Clinicians Primarily Practicing in Nursing Homes and Care Quality for Residents with Dementia

Abstract Physicians and advanced practitioners (APs) who primarily practice in nursing homes (NHs), often called “SNFists,” provide care in more than 50% of U.S. NHs. Little is known about SNFists’ impact on care quality for long-stay NH residents with dementia. We estimated the association between receipt of care from a SNFist and care quality for these residents using claims for a nationwide sample of Medicare beneficiaries, 2013–2019. The intervention of interest was resident attribution to a SNFist based on a plurality of evaluation and management visits. SNFists included generalist physicians and APs. Estimation was based on a machine learning approach incorporating a doubly-robust procedure using a generalized estimating equation with inverse probability treatment weighting. We also conducted stratified analyses for physicians and APs, and a sensitivity analysis that included physicians of any specialty, and APs. Among the 417,378 residents in our sample, 58% (242,540) were attributed to SNFists. In adjusted analyses, attribution to a SNFist vs. a non-SNFist was associated with 7% lower odds of an ambulatory care sensitive (ACS) hospitalization (OR: 0.93; 95% CI, 0.90-0.96) and 7% lower odds of an ACS ED visit (OR: 0.93; 95% CI, 0.90-0.96). In stratified analyses, attribution to a physician SNFist vs. non-SNFist physician was associated with 13% lower odds (95% CI, 0.83-0.90) and 7% lower odds (95% CI, 0.88-0.97) of an ACS hospitalization or ED visit, respectively; AP-SNFist comparisons were not statistically significant. Results of the sensitivity analysis were consistent with primary results. SNFists may enhance care quality for residents with dementia.