Health Systems (2015) 4, 29–40
© 2015 Operational Research Society Ltd. All rights reserved 2047-6965/15
ORIGINAL ARTICLE
Hospital and skilled nursing facility patient
flows during Hurricane Katrina and the Midwest
floods of 2008
Kun Zhang1 and
David H. Howard1
1
Department of Health Policy and Management,
Emory University, Atlanta, U.S.A.
Correspondence: David H. Howard,
Department of Health Policy and
Management, Emory University, 1518 Clifton
Road NE, Atlanta, GA 30322, U.S.A.
Tel.: +404-727-3907;
Fax: +404-727-9198;
E-mail: david.howard@emory.edu
Received: 30 May 2013
Revised: 17 February 2014
2nd Revision: 24 June 2014
Accepted: 30 June 2014
www.palgrave-journals.com/hs/
Abstract
Simulation and surge studies benefit from realistic assumptions about changes in
patient flows during disasters. We sought to determine the impact of Hurricane
Katrina and the 2008 Midwest floods on hospital and skilled nursing facility (SNF)
discharge patterns. We used Medicare claims to identify beneficiaries admitted to
hospitals or SNFs in the affected areas for each disaster. We used Cox proportional
hazards regression with time-varying covariates for disasters to assess the impact
of disasters on the likelihood that a patient would be discharged. Discharges from
SNFs and hospitals declined in the week following Hurricane Katrina. Discharges
from SNFs declined in the 3-week period during the Midwest floods but hospital
discharge rates were unaffected. Reductions in discharge rates may reduce the
ability of health-care facilities to create surge capacity during disasters.
Health Systems (2015) 4(1), 29–40. doi:10.1057/hs.2014.16;
published online 22 August 2014
Keywords: surge capacity; disasters; disaster planning; hospitals; skilled nursing facilities
Introduction
Hospitals’ disaster planning efforts often focus on the ability to create ‘surge
capacity’, that is, the capacity of the hospital to treat a large influx of disaster
victims. There are a number of guidelines and simulation models for helping
hospitals plan and evaluate surge capacity (for example, Abir et al, 2013;
Clarity Healthcare, Inc., 2013; Los Alamos National Laboratory, 2013). These
initiatives often focus on the triage and care of victims. They either assume
that admissions and discharges to skilled nursing facilities (SNFs) will be
unaffected by a disaster or make no assumptions at all. For example, an
Agency for Healthcare Research and Quality paper on ‘Optimizing Surge
Capacity’ (Barbera & Macintyre, 2007) states that hospitals may ‘Discharge
patients early’ to promote surge capacity but does not mention coordinating
early discharge decisions with home health agencies or SNFs. An Iowa
Department of Public Health surge planning guide (Hansen & Quinlisk,
2006) advises hospitals to ‘Work with home healthcare agencies to arrange
at-home follow-up care for patients who have been discharged early … ’ but
does not mention that home health agencies may send their own patients to
hospitals for care. On average, 20% of inpatients insured by Medicare are
discharged to a SNF (CMS, 2011), and nursing home residents are hospita-
lized at a rate of 25–49% per year (Castle, 2008).
Changes in SNF discharge and admittance rates may have important
implications for hospitals’ ability to accept new patients. Many states
designate nursing homes as potential surge sites or as spillover sites to relieve
30 Hospital and skilled nursing facility patient flows
pressure on hospitals (Moser et al, 2006; Ahronheim et al,
2009; California Department of Public Health, 2013; CDC,
2013). Nursing homes, by contrast, may focus on taking
care of their existing patients during a disaster (Eiring et al,
2012) and be reluctant to accept new admittees, increasing
pressure on hospitals.
Understanding how disasters affect these flows is critical
to accurately assessing surge capacity and the demands
placed on hospitals and SNFs during disasters. We under-
took this study to describe flows between hospitals and
SNFs using two disasters as an example: Hurricane Katrina
and the Midwestern floods in 2008.
Hurricane Katrina
The case of Hurricane Katrina is well-known in the pre-
paredness community. The hurricane made landfall in
Louisiana on 29 August 2005. Hospitals and nursing
homes struggled to provide care during the storm and the
flood that followed. Over 20 hospitals in Louisiana par-
tially or fully evacuated (Gray & Kebert, 2006). There were
1749 patients in the 11 hospitals in the flooded areas of
New Orleans. The hospitals also provided shelter and care
to ambulatory patients (e.g., hemodialysis patients) who
sought care in advance of the storm, patients’ families,
displaced residents, and even pets. Many hospitals evacu-
ated stable patients before the storm, but did not attempt
to evacuate or faced obstacles evacuating newborns and
patients with serious conditions. During the flood,
patients and health-care workers suffered from a lack of
electricity, heat, sewage backups, and a shortage of sup-
plies. Post-flood patient evacuations took up to a week.
Many nursing homes evacuated in advance of the storm
(Department of Health and Human Services (DHHS),
2006). Others evacuated after the storm or were incapable
of providing care because of flood-related damage. A
number of residents died during the storm (Dosa et al,
2010), including 34 who died in the now infamous St.
Rita’s facility. Residents who are evacuated during hurri-
canes are more likely to be hospitalized (Dosa et al, 2012;
Thomas et al, 2012).
Midwestern floods
There were numerous floods during 2008. Many Midwes-
tern states experienced record-level flooding. Southern
Indiana, Eastern Iowa, and Southern Wisconsin were hard-
est hit, as measured by annual exceedance probabilities
(Holmes et al, 2010).
Various regions in these states experienced flooding
events beginning in January 2008. For purposes of the
analysis, we focused on the period 7 June 2008–1 July
2008. Many parts of the Midwest received ‘excessive
amounts’ of rainfall beginning on 7 June. The flooding
that followed was far more severe than the flooding that
occurred previously during the year. In many locations,
the floodwaters had receded by late June. Amtrak (the
U.S. passenger rail service) resumed partial service in Iowa
on 1 July 2008 (Amtrak, 2008).
Health Systems
Kun Zhang and David H. Howard
Flooding damaged homes and businesses, including hos-
pitals. Some nursing homes and hospitals, including Mercy
Medical Center in Cedar Rapids and Columbus Regional
Hospital in Indiana, evacuated. Nursing homes and hospi-
tals received assistance from local governments and the
National Guard. Many commentators remarked upon how
much more smoothly hospital evacuations proceeded dur-
ing the flood compared with the chaotic situation that
prevailed after Hurricane Katrina (Basler, 2008).
Methods
We used the MEDPAR database for 2005 and 2008 for this
study. MEDPAR is a 100% sample of hospital and SNF
admissions by fee-for-service Medicare beneficiaries. SNFs
are facilities that provide short-term care to patients after a
hospital discharge. The United States Medicare program
pays for 100 days of SNF care after a hospital discharge.
Many SNFs are also nursing homes, and short-stay patients
may become long-stay patients after they have used up
their Medicare-SNF eligibility for a stay.
We calculated weekly average admissions and discharges
by destination for hospitals and nursing homes. Discharge
destination categories are: home, hospital, SNF, and
discharged dead. We calculated the average number of
patients in hospitals and SNFs on a weekly basis based on
prior admissions and discharges for each facility.
We created two analytic data sets from MEDPAR. The
first includes Medicare beneficiaries admitted to the 45
hospitals and 61 SNFs in Louisiana parishes with full
eligibility for Federal Emergency Management Agency
Individual and Public Assistance benefits (FEMA, 2005).
All of the patients in our analysis have Medicare as either a
primary or secondary payer.
We describe discharges and admissions for the periods
1 January 2005 through 1 week before the Louisiana
landfall of Hurricane Katrina (22 August 2005), 1 week
before landfall to the date of the landfall (29 August 2005),
the week beginning with the landfall, the following week,
and the period beginning 2 weeks after landfall to 31
December 2005.
The second data set includes Medicare beneficiaries
admitted to hospitals and SNFs in counties in Wisconsin,
Iowa, Illinois, Indiana, and Missouri with full eligibility for
Federal Emergency Management Agency Individual and
Public Assistance benefits. Of the 109 counties, 4 were in
Illinois, 56 were in Indiana, 15 were in Iowa, 4 were in
Missouri, and 30 were in Wisconsin. We describe discharges
and admissions for the periods 1 January 2008 through
1 week before the flood 31 May 2008, the week preceding the
flood (31 May 2008–6 June 2008), the three and a half week
period after the start of the flood (7 June 2008–1 July 2008),
the week after this period (2 July 2008–8 July 2008), and the
remainder of the year (9 July 2008–31 December 2008).
We tested the significance of the relationship between
each event and discharge rates using a Cox proportional
hazards model with a time-varying covariate for the
disaster. We included all patients admitted to hospitals
 Hospital and skilled nursing facility patient flows Kun Zhang and David H. Howard 31

