08 1.99 2.18 0.69 0.58 0.83
Swallowing Disorder 1.06* 1.00 1.11 1.40 1.25 1.56
Vomiting 2.85 2.72 3.00 1.49 1.27 1.74
Weight loss ≥ 5% in 1 month or ≥ 10% in 6 months 1.59 1.54 1.63 2.03 1.88 2.18
Wound Infection 0.75 0.69 0.81 1.24 0.96 1.58
Physical and cognitive function
Acute onset mental status change 2.96 2.83 3.10 2.18 1.96 2.43
ADL total score 1.03 1.03 1.03 1.08 1.07 1.09
CFS (ref: Intact)
Mild or moderate impairment 1.19 1.16 1.23 1.31 1.22 1.41
Severe impairment 1.52 1.47 1.59 1.67 1.52 1.82
Independent walking in corridors in last 7 days 1.82 1.75 1.90 1.08† 0.92 1.26
Rarely understood by others 0.75 0.72 0.79 1.07† 0.97 1.17
Risk score
Low care 1.36 1.29 1.43 1.35 1.08 1.68
RUG IV Case-mix Index 1.45 1.39 1.52 1.49 1.35 1.65
Notes: OR = odds ratio, CI = confidence interval, N/A=not available due to sample size;
* P <0.05;
† Not significant,P > 0.05;
All remaining odds ratios were significant at P < 0.01 level if not specified;
Standard errors were clustered at nursing home level.
Supplemental Table 2. Resident-level Multinomial Logit Regression on Emergency Department Visit without Hospitalization or Observation Stay in 2012 Q3 (N=708,682)
Outpatient ED vs Alive without Outpatient ED
Outpatient ED vs Alive without Outpatient ED
Variables OR 95% CI OR 95% CI
Sociodemographic and enrollment characteristics
Age 0.99 0.99 0.99 1.05 1.05 1.05
Female 0.87 0.84 0.89 0.69 0.65 0.73
Non-Hispanic White 0.80 0.77 0.83 1.91 1.76 2.07
Medicare Disability Insurance Benefits 0.82 0.72 0.92 N/A N/A N/A
Medicare end-stage renal disease coverage 2.40 2.24 2.58 1.64 1.31 2.06
Medicaid dual-eligible status 1.14 1.09 1.18 0.92* 0.87 0.99
Comorbidities
Anxiety 1.27 1.23 1.30 1.03† 0.97 1.09
Cardiovascular 1.21 1.15 1.28 1.07† 0.99 1.16
Infections 1.46 1.39 1.54 1.23 1.11 1.36
Pulmonary 1.17 1.13 1.21 1.08 1.02 1.16
Clinical conditions and treatments
Admitted from Acute hospital 2.30 2.19 2.42 0.95† 0.89 1.01
Any pressure ulcers of class ≥2 1.16 1.11 1.21 1.55 1.43 1.68
Fall History
Last 31-180 Days 1.52 1.45 1.59 0.90† 0.80 1.01
Since admission or Prior Assessment 1.85 1.80 1.90 1.26 1.19 1.33
Fever 1.18 1.11 1.25 1.16 1.03 1.29
Indwelling Catheter 1.33 1.27 1.39 1.32 1.20 1.45
Insulin injection 1.24 1.20 1.28 1.16 1.08 1.24
Internal bleeding 1.57 1.44 1.73 1.40 1.16 1.70
NH episode days 1.00 1.00 1.00 1.00† 1.00 1.00
Obesity (BMI > 31.15) 0.97* 0.94 1.00 0.73 0.68 0.79
Pain in last 5 days 1.29 1.26 1.33 1.05† 0.99 1.11
Rejection of care ≥4 days per week 1.16 1.10 1.23 1.22 1.10 1.35
Shortness of breath
With exertion 1.20 1.15 1.26 1.29 1.18 1.40
Surgical wound 1.24 1.18 1.31 0.70 0.61 0.80
Swallowing Disorder 1.13 1.06 1.21 1.39 1.26 1.53
Urinary Tract Infection 1.19 1.13 1.26 0.82 0.73 0.92
Vomiting 1.46 1.37 1.55 1.31 1.16 1.49
Weight loss ≥ 5% in 1 month or ≥ 10% in 6 months 1.35 1.30 1.40 1.83 1.71 1.96 Physical and cognitive function
Acute onset mental status change 1.62 1.54 1.71 1.99 1.82 2.18
ADL total score 1.01 1.01 1.01 1.09 1.08 1.10
CFS (ref: Intact)
Mild or moderate impairment 1.07 1.04 1.11 1.29 1.21 1.38
Severe impairment 1.15 1.10 1.20 1.63 1.52 1.76
Independent walking in corridors in last 7 days 1.29 1.22 1.36 1.26 1.11 1.44 Risk score
Nursing Case Mix Index 1.29 1.23 1.36 1.32 1.21 1.45
Notes: OR = odds ratio, CI = confidence interval, Outpatient ED = Emergency Department Visit without Hospitalization or Observation Stay, N/A=not available due to sample size;
* P <0.05;
† Not significant,P > 0.05;
All remaining odds ratios were significant at P < 0.01 level if not specified;
Standard errors were clustered at nursing home level.
