Preventing hospitalizations from nursing homes is harder than it looks

I applaud the publication of negative studies. From JAMA Internal Medicine, “Effects of an Intervention to Reduce Hospitalizations From Nursing Homes: A Randomized Implementation Trial of the INTERACT Program“:

Importance: Medicare payment initiatives are spurring efforts to reduce potentially avoidable hospitalizations.

Objective: To determine whether training and support for implementation of a nursing home (NH) quality improvement program (Interventions to Reduce Acute Care Transfers [INTERACT]) reduced hospital admissions and emergency department (ED) visits.

Design, Setting, and Participants: This analysis compared changes in hospitalization and ED visit rates between the preintervention and postintervention periods for NHs randomly assigned to receive training and implementation support on INTERACT to changes in control NHs. The analysis focused on 85 NHs (36 717 NH residents) that reported no use of INTERACT during the preintervention period.

Interventions: The study team provided training and support for implementing INTERACT, which included tools that help NH staff identify and evaluate acute changes in NH resident condition and document communication between physicians; care paths to avoid hospitalization when safe and feasible; and advance care planning and quality improvement tools.

Main Outcomes and Measures: All-cause hospitalizations, hospitalizations considered potentially avoidable, 30-day hospital readmissions, and ED visits without admission. All-cause hospitalization rates were calculated for all resident-days, high-risk days (0-30 days after NH admission), and lower-risk days (≥31 days after NH admission).

We’d like to reduce hospitalizations from people who live in nursing homes, by keeping them from getting sick or hurt. The INTERACT program was designed to do just that. It supported and trained nursing home workers in identifying and evaluating issues in residents in nursing homes, communicating with doctors, and implementing quality improvement. Nursing homes were randomized to this or usual care. The main outcome of interest was hospitalizations, avoidable hospitalizations, readmissions, and ED visits.

Eighty-five nursing homes with 281 752 person-months were included in the analysis. There was no significant change in the number of hospitalizations in the intervention group versus the control group. There was no significant change in readmissions, ED visits, or any of the sub-analyses of hospitalizations. There was a small, but statistically significant reduction in avoidable hospitalizations, but once they applied a Bonferroni correction, it was no longer significant.

Let’s talk about that for a second. When you do a lot of statistical tests on a lot of potential outcomes, you increase the chance that something will be “significant” by chance alone. When that’s the case it’s good practice to apply a correction to account for that. Since they had six outcomes, the Bonferroni correction reduced the p-value threshold from 0.05 to 0.008. The result (as p=0.01) was no longer significant. Good for them. For more information on significance and p-values, I encourage you to watch our Healthcare Triage episodes on the subject here and here.

We all want to improve the care in nursing homes and prevent hospitalizations and ED visits, if possible. This trial showed a pretty big intervention didn’t work. Let’s acknowledge that and try to do better, instead of doing the same things over and over again. It may take more investment. Sometimes good things cost money.


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