Table 1 Admissions and discharges in 45 hospitals and 61 SNFs affected by Katrina

Time period a

Per week in Per week pre- 1 week pre- 1 week post- The second week post- Per week 3 September –31
2005 landfall landfall landfall landfall December 2005

N (%)
SNFs
Admissions 125 136 117 10 98 112
Censusb 510 542 571 473 307 489
Discharges 84 91 148 125 43 72
Home 25 (29.8) 27 (29.7) 59 (39.9) 14 (11.2) 10 (23.3) 18 (25.0)
Hospital 33 (39.3) 36 (39.6) 39 (26.4) 20 (16.0) 17 (39.5) 29 (40.3)
Other SNFs 23 (27.4) 23 (25.3) 45 (30.4) 86 (68.8) 13 (30.2) 19 (26.4)
Dead 3 (3.6) 5 (5.5) 5 (3.4) 5 (4.0) 3 (7.0) 6 (8.3)
Admits per 1.49 1.49 0.79 0.08 2.28 1.56
discharge

Hospitals
Admissions 1161 1310 1392 379 726 915
Censusb 1005 1104 966 1026 669 817
Discharges 1161 1277 1426 680 705 962
Home 848 (73.0) 944 (73.9) 1043 (73.1) 367 (54.0) 468 (66.4) 684 (71.1)
Hospital 68 (5.8) 73 (5.7) 83 (5.8) 133 (19.6) 67 (9.5) 54 (5.7)
SNFs 210 (18.1) 235 (18.4) 227 (15.9) 144 (21.2) 150 (21.3) 167 (17.3)
Dead 36 (3.1) 25 (2.0) 73 (5.1) 36 (5.3) 20 (2.8) 57 (5.9)
Admits per 1.00 1.03 0.98 0.56 1.03 0.95
discharge
a
The week of Katrina includes 7 days with the landfall of Katrina as the starting day.
b
Number of patients in the beginning day of a week.

and SNFs in 2005 and 2008. The dependent variable was
the time to discharge. Patients who were not discharged
are right-censored on 31 December. We controlled for age,
sex, race/ethnicity (white, black, Hispanic, other), and the
reason for admission. For the analysis of Hurricane
Katrina, the time-varying indicator was set equal to 1 for
the period 29 August 2005–6 September 2005. For the
analysis of the floods, the time-varying indicator was set
equal to 1 for the period 7 June 2008–1 July 2008. Patients
whose inpatient or SNF stay overlaps with one of these
periods are ‘exposed’ to the events, and the time-varying
indicator switches from ‘0’ to ‘1’ and then, for patients
who are still in the facility at the end of the event period,
back to ‘0’ again. The time varying indicator is ‘0’ for
patients whose inpatient or SNF stay does not overlap with
one of these periods. Analyses were performed in Stata
version 11.0 (Stata Corporation; College Station, TX).This
study, which was part of a larger effort to assess prepared-
ness planning in health-care providers, was approved by
Emory’s Institutional Review Board.
Results
Trends
Table 1 shows patient flows in the hospitals and SNFs
affected by Katrina. The first column shows the average per
week for all of 2005, the other columns show averages for
various periods during 2005.
Admissions to SNFs plummeted in the week following
landfall, from an average of 137 pre-landfall to 10. Admis-
sions rebounded the following week, though not to pre-
Katrina levels. The number of discharges increased during
the week before landfall and remained elevated the follow-
ing week. Decreases in the number of patients discharged
to home or hospitals were offset by increases in the
number of patients transferred to other SNFs.
Admissions at the hospitals declined steeply in the week
following landfall and never returned to pre-hurricane
levels. The number of discharges also declined. While the
number of discharges to SNFs decreased, the proportion of
discharges going to SNFs increased slightly, from 18.4% in
early 2005 to 21.2% in the week following landfall. The
proportion of patients discharged to home decreased from
73.9% pre-landfall to 54% in the week following landfall.
The combined effect of the decrease in admissions and
discharges was to leave the total number of patients in the
hospitals (i.e., the census) more or less unchanged, from
1104 pre-landfall to 1026 in the week following landfall.
Thereafter, the number of patients declined due in part to
a nearly 2 to 1 ratio of discharges to admissions during the
week after landfall.
Table 2 displays admission and discharge patterns for
hospitals and SNFs in areas affected by the Midwest floods

Health Systems
32 Hospital and skilled nursing facility patient flows Kun Zhang and David H. Howard