Supplemental Table 3. Resident-level Multinomial Logit Regression on Potentially Avoidable Emergency Department Visit in 2012 Q3 (N=708,682)
Potentially Avoidable ED vs Alive without Potentially
Avoidable ED
Death vs Alive without Potentially Avoidable ED
Variables OR 95% CI OR 95% CI
Sociodemographic and enrollment characteristics
Age 0.99 0.99 1.00 1.05 1.04 1.05
Female 0.95 0.92 0.98 0.66 0.62 0.70
Non-Hispanic White 0.79 0.76 0.82 1.88 1.74 2.03
Married 0.93 0.90 0.97 0.87 0.81 0.92
Medicare Disability Insurance Benefits 0.91 0.79 1.05 0.03 0.00 0.22
Medicare end-stage renal disease coverage 1.70 1.56 1.86 1.84 1.51 2.24
Medicaid dual-eligible status 1.14 1.09 1.19 0.93* 0.87 0.99
Comorbidities
Anxiety 1.13 1.10 1.17 1.05† 0.99 1.11
Cardiovascular 1.30 1.23 1.38 1.09* 1.01 1.18
Diabetes 1.12 1.07 1.17 1.01† 0.94 1.08
Infections 2.99 2.88 3.10 1.08* 1.01 1.15
Musculoskeletal 0.90 0.86 0.93 1.00† 0.94 1.06
Neurological 0.93 0.89 0.96 0.86 0.80 0.92
Pulmonary 1.30 1.25 1.35 1.08* 1.01 1.15
Severe mental illness 1.09 1.05 1.14 0.91 0.85 0.98
Clinical conditions and treatments
Admitted from acute hospital 3.21 2.99 3.44 0.95† 0.89 1.02
Any pressure ulcers of class ≥2 1.36 1.29 1.43 1.53 1.41 1.66
Fall History
Last 31-180 Days 2.05 1.94 2.17 0.94† 0.84 1.05
Since admission or Prior Assessment 1.14 1.10 1.18 1.27 1.20 1.34
Fever 1.85 1.75 1.96 1.28 1.15 1.42
Indwelling Catheter 1.09 1.03 1.15 1.32 1.21 1.45
Insulin injection 1.27 1.21 1.33 1.15 1.06 1.26
Obesity (BMI > 31.15) 1.12 1.09 1.16 0.72 0.67 0.77
Pain in last 5 days 1.14 1.10 1.18 1.03† 0.97 1.09
Shortness of breath
Sitting 2.33 2.20 2.47 1.86 1.67 2.07
With exertion 1.46 1.38 1.54 1.19 1.09 1.31
Lying flat 1.15 1.09 1.22 1.21 1.09 1.33
Surgical wound 0.84 0.78 0.90 0.76 0.67 0.86
Swallowing Disorder: Choke Drinking Meal 0.95† 0.88 1.03 1.36 1.23 1.50
Vomiting 1.48 1.38 1.58 1.34 1.19 1.51
Weight loss ≥5% in 1mo or ≥10% in 6mo 1.43 1.37 1.49 1.84 1.72 1.97
Wound Infection 0.76 0.69 0.84 1.16† 0.94 1.42
Physical and cognitive function
Acute onset mental status change 1.91 1.80 2.02 2.09 1.92 2.29
ADL total score: 0-28 1.02 1.02 1.03 1.09 1.08 1.10
CFS (ref: Intact)
Mild or moderate impairment 1.11 1.07 1.15 1.35 1.26 1.44
Severe impairment 1.25 1.18 1.32 1.65 1.53 1.79
Independent walking in corridors, last 7 days 1.36 1.28 1.46 1.27 1.11 1.44
Rarely understood by others 0.79 0.74 0.85 1.13 1.03 1.23
Risk score
RUG-IV Case-mix Index 1.12 1.06 1.18 1.30 1.19 1.43
Notes: OR = odds ratio, CI = confidence interval, ED=emergency department, N/A=not available due to sample size;
* P <0.05;
† Not significant,P > 0.05;
All remaining odds ratios were significant at P < 0.01 level if not specified;
Standard errors were clustered at nursing home level.
