Of the 517,687 residents who met the inclusion criteria and did not die during follow-up, 1,605 had missing data (most commonly: DNR/DNH [1,009], diagnoses , and race ). Of the remaining 516,082 residents, a total of 19.3 percent were hospitalized, 18.5 percent of white and 24.1 percent of black residents. The sample was largely female and older than 75. Eleven percent of residents were black and 4 percent were identified as “other.” A minority of residents had minimal ADL impairment (14.3 percent) and the remainder was split between moderate and severe impairment ().
Characteristics of Long-Stay Nursing Home Residents Who Were Either Hospitalized or Remained in the Nursing Home by the End of the 150 Day Follow-up Period (N=516,082)
A full description of facility and market characteristics are available from Intrator et al. (2007)
. Across NHs, the mean percent of residents identified as black was 11.4 (SD=18.4) but the distribution was highly skewed; nearly 25 percent of NHs had fewer than 1 percent of residents identified as black while the top percentile reported over 87 percent of residents identified as black (not shown). When stratified by quartiles of the percent of residents identified as black, clear trends in NH ownership, staffing, and resource availability emerged ().
Characteristics of Nursing Homes by the Percent of Residents Identified as Black (Divided into Distribution Quartiles)
Three-quarters of states reported a bed hold policy and the average Medicaid per diem payment rate was $104 (SD=20).
Results of the multilevel model are presented in . It revealed incremental increases in the risk of hospitalization for all residents in a NH as the percent of black residents in the NH increased. Residents in states with a bed hold policy were more likely to be hospitalized than were residents in states without a policy (adjusted odds ratio [AOR]: 1.37, 95 percent confidence interval [CI]: 1.12–1.68). The effect of the Medicaid rate differed by resident race. When compared with white residents in states with lower Medicaid rates, white residents in states with higher rates ($10 increase) showed a 4 percent decreased probability of hospitalization (AOR: 0.96, 95 percent CI: 0.93–1.00) while black residents showed a 22 percent decreased probability of hospitalization (AOR: 0.78, 95 percent CI: 0.69–0.87).
Multivariable Multi-Level Model Results
Both age and ADL impairment modified the effect of resident race on the risk of hospitalization. For younger, minimally impaired residents, blacks had lower odds of hospitalization compared with whites (AOR: 0.82, 95 percent CI: 0.77–0.88). With increasing age, the odds of hospitalization were still lower for black (AOR: 0.85, 95 percent CI: 0.76–0.94) compared with white residents (AOR: 0.97, 95 percent CI: 0.95–0.98). Although impairment increased the risk of hospitalization for all residents, the odds were substantially higher for black residents with severe impairment than for similar whites (black AOR: 1.66, 95 percent CI: 1.40–1.96; White AOR: 1.25, 95 percent CI: 1.22–1.29).