Table 2 Admissions and discharges in 45 hospitals and 61 SNFs in flooded areas

Time perioda

Per week in 2008 Per week pre-flood 1 week pre-flood 1 week post-flood 3 weeks post-flood Per week post-flood in 2008

N (%)
SNFs
Admissions 1660 1746 1697 1609 1598 1601
Censusb 6977 7190 7750 7734 7850 6733
Discharges 1276 1229 1180 1259 1349 1252
Home 617 (48.4) 572 (46.5) 607 (51.4) 645 (51.2) 710 (52.6) 648 (51.8)
Hospital 383 (30.0) 372 (30.3) 337 (28.6) 381 (30.3) 382 (28.3) 392 (31.3)
Other SNFs 118 (9.2) 113 (9.2) 150 (12.7) 136 (10.8) 130 (9.6) 119 (9.5)
Dead 158 (12.4) 172 (14.0) 86 (7.3) 97 (7.7) 127 (9.4) 93 (7.4)
Admits per discharge 1.30 1.42 1.44 1.28 1.18 1.28

Hospitals
Admissions 7580 8001 7862 7403 7319 7225
Censusb 6897 7343 6617 6718 6687 6571
Discharges 7610 8035 7535 7438 7484 7329
Home 5049 (66.3) 5313 (66.1) 4967 (65.9) 4973 (66.9) 5013 (67.0) 4847 (66.1)
Hospital 274 (3.6) 283 (3.5) 252 (3.3) 299 (4.0) 276 (3.7) 263 (3.6)
SNFs 2055 (27.0) 2171 (27.0) 2091 (27.8) 1949 (26.2) 1963 (26.2) 1977 (27.0)
Dead 232 (3.0) 268 (3.3) 225 (3.0) 217 (2.9) 232 (3.1) 242 (3.3)
Admits per discharge 1.00 1.00 1.04 1.00 0.98 0.99
a
We date the start of the flood as 7 June 2008.
b
Number of patients in the beginning day of a week.

of 2008. The layout is similar to Table 1, except that we 3

present average weekly admissions and discharges for the
Admission−to−discharge ratio

week following the start of the flood and the period from
7 June 2008 to 1 July 2008 (which includes the first week)
2
because the floods lasted longer than Hurricane Katrina.
The number of patients admitted to SNFs declined by
about 8% during the flood and remained depressed for the
rest of the year. More patients were discharged to home 1

during the flood. Otherwise, it appears the flood led to

Katrina

relatively little disruption in SNF admission and discharge

patterns and rates.
Hospital admissions declined after the flood, from
8001 per week to 7403 per week in the three and a half
week period after the start of the flood. The proportion of
patients discharged to SNFs declined slightly, from about
27% pre-flood to 26.2% in the 3 weeks following the
flood.
Figures 1 and 2 display admission-to-discharge ratios
for hospitals and SNFs in Katrina-affected areas in 2005
and flood-affected areas in 2008. The figures illustrate
the disruption brought about by Hurricane Katrina and
the relative lack of disruption during the floods. The
admission-to-discharge ratios for SNFs are almost always
above 1, reflecting patients’ extended lengths of stay.
Many patients admitted in 2005 or 2008 were not
discharged until later years. Our data series do not
capture patients admitted before 2005 and 2008. In
hospitals, by contrast, almost all of the patients admitted
in 2005 and 2008 were discharged in the same year they
were admitted.
Skilled nursing facility Hospital
0
Jan Jan Mar Apr May May Jun Jul Aug Sep Oct Nov Dec
Figure 1 Admission-to-discharge ratio in 2005 in Katrina-
affected areas.
Statistical analysis
Table 3 describes characteristics of the sample by provider
type and disaster event. There are 60,359 persons in the
Hurricane Katrina hospital sample and 6238 patients in
the SNF sample, of whom 4320 were discharged in 2005
and 1918 remained in the SNF, possibly as long-stay
patients, at the end of the year. The numbers in the table
refer to the number of patients in the sample who have
the associated characteristic and the numbers in parenth-
eses refer to the percent of the sample. For example, of the
6238 SNF admissions that satisfied the sample inclusion
criteria for the analysis of Hurricane Katrina, 4105, or
65.8%, were admissions of female beneficiaries. In the

Health Systems
 Hospital and skilled nursing facility patient flows Kun Zhang and David H. Howard 33