Supplemental Table 4. Multivariate Random-Effect Linear Regressions Measuring the Association of Nursing Home Risk-adjusted Rates of Emergency Department Visits with Nursing Home Compare Health Inspection Five-star Rating Pooled 2011 Q2-2013 Q3 (N = 143,271)
Variables Risk-adjusted
Any ED rates ǂ (Coef., 95% CI)
Risk-adjusted Outpatient ED
rates ǂ (Coef., 95% CI)
Risk-adjusted potentially avoidable
ED rates ǂ (Coef., 95% CI) Nursing Home Characteristics
Health Inspection rating ≥3 stars -0.22** -0.19** -0.11**
(-0.33 - -0.11) (-0.24 - -0.13) (-0.17 - -0.04) Structure
Alzheimer’s unit -0.28** -0.17** -0.08
(-0.44 - -0.11) (-0.25 - -0.09) (-0.17 - 0.01)
Chain -0.25** -0.10* -0.11*
(-0.41 - -0.09) (-0.18 - -0.02) (-0.20 - -0.02) Ownership (ref: For profit)
Non-profit -0.25* -0.18** -0.06
(-0.45 - -0.04) (-0.28 - -0.09) (-0.17 - 0.05)
Government -0.51** -0.22* -0.15
(-0.87 - -0.16) (-0.39 - -0.04) (-0.33 - 0.03)
Number of beds (≥100) -0.39** -0.19** -0.21**
(-0.56 - -0.21) (-0.28 - -0.11) (-0.30 - -0.11)
Occupancy rate+ -0.11* -0.10** -0.06*
(-0.20 - -0.02) (-0.15 - -0.06) (-0.12 - -0.01) Resident Mix
RUG-IV Case-mix Index+ -0.59** -0.17** -0.17**
(-0.70 - -0.48) (-0.22 - -0.11) (-0.24 - -0.10)
% Medicaid residents+ 0.19** 0.17** 0.08*
(0.07 - 0.30) (0.12 - 0.23) (0.02 - 0.14)
% Medicare residents+ 0.61** 0.19** 0.18**
(0.48 - 0.75) (0.13 - 0.25) (0.11 - 0.25)
% Residents with advance directives+ -0.07* -0.05** -0.03
(-0.13 - -0.01) (-0.08 - -0.01) (-0.06 - 0.01) Staffing
Any Nurse Practitioner or Physician Assistant -0.13* -0.06* -0.12**
(-0.25 - -0.01) (-0.13 - -0.00) (-0.19 - -0.05)
Registered Nurse to total nurses ratio+ -0.14** -0.15** -0.07**
(-0.24 - -0.05) (-0.19 - -0.10) (-0.13 - -0.02)
Any mental health provider 0.06 0.04 0.03
(-0.07 - 0.18) (-0.03 - 0.10) (-0.05 - 0.11) Market Factors
Urban county 1.19** 0.06 0.09
(0.93 - 1.45) (-0.06 - 0.19) (-0.04 - 0.22)
Unconcentrated market (HHI < 0.15) 0.16 -0.03 0.02
(-0.06 - 0.37) (-0.14 - 0.08) (-0.09 - 0.13)
% Medicare Advantage Penetration+ -0.74** -0.39** -0.32**
(-0.86 - -0.61) (-0.45 - -0.33) (-0.39 - -0.25)
Primary care physician per 1,000 population+ 0.87** -0.03 0.24**
(0.74 - 1.00) (-0.08 - 0.02) (0.17 - 0.30)
% Older population (≥ 65)+ -0.59** -0.15** -0.24**
(-0.69 - -0.50) (-0.20 - -0.11) (-0.29 - -0.19)
Median Household Income+ -0.15** -0.11** -0.10**
(-0.27 - -0.04) (-0.16 - -0.06) (-0.16 - -0.04) Year (ref: 2011)
2012 0.23** 0.09** 0.09**
(0.14 - 0.32) (0.04 - 0.14) (0.03 - 0.15)
2013 0.46** 0.19** 0.19**
(0.35 - 0.57) (0.13 - 0.25) (0.12 - 0.26)
Constant -0.48 0.01 -0.00
(-1.15 - 0.19) (-0.35 - 0.37) (-0.33 - 0.33)
Observations 143,271 143,271 143,200
Number of unique nursing homes 15,189 15,189 15,185
Note: ED= emergency department, Outpatient ED = Emergency Department Visit without Hospitalization or Observation Stay, CI = Confidence Interval;
** p<0.01, * p<0.05;
95% Confidence interval in parentheses;
Huber–White sandwich estimator of standard errors were used to adjust for heteroscedasticity;
ǂ Outcomes were centered at state-quarter level;
+ Continuous variables were standardized with a mean of zero and a standard deviation of one.
§ State fixed effects were not presented.