Association of Medicare Home Health Ratings With Older Adult Fall Injuries: An Instrumental Variables Analysis

Objectives: To understand the role of high-quality home health care for fall prevention. Design: A 100% sample of national Medicare claims and home health survey data (2015-2017) were used to assess fall injuries and receipt of a fall risk assessment among recently hospitalized Medicare fee-for-service home health users aged ≥66 years. Subanalyses examined patients by prior fall history status and hospital admission diagnosis type (eg, neurologic, respiratory, cardiovascular, infection, and orthopedic diagnoses). An instrumental variables design addressed potential endogeneity in home health care use by patient fall risk. Setting and Participants: Home health agencies and Medicare fee-for-service beneficiaries. Methods: Multivariate regression and instrumental variables. Results: Among 962,610 patients with hospital discharges to home health, being treated by home health agencies with the highest star ratings in a person's zip code was associated with a 1.8–percentage point (ppt) (95% CI: 0.1, 3.5; P = .03) higher likelihood of receipt of fall risk assessment. There was no overall change in 30-day (−0.6 ppt, 95% CI: −1.3, 0.1; P = .09), 15-day (−0.3 ppt, 95% CI: −0.0.8, 0.2; P = .35), or 7-day fall injury risk (−0.2 ppt, 95% CI: −0.5, 0.1; P = .22), but a 1.9-ppt (95% CI: −3.9, −0.02; P = .048) lower 30-day fall injury risk for individuals with a history of falls. Effects were directionally similar by diagnosis type. Conclusions and Implications: Fall injury risk is reduced at higher-rated home health agencies. Star ratings may be adequate indicators of quality for key outcomes not explicitly measured in the ratings.