3 Table 3 Summary of the characteristics of admitted

patients
Admission−to−discharge ratio

Admitted in 2005 in Admitted in 2008

2 Katrina-affected in flood-affected
areas areas

SNFs
1 Age 78.8 82
Female 4105 (65.8) 44,356 (66.8)
Severe
floods
Black 4834 (77.5) 2855 (4.3)
Skilled nursing facility
Hospital Hispanic 1285 (20.6) 133 (0.2)
0 Reason for admission
Jan Jan Mar Apr May May Jun Jul Aug Sep Oct Nov Dec Cardiaca 593 (9.5) 4050 (6.1)
Pulmonaryb 512 (8.2) 3785 (5.7)
Figure 2 Admission-to-discharge ratio in 2008 in flood-affected
Musculoskeletalc 412 (6.6) 3187 (4.8)
areas.
Diabetes 281 (4.5) 2590 (3.9)
Cerebrovascular disease 287 (4.6) 1195 (1.8)
regression analysis, we controlled for 18 different admis- Rehabilitation 175 (2.8) 730 (1.1)
sion categories. For purposes of display here, we collapsed Othera 3980 (63.8) 50,863 (76.6)
some of the categories with small numbers of patients N 6238 66,401
into larger groups.
The second column of Table 3 shows summary charac- Hospitals
teristics of the patients included in the analysis of the Age 71.1 79.4
floods. There are 395,849 patients in the hospital sample Female 33,379 (55.3) 252,156 (63.7)
and 66,401 in the SNF sample, of whom 46,574 were Black 43,760 (72.5) 371,702 (93.9)
Hispanic 15,271 (25.3) 19,792 (5.0)
discharged. There were 19,827 who remain in SNFs, not
Reason for admission
counting patients transferred to other SNFs, at the end of
Cardiaca 7485 (12.4) 32,460 (8.2)
2008, either as short- or long-stay patients. Pulmonaryb 4406 (7.3) 26,522 (6.7)
Table 4 shows incident rate ratios associated with the Musculoskeletalc 2052 (3.4) 49,877 (12.6)
time-varying indicators for each disaster. Incident rate Diabetes 2535 (4.2) 18,605 (4.7)
ratios are similar to odds ratios; values greater than 1 Cerebrovascular disease 966 (1.6) 5542 (1.4)
indicate that the event (i.e., discharge) is more likely to Rehabilitation 181 (0.3) 396 (0.1)
occur within a given time period and values less than 1 Othera 42,734 (70.8) 262,448 (66.3)
indicate that the event is less likely. The higher the ratio, N 60,359 395,849
the shorter the time period to the event. a
Includes: hypertension, heart failure, acute myocardial infarction, cardiac
Full results from the regression analyses are available as dysrhythmia.
an Appendix. Discharge rates declined in SNFs overall and b
Includes: pneumonia, chronic bronchitis, chronic airway obstruction.
c
across all discharge destinations, including transfers to Includes: osteoarthrosis, fracture, disorder of joint and muscle.
other SNFs. Within hospitals during Katrina, overall dis-
charge rates and discharge rates to home declined. There
was an increase in the hospital transfer rate. The decline in numerous case studies and descriptive reports (e.g.,
the hospital-to-SNF transfer rate was not significant. Dur- Rudowitz et al, 2006). Mortality among nursing home and
ing the Midwest flood, there was no significant change in dialysis patients increased during and immediately follow-
the overall discharge rate or the rate at which patients were ing Hurricane Katrina (Kutner et al, 2009; Dosa et al, 2010).
discharged to home. The hospital transfer rate increased. Nursing home and dialysis patients were also more likely to
There was a significant increase in the hospital-to-SNF be admitted to a hospital (Dosa et al, 2010, 2012; Howard
transfer rate, but the magnitude of the increase was small. et al, 2012). Our analysis adds to the literature by describing
how patients transitioned between health-care facilities
during disasters. In contrast to prior studies of nursing
Discussion home and dialysis patients, we find that hospital admission
Hospital and SNF discharge rates declined during Katrina. rates among SNF patients declined after Hurricane Katrina.
SNFs discharge rates declined during the Midwest floods. It is unclear whether this pattern is attributable to differ-
Hospitals discharged more patients to other hospitals ences in patient characteristics or the ability of SNFs
during the disasters but not to SNFs. The Midwest floods (vs nursing homes without skilled nursing beds) to provide
of 2008 seem to have had relatively little effect on hospi- care during Hurricane Katrina and the ensuing floods.
tals’ admission and discharge patterns. The results – both Our analysis was based on billing records for patients
the direction and the magnitude – should prove useful in with Medicare, either as a primary or secondary payer.
defining surge capacity and community-wide health- Elderly persons are especially vulnerable to disasters
care disaster plans. Hurricane Katrina has the subject of (Aldrich & Benson, 2008), and so it is important to

