Clinician Volume and Outcomes Among Patients Admitted to Nursing Homes for Postacute Care

Abstract

Importance: Little is known about the role of physician and advanced practitioner patient volume in postacute care outcomes in US nursing homes.

Objective: To examine the association between patient volume (the number of nursing home residents seen per year) and patient outcomes.

Design, setting, and participants: This cohort study used Medicare Part A and Part B claims and the nursing home minimum data set from 2012 to 2019. Eligible participants were Medicare fee-for-service beneficiaries aged 65 years or older who were admitted to a nursing home for postacute care and seen by a physician (internal medicine, family medicine, general practice, or geriatrics) or advanced practitioner (nurse practitioner or physician assistant) during their stay. The analyses were conducted between October 19, 2022, and June 6, 2025.

Exposure: Treating clinician's patient panel size.

Main outcomes and measures: Patient volume was measured by counting the number of unique patients seen by each clinician and categorized into deciles. Analyses were conducted at the patient-year level. Four risk-adjusted outcomes of care-30-day rehospitalization, emergency department (ED) visit, successful discharge to community, and improvement in functional status at discharge-were measured using Medicare's quality measures specifications. Poisson regression models with nursing home-level random effects were used to measure the association between each outcome adjusted for patient risk factors and the decile of patient volume. The models also included nursing home characteristics and an indicator for year.

Results: Of the 6 193 638 patient-years in the sample, 3 977 686 (64.2%) were of female and 2 215 952 (35.8%) of male participants; 548 241 patient-years (8.9%) were of Black and 5 376 750 (86.8%) of White participants. Patients of clinicians in the lowest decile of patient volume did not experience significantly different outcomes compared with those in the highest decile: the incidence rate ratio (IRR) was 1.05 (95% CI, 0.76-1.46) for rehospitalizations, 0.96 (95% CI, 0.86-1.07) for successful discharge to community, 1.03 (95% CI, 0.90-1.19) for ED visits, and 0.96 (95% CI, 0.88-1.40) for functional improvement at discharge from the nursing home.

Conclusions and relevance: In this cohort study of Medicare beneficiaries, we did not find an association between clinician panel size and nursing home postacute care outcomes. These findings may inform the design of care models for clinicians practicing in nursing homes.

Figure.. Difference in Rates of Postacute Care Outcomes of Nursing Home Patients by Decile of Patient Volume Compared With Top Decile of Patient Volume

The forest plots present the incidence rate ratios (IRRs) for each decile category of patient volume relative to the reference group (top volume category based on the distribution of patients: 205 or more patients), estimated using Poisson regression models with nursing home random effects. Patient volume deciles are based on the distribution of patient volume in the sample. Rehospitalizations and emergency department visits are measured during the 30 days following nursing home admission. Successful discharge to community indicates that the patient was discharged from the nursing home and was not readmitted to the nursing home or hospital or died within 30 days. Functional status improvement indicates improvement in functional status (minimum data set activity of daily living score) of 1 point or more from admission to discharge from the nursing home.