External Validation of the Skilled Nursing Facility Prognosis Score for Predicting Mortality, Hospital Readmission, and Community Discharge in Veterans

• Published in: Journal of the American Geriatrics Society (JAGS) Vol. 68; no. 9; pp. 2090 - 2094
• Main Authors: Burke, Robert E., Canamucio, Anne, Medvedeva, Elina, Manges, Kirstin A., Ersek, Mary
• Format: Journal Article
• Language: English
• Published: Hoboken, USA John Wiley & Sons, Inc 01-09-2020; Wiley Subscription Services, Inc
• Subjects: advance care planning; Advance directives; Aged; Aged, 80 and over; Calibration; Catheters; Comorbidity; Congestive heart failure; Embedding; Female; Heart Failure; Hospitalization; Humans; Male; Medicaid; Medical prognosis; Medicare; Medicare - statistics & numerical data; Mortality - trends; Nomograms; Nursing; Patient Discharge - statistics & numerical data; Patient Readmission - statistics & numerical data; post‐acute care; Predictive Value of Tests; Prognosis; prognostic score; Retrospective Studies; Skilled Nursing Facilities; skilled nursing facility; Subacute Care; United States; Veterans - statistics & numerical data; United States; prognostic score; post-acute care; skilled nursing facility; advance care planning
• ISSN: 0002-8614; 1532-5415
• DOI: 10.1111/jgs.16650

BACKGROUND/OBJECTIVES
Prognostic tools are needed to identify patients at high risk for adverse outcomes receiving post‐acute care in skilled nursing facilities (SNFs) and provide high‐value care. The SNF Prognosis Score was developed in a Medicare sample to predict a composite of long‐term SNF stay, hospital readmission, or death during the SNF stay. Our goal was to evaluate the score's performance in an external validation cohort.
DESIGN
Retrospective observational analysis.
SETTING
We used a Veterans Administration (VA) Residential History File that concatenates VA, Medicare, and Medicaid claims to identify care trajectories across settings and payers for individual veterans.
PARTICIPANTS
Previously community‐dwelling veterans receiving post‐acute care in a SNF after hospitalization from January 1, 2012, to December 31, 2014. Both VA and non‐VA hospitals and SNFs were included.
MEASUREMENTS
We calculated the five‐item SNF Prognosis Score for all eligible veterans in our sample and determined its discrimination (using a receiver operating characteristic curve) and calibration (plotting observed and expected events).
RESULTS
The 386,483 veterans in our sample had worse physical function, more comorbidities, and were more likely to be treated for heart failure, but they had shorter index hospital lengths of stay and fewer catheters than the original Medicare cohort. The SNF Prognosis Score had similar discrimination (C‐statistic = .70; .75 in the derivation cohort) and calibration at low to moderate levels of risk; at high levels, calibration was poorer with the score overestimating risks of adverse events.
CONCLUSION
The SNF Prognosis Score has reasonable discrimination and calibration, and it is simple to calculate using an admission SNF assessment and a nomogram. Future work embedding the score into practice is needed to determine real‐world feasibility, acceptability, and effectiveness.
See related editorial by Kaehr et al. in this issue.