Health Systems
34 Hospital and skilled nursing facility patient flows
Table 4 Results from Cox proportional hazards regressions of time to discharge
All discharges
Home
Incidence rate ratio (95% CI) P-value
SNFs
Katrina 0.50 (0.44–0.56) <0.001 0.47 (0.38–0.59)
Midwest floods 0.61 (0.59–0.63) <0.001 0.62 (0.60–0.65)
Hospitals
Katrina 0.86 (0.82–0.89) <0.001 0.79 (0.75–0.82)
Midwest floods 1.01 (1.00–1.03) 0.069 1.01 (1.00–1.03)
Notes: Incident ratio ratios are similar to odds ratios; values greater than 1 indicate that the event (i.e., discharge) is more likely to occur within a given time
period and values less than 1 indicate that the event is less likely. The higher the ratio, the shorter the time period to the event.
consider how disaster plans intend to accommodate this
group. Admission and discharge patterns for inpatients
with other forms of insurance, most of whom are younger
than age 65, may differ. We would expect that there are
lower rates of discharge to SNFs among younger patients.
Billing records may be inaccurate for some hospitals and
SNFs, particularly those that had to close during or shortly
after Hurricane Katrina. Following Hurricane Katrina and
the Midwest floods, CMS (2013) modified billing procedures
to facilitate claims filing and processing procedures to avoid
inappropriate denials. We believe that facilities, especially
those under duress, would take advantage of every opportu-
nity to obtain reimbursement for the services they provided,
but this is an unverifiable assumption. CMS (2009) also
relaxed coverage criteria for SNF stays, which may have
affected hospital discharge and SNF admissions patterns.
We purposely limited attention to providers in regions
affected by the disasters to increase the relevance of our
results to surge planning models. However, the disasters had
far-reaching effects on health-care use, particularly in the
cities that received large numbers of evacuees (Eastman et al,
2007). The experience of any particular provider among the
group of providers included in this analysis varied from the
norm. Some providers were forced to evacuate, others con-
tinued operations with little disruption.
We selected Hurricane Katrina and the Midwest floods of
2008 because they were recent, major disasters that
affected large regions of the country. Both were flooding
disasters, but there are some important differences. In New
Orleans, only three hospitals operated during Hurricane
Katrina and the flood that followed. Many large hospitals
evacuated patients and remained closed for months after
the storm. Charity Hospital, a 2000-plus bed hospital in
downtown New Orleans closed permanently (Rudowitz
et al, 2006). The Midwest floods did not affect a major
urban area and occurred long after Hurricane Katrina,
giving hospitals, SNFs, and local preparedness planners
time to revise their plans based on the widely perceived
failings of the health-care system during Hurricane
Katrina. At least two medium-sized hospitals (Columbus
Regional Hospital in Indiana and Mercy Medical Center in
Health Systems
Kun Zhang and David H. Howard
Discharge destination
Hospital SNF
<0.001 0.28 (0.22–0.35) <0.001 0.88 (0.73–1.05) 0.14
<0.001 0.58 (0.55–0.61) <0.001 0.64 (0.58–0.71) <0.001
<0.001 1.55 (1.36–1.75) <0.001 0.92 (0.84–1.01) 0.089
0.089 1.12 (1.05–1.19) <0.001 1.00 (0.97–1.02) 0.92
Iowa) had to evacuate patients, but most facilities were
able to operate through the floods. In light of these
differences, it is not surprising that we observe differences
in admission and discharge patterns in regions affected by
Hurricane Katrina and the Midwest floods and that effects
were small to non-existent during the Midwest floods.
Obviously the experiences of hospitals and SNFs will
vary based on the magnitude, intensity, and duration of
a disaster. During the 1994 Los Angeles Northridge earth-
quake, many nursing homes were able to accept patients
from damaged nursing homes, damaged hospitals, and
hospitals that had exceeded their capacities (Saliba et al,
2004). However, many nursing homes were damaged and,
for purposes of planning, it is unclear a priori which
facilities will and will not be able to accept new patients.
Our analysis was limited to facilities in the areas affected
by the disasters and did not examine admission patterns
among providers outside the disaster area that treated
evacuated patients. Following Hurricane Katrina, over 200
evacuees received care in Houston-area hospitals
(Hamilton & Smart, 2008). A more comprehensive analysis
would require linking admission records with enrollment
data that include information about patients’ residential
location.
Policy implications
Evaluation of hospital discharge and admission patterns
during disasters is important for developing surge capacity
plans grounded in reality. Unrealistic and invalid assump-
tions were an important source of the response failure
during Hurricane Katrina (Lousiana Recovery Authority,
2013). Despite the differences between Hurricane Katrina
and the Midwest floods, we can draw some general lessons
for preparedness planning.
The CDC and many states’ disaster plans list SNFs as
alternate care sites to be used for ‘expanding’ the health-
care system and creating surge capacity at hospitals. The
ability of SNFs to meet this need during disasters should be
informed by real world experiences. We find that during
two previous disasters, discharge rates declined. In
 Hospital and skilled nursing facility patient flows
additional to dealing with a surge in demand from persons
affected by disasters, hospitals should anticipate that it
may be more difficult to discharge existing patients.
Admissions to SNFs decreased during Katrina and were
more or less unchanged during the Midwest floods. Nur-
sing homes face challenges providing care to their current
residents during disasters. They are probably reluctant to
accept new patients, especially patients with complex
medical conditions that require extra staff time and/or
specialized medical equipment and supplies. Our results
suggest that SNFs do not always serve as a ‘safety valve’
during disasters, and that plans to create surge capacity
should not assume that hospitals can free up bed space by
discharging patients to SNFs during any disaster that
compromises the structural integrity of nursing homes,
disrupts SNFs food or water supplies, shuts off electricity,
or increases staff absenteeism.
In general, surge capacity planning should adopt a
systems perspective and take into account how bottle-
necks may develop in the system as a result of changes to
discharge and admission patterns. To the best of our
knowledge, this issue has received almost no attention in
the literature on surge capacity planning. Most prior work
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BARBERA JA and MACINTYRE AG (2007) Medical Surge Capacity and Capability:
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During Large-Scale Emergencies. U.S. Department of Health and Human
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BASLER B (2008) The Midwest floods-an emergency disaster plan that
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health facilities. [WWW document] http://www.publichealthpractices
.org/practice/standards-and-guidelines-healthcare-surge-during-emerg
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CASTLE NG (2008) Nursing home evacuation plans. American Journal of
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CDC. (2013) Public health preparedness capabilities: national standards
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Kun Zhang and David H. Howard 35
on the subject addresses issues like triage protocols and
alternate care sites. Disaster plans that assess each facility
in isolation fail to account for how patients transition
from one facility to another. If hospitals and SNFs dis-
charge fewer patients during disasters because patients
cannot go home or receiving facilities are not willing to
accept transfers, it affects the ability of the health-care
system to accommodate new patients.
Local and state disaster planners should continue to
move forward with efforts to incorporate nursing homes
into community-wide disaster plans. Hospitals should also
coordinate plans and responses with community providers
and nursing homes. In 2008, only 20% of hospitals
included long-term care facilities in mass casualty drills
(Niska & Shimizu, 2011).
Acknowledgements
This study was funded by a grant from the Centers for Disease
Control and Prevention (CDC) [5-P01-TP000300]. The con-
tents of this presentation are solely the responsibility of the
authors and do not necessarily represent the official views of
the Centers for Disease Control and Prevention.
CMS. (2011) Medicare & medicaid statistical supplement. [WWW docu-
ment] http://www.cms.gov/Research-Statistics-Data-and-Systems/Sta-
tistics-Trends-and-Reports/MedicareMedicaidStatSupp/2011.html
(accessed 1 September 2012).
CMS. (2013) Center for medicare & medicaid services: CMS response to
the hurricane emergency – Gustav/Ike medicare fee-for-service. [WWW
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Emergency/downloads//GustavMasterQsAs_100308.pdf (accessed 4
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hurricane evacuation policies on nursing home residents. Journal of the
American Medical Directors Association 13(2), 190.e1–190.e7.
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Alternate site surge capacity in times of public health disaster maintains
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plans and capabilities. American Journal of Disaster Medicine 7(2),
127–135.
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1603-DR, Louisiana disaster declaration as of 10 July. [WWW document]
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GRAY BH and KEBERT K. (2006) After Katrina. Hospitals in Hurricane Katrina.
The Urban Institute, Washington DC. [WWW document] http://
www.urban.org/uploadedpdf/411348_katrinahospitals.pdf (accessed
4 August 2012).
HANSEN MM and QUINLISK P (2006) Guidelines for Hospital Surge
Capacity Management. Iowa Department of Public Health, Des Moines,
Iowa.
HAMILTON DR and SMART KT (2008) Houston’s medical disaster response
to Hurricane Katrina 2008. [WWW document] http://www.dsls.usra
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.edu/education/grandrounds/archive/2008/20080226/hamilton.pdf
(accessed 10 January 2014).
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p 64, U.S. Geological Service, Washington DC.
HOWARD D, ZHANG R, HUANG Y and KUTNER N. (2012) Hospitalization rates
among dialysis patients during Hurricane Katrina. Prehospital and
Disaster Medicine 27(4), 325–329.
KUTNER NG et al (2009) Effect of Hurricane Katrina on the mortality of
dialysis patients. Kidney International 76(7), 760–766.
Los Alamos National Laboratory. (2013) HCSim: agent-based healthcare
surge capacity model. [WWW document] http://www.lanl.gov/pro-
grams/nisac/hcsim.shtml (accessed 10 January 2014).
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docs/searchable/reports/EmerPreparedness_1.pdf (accessed 4 April 2013).
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gency response: United States. National Health Statistics Reports.
Number 27. Department of Health and Human Services, Washington
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RUDOWITZ R, ROWLAND D and SHARTZER A (2006) Health care in
New Orleans before and after Hurricane Katrina. Health Affairs 25(5),
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nursing facilities during community disaster. American Journal of Public
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 Appendix

Hospital and skilled nursing facility patient flows

Table Al Discharge patterns from SNFs in areas affected by Hurricane Katrina in 2005

Discharge in general Discharged to home Discharged to hospital Discharged to other SNFs

HR SE CI HR SE CI HR SE CI HR SE CI

Katrina 0.5 0.030 [0.443 0.561] 0.47 0.055 [0.379 0.594] 0.279 0.034 [0.22 0.353] 0.876 0.079 [0.734 1.045]
Age 0.99 0.001 [0.987 0.992] 0.98 0.002 [0.975 0.985] 0.991 0.002 [0.987 0.996] 0.997 0.003 [0.992 1.003]
Female 0.87 0.030 [0.815 0.931] 0.92 0.057 [0.812 1.037] 0.804 0.042 [0.725 0.892] 0.929 0.060 [0.819 1.054]
White 0.73 0.105 [0.552 0.967] 0.84 0.227 [0.496 1.429] 0.709 0.157 [0.460 1 093] 0.650 0.170 [0.389 1.085]
Black 0.77 0.113 [0.580 1.028] 0.87 0.238 [0.505 1.485] 0.721 0.163 [0.463 1.123] 0.741 0.198 [0.439 1.251]
Hispanic 0.82 0.191 [0.517 1.294] 1.38 0.545 [0.638 2.993] 0.262 0.143 [0.0898 0.764] 1.100 0.418 [0.522 2.317]

Reasons for admission

Chronic airway obstruction 0.99 0.104 [0.805 1.216] 0.38 0.110 [0.213 0.666] 1.580 0.217 [1.206 2.069] 0.939 0.189 [0.634 1.392]
Chronic bronchitis 2.07 0.283 [1.579 2.701] 3.64 0.651 [2.563 5.169] 1.444 0.377 [0.866 2.409] 0.986 0.375 [0.468 2.080]
Pneumonia 1.02 0.079 [0.878 1.188] 1.09 0.143 [0.843 1.411] 1.069 0.131 [0.841 1.358] 0.853 0.132 [0.629 1.156]

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Diabetes 0.73 0.056 [0.630 0.848] 0.46 0.076 [0.332 0.633] 1.110 0.116 [0.905 1.362] 0.551 0.086 [0.405 0.749]
Hypertension 0.69 0.067 [0.573 0.837] 0.49 0.098 [0.332 0.727] 0.811 0.118 [0.610 1.077] 0.731 0.127 [0.519 1.028]
Heart failure 0.99 0.075 [0.852 1.148] 0.75 0.115 [0.555 1.011] 1.340 0.145 [1.084 1.657] 0.800 0.123 [0.592 1.082]
Cerebrovascular disease 0.82 0.057 [0.711 0.935] 0.54 0.079 [0.403 0.716] 0.858 0.095 [0.690 1.067] 1.092 0.125 [0.873 1.366]
Acute myocardial infarction 1.39 0.286 [0.929 2.078] 1.63 0.548 [0.844 3.151] 1.274 0.453 [0.634 2.557] 1.289 0.491 [0.611 2.718]
Cardiac dysrhythmia 1.08 0.140 [0.840 1.394] 1.05 0.244 [0.663 1.655] 1.120 0.228 [0.752 1.670] 1.096 0.263 [0.685 1.753]
Skin disease 1 0.072 [0.869 1.154] 0.82 0.112 [0.624 1.068] 1.277 0.135 [1.038 1.571] 0.824 0.122 [0.617 1.101]
Disorder of nervous system 0.96 0.102 [0.778 1.182] 0.58 0.139 [0.363 0.928] 0.981 0.168 [0.702 1.371] 1.333 0.227 [0.956 1.860]
Disorder of urinary tract 0.95 0.067 [0.825 1.087] 0.67 0.097 [0.507 0.893] 0.979 0.110 [0.786 1.221] 1.206 0.141 [0.960 1.516]
Renal failure 1.31 0.201 [0.974 1.772] 0.26 0.152 [0.0844 0.816] 2.165 0.418 [1.484 3.160] 1.442 0.405 [0.832 2.502]
Fracture 1.02 0.097 [0.849 1.233] 0.95 0.165 [0.671 1.330] 0.835 0.141 [0.600 1.163] 1.376 0.212 [1.017 1.861]
Osteoarthrosis 0.73 0.087 [0.579 0.922] 1 0.182 [0.701 1.430] 0.621 0.129 [0.413 0.933] 0.566 0.140 [0.349 0.917]
Disorder of joint and muscle 0.54 0.063 [0.431 0.678] 0.39 0.094 [0.244 0.624] 0.756 0.120 [0.554 1.032] 0.429 0.103 [0.268 0.685]
Rehabilitation 2.14 0.246 [1.709 2.682] 3.79 0.574 [2.816 5.100] 1.189 0.292 [0.735 1.923] 1.491 0.391 [0.892 2.491]
General symptoms 0.88 0.118 [0.675 1.143] 0.65 0.174 [0.380 1.096] 0.996 0.207 [0.664 1.496] 0.947 0.227 [0.592 1.515]
N 6463 6463 6463 6463
Note: Hazard ratio are reported, 95% CIs in the parentheses.
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Health Systems

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Hospital and skilled nursing facility patient flows
Table A2 Discharge patterns from hospitals in areas affected by Hurricane Katrina in 2005
Discharge in general Discharged to home Discharged to other Discharged to SNFs

HR SE CI HR SE CI HR SE CI HR SE CI

Katrina 0.856 0.017 [0.822 0.89] 0.785 0.019 [0.749 0.823] 1.545 0.098 [1.364 1.748] 0.920 0.043 [0.840 1.008]
Age 1.000 0.000 [0.999 1.000] 0.993 0.000 [0.993 0.994] 1.009 0.001 [1.006 1.011] 1.031 0.001 [1.029 1.032]
Female 0.999 0.009 [0.982 1.016] 0.956 0.009 [0.938 0.975] 0.913 0.032 [0.852 0.977] 1.226 0.025 [1.177 1.277]
White 1.023 0.033 [0.961 1.088] 1.040 0.037 [0.969 1.116] 0.910 0.120 [0.704 1.178] 1.068 0.089 [0.908 1.256]
Black 0.918 0.030 [0.861 0.978] 0.901 0.033 [0.838 0.967] 1.111 0.148 [0.857 1.442] 0.977 0.083 [0.828 1.154]
Hispanic 0.976 0.070 [0.848 1.124] 0.983 0.082 [0.835 1.157] 1.134 0.312 [0.661 1.944] 0.901 0.156 [0.642 1.266]

Reasons for admission

Chronic airway obstruction 1.049 0.123 [0.834 1.319] 1.070 0.143 [0.823 1.391] 0.964 0.483 [0.361 2.572] 1.079 0.300 [0.626 1.860]
Chronic bronchitis 1.129 0.028 [1.076 1.185] 1.204 0.033 [1.141 1.270] 0.837 0.100 [0.663 1.058] 0.976 0.063 [0.860 1.108]
Pneumonia 0.956 0.020 [0.917 0.997] 0.895 0.023 [0.852 0.941] 0.825 0.078 [0.686 0.991] 1.243 0.055 [1.140 1.355]
Diabetes 0.928 0.031 [0.869 0.991] 0.862 0.033 [0.800 0.930] 1.470 0.163 [1.182 1.828] 1.105 0.093 [0.938 1.303]

Kun Zhang and David H. Howard

Hypertension 1.989 0.140 [1.733 2.283] 2.366 0.174 [2.049 2.733] 0.646 0.324 [0.242 1.724] 0.782 0.217 [0.454 1.348]
Heart failure 1.188 0.020 [1.150 1.227] 1.301 0.024 [1.256 1.349] 0.858 0.067 [0.736 0.999] 0.861 0.039 [0.788 0.940]
Cerebrovascular disease 0.813 0.023 [0.769 0.860] 0.471 0.020 [0.433 0.512] 1.373 0.123 [1.152 1.637] 2.106 0.092 [1.933 2.295]
Acute myocardial infarction 1.000 0.030 [0.942 1.061] 1.028 0.035 [0.961 1.100] 1.435 0.151 [1.168 1.764] 0.710 0.061 [0.599 0.841]
Cardiac dysrhythmia 1.687 0.043 [1.605 1.773] 1.986 0.054 [1.883 2.094] 0.915 0.129 [0.694 1.205] 0.775 0.067 [0.655 0.918]
Skin disease 0.719 0.019 [0.682 0.758] 0.600 0.020 [0.562 0.641] 1.669 0.124 [1.443 1.930] 0.934 0.055 [0.832 1.047]
Disorder of nervous system 0.669 0.039 [0.596 0.750] 0.461 0.038 [0.392 0.543] 0.679 0.161 [0.427 1.081] 1.411 0.126 [1.184 1.681]
Disorder of urinary tract 1.066 0.027 [1.014 1.121] 0.768 0.027 [0.717 0.822] 0.939 0.103 [0.757 1.164] 2.191 0.090 [2.021 2.375]
Renal failure 0.781 0.104 [0.601 1.015] 0.660 0.106 [0.482 0.904] 1.905 0.675 [0.951 3.815] 0.817 0.289 [0.408 1.635]
Fracture 0.920 0.032 [0.859 0.985] 0.132 0.014 [0.107 0.163] 1.490 0.171 [1.189 1.867] 3.399 0.142 [3.133 3.689]
Osteoarthrosis 1.342 0.041 [1.263 1.424] 0.833 0.037 [0.764 0.908] 0.262 0.076 [0.148 0.462] 4.220 0.186 [3.870 4.601]
Disorder of joint and muscle 1.271 0.134 [1.034 1.564] 1.160 0.146 [0.906 1.485] 1.724 0.653 [0.821 3.622] 1.665 0.373 [1.073 2.583]
Rehabilitation 0.518 0.011 [0.497 0.539] 0.513 0.012 [0.489 0.537] 0.921 0.060 [0.810 1.047] 0.444 0.023 [0.401 0.491]
General symptoms 1.852 0.058 [1.742 1.969] 1.943 0.068 [1.814 2.081] 1.197 0.191 [0.875 1.637] 1.755 0.136 [1.509 2.043]
N 60,057 60,057 60,057 60,057
Note: Hazard ratio are reported, 95% CIs in the parentheses.
 Hospital and skilled nursing facility patient flows
Table A3 Discharge patterns from SNFs in areas affected by the Midwest floods in 2008
Discharge in general Discharged to home Discharged to hospital Discharged to other SNFs

HR SE CI HR SE CI HR SE CI HR SE CI

Flood 0.610 0.010 [0.591 0.630] 0.621 0.014 [0.595 0.649] 0.578 0.017 [0.546 0.612] 0.639 0.032 [0.579 0.705]
Age 0.988 0.000 [0.988 0.989] 0.985 0.001 [0.984 0.986] 0.988 0.001 [0.986 0.989] 1.012 0.001 [1.009 1.014]
Female 0.923 0.008 [0.907 0.939] 1.025 0.013 [1.001 1.050] 0.783 0.012 [0.760 0.806] 0.945 0.026 [0.895 0.998]
White 1.055 0.046 [0.969 1.149] 1.109 0.066 [0.987 1.246] 0.931 0.066 [0.811 1.069] 1.371 0.221 [1.001 1.879]
Black 1.003 0.047 [0.915 1.100] 0.845 0.055 [0.743 0.960] 1.183 0.089 [1.021 1.370] 1.168 0.201 [0.834 1.637]
Hispanic 0.904 0.090 [0.744 1.098] 0.795 0.115 [0.598 1.056] 1.025 0.155 [0.762 1.377] 0.949 0.336 [0.474 1.901]

Reasons for admission

Chronic airway obstruction 1.034 0.035 [0.968 1.105] 0.832 0.042 [0.753 0.920] 1.337 0.067 [1.212 1.474] 1.078 0.115 [0.875 1.328]
Chronic bronchitis 1.247 0.087 [1.088 1.430] 1.093 0.111 [0.896 1.333] 1.528 0.162 [1.242 1.881] 1.023 0.249 [0.635 1.649]
Pneumonia 1.014 0.026 [0.964 1.066] 0.799 0.032 [0.740 0.863] 1.227 0.048 [1.136 1.325] 1.347 0.093 [1.176 1.542]
Diabetes 0.803 0.025 [0.754 0.854] 0.656 0.031 [0.597 0.721] 0.978 0.046 [0.891 1.073] 0.903 0.090 [0.744 1.097]
Hypertension 0.819 0.032 [0.758 0.885] 0.777 0.043 [0.696 0.866] 0.889 0.056 [0.786 1.007] 0.757 0.095 [0.592 0.967]

Kun Zhang and David H. Howard

Heart failure 1.013 0.026 [0.963 1.065] 0.829 0.032 [0.769 0.895] 1.279 0.050 [1.185 1.380] 1.092 0.082 [0.942 1.265]
Cerebrovascular disease 0.710 0.019 [0.673 0.749] 0.554 0.023 [0.510 0.602] 0.839 0.035 [0.772 0.911] 1.035 0.075 [0.898 1.193]
Acute myocardial infarction 1.298 0.078 [1.154 1.461] 1.269 0.106 [1.077 1.495] 1.352 0.134 [1.113 1.643] 1.209 0.226 [0.838 1.744]
Cardiac dysrhythmia 1.012 0.042 [0.933 1.098] 0.916 0.055 [0.815 1.030] 1.107 0.073 [0.972 1.261] 1.126 0.135 [0.891 1.425]
Skin disease 0.826 0.031 [0.768 0.888] 0.720 0.039 [0.649 0.800] 0.956 0.055 [0.855 1.070] 0.898 0.106 [0.712 1.133]
Disorder of nervous system 0.481 0.020 [0.443 0.522] 0.290 0.021 [0.251 0.335] 0.622 0.038 [0.551 0.702] 0.898 0.085 [0.745 1.082]
Disorder of urinary tract 0.851 0.029 [0.796 0.911] 0.693 0.036 [0.626 0.767] 0.935 0.052 [0.839 1.041] 1.331 0.114 [1.125 1.575]
Renal failure 1.045 0.044 [0.963 1.135] 0.726 0.050 [0.635 0.829] 1.503 0.086 [1.343 1.682] 1.056 0.151 [0.798 1.399]
Fracture 0.916 0.030 [0.859 0.976] 0.932 0.041 [0.855 1.017] 0.899 0.050 [0.806 1.002] 0.902 0.090 [0.742 1.096]
Osteoarthrosis 1.363 0.057 [1.256 1.478] 2.067 0.095 [1.889 2.263] 0.546 0.061 [0.439 0.679] 0.444 0.100 [0.286 0.690]
Disorder of joint and muscle 0.887 0.021 [0.846 0.929] 0.923 0.030 [0.867 0.983] 0.883 0.036 [0.816 0.956] 0.704 0.058 [0.599 0.828]
Rehabilitation 1.501 0.015 [1.472 1.531] 1.758 0.023 [1.713 1.804] 1.134 0.021 [1.094 1.175] 1.469 0.046 [1.381 1.562]
General symptoms 0.956 0.025 [0.909 1.005] 0.937 0.033 [0.874 1.005] 0.963 0.041 [0.885 1.047] 1.027 0.080 [0.881 1.198]
N 86,243 86,243 86,243 86,243
Note: Hazard ratio are reported, 95% CIs in the parentheses.
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Table A4 Discharge patterns from hospitals in areas affected by the Midwest floods in 2008

Hospital and skilled nursing facility patient flows

Discharge in general Discharged to home Discharged to other Discharged to SNFs

HR SE CI HR SE CI HR SE CI HR SE CI

Flood 1.012 0.007 [0.999 1.025] 1.014 0.008 [0.998 1.030] 1.117 0.037 [1.047 1.191] 0.998 0.013 [0.974 1.023]
Age 1.000 0.000 [1.000 1.000] 0.990 0.000 [0.989 0.990] 0.986 0.001 [0.985 0.987] 1.040 0.000 [1.039 1.041]
Female 1.025 0.003 [1.018 1.032] 0.963 0.004 [0.955 0.970] 0.865 0.015 [0.837 0.894] 1.203 0.008 [1.187 1.218]
White 1.010 0.014 [0.983 1.038] 0.974 0.015 [0.945 1.004] 1.293 0.098 [1.115 1.499] 1.162 0.037 [1.092 1.237]
Black 0.898 0.014 [0.872 0.925] 0.853 0.015 [0.825 0.883] 0.913 0.075 [0.777 1.073] 1.096 0.038 [1.024 1.172]
Hispanic 1.017 0.031 [0.959 1.079] 1.028 0.035 [0.962 1.099] 0.977 0.161 [0.706 1.350] 0.901 0.066 [0.781 1.040]

Reasons for admission

Chronic airway obstruction 1.411 0.086 [1.253 1.589] 1.546 0.108 [1.349 1.773] 0.994 0.376 [0.474 2.085] 1.137 0.152 [0.875 1.478]
Chronic bronchitis 1.180 0.011 [1.159 1.202] 1.394 0.014 [1.366 1.423] 0.578 0.040 [0.505 0.661] 0.776 0.018 [0.742 0.811]
Pneumonia 1.055 0.009 [1.038 1.072] 1.040 0.011 [1.020 1.061] 0.761 0.039 [0.688 0.841] 1.112 0.016 [1.080 1.145]
Diabetes 0.987 0.014 [0.960 1.014] 0.881 0.015 [0.852 0.911] 0.946 0.067 [0.823 1.087] 1.400 0.038 [1.329 1.476]
Hypertension 1.876 0.063 [1.756 2.004] 2.409 0.087 [2.244 2.586] 1.480 0.303 [0.992 2.210] 0.694 0.072 [0.566 0.851]
Heart failure 1.065 0.008 [1.049 1.082] 1.135 0.011 [1.115 1.156] 0.986 0.043 [0.906 1.073] 0.921 0.014 [0.894 0.949]

Kun Zhang and David H. Howard

Cerebrovascular disease 1.008 0.011 [0.986 1.031] 0.591 0.011 [0.570 0.612] 0.994 0.061 [0.881 1.121] 1.910 0.030 [1.853 1.969]
Acute myocardial infarction 0.979 0.010 [0.959 0.999] 0.998 0.013 [0.973 1.023] 2.280 0.084 [2.121 2.451] 0.752 0.017 [0.720 0.786]
Cardiac dysrhythmia 1.478 0.013 [1.453 1.504] 1.829 0.018 [1.794 1.864] 1.611 0.073 [1.474 1.760] 0.687 0.016 [0.656 0.719]
Skin disease 1.014 0.013 [0.989 1.040] 0.934 0.015 [0.905 0.963] 1.216 0.073 [1.081 1.368] 1.215 0.029 [1.160 1.274]
Disorder of nervous system 0.615 0.011 [0.595 0.636] 0.242 0.008 [0.227 0.259] 0.971 0.073 [0.838 1.125] 1.318 0.028 [1.265 1.373]
Disorder of urinary tract 1.268 0.015 [1.239 1.297] 1.013 0.016 [0.981 1.045] 0.595 0.055 [0.496 0.713] 1.806 0.031 [1.746 1.869]
Renal failure 1.011 0.061 [0.897 1.139] 0.913 0.066 [0.792 1.052] 0.785 0.262 [0.408 1.510] 1.291 0.157 [1.017 1.637]
Fracture 0.935 0.011 [0.913 0.957] 0.129 0.005 [0.120 0.140] 0.637 0.051 [0.544 0.746] 2.334 0.031 [2.274 2.396]
Osteoarthrosis 1.576 0.013 [1.552 1.601] 1.404 0.014 [1.376 1.432] 0.155 0.020 [0.120 0.200] 2.469 0.033 [2.406 2.534]
Disorder of joint and muscle 1.113 0.033 [1.049 1.181] 0.753 0.033 [0.690 0.821] 0.911 0.159 [0.647 1.282] 1.994 0.084 [1.836 2.167]
Rehabilitation 0.438 0.005 [0.428 0.447] 0.452 0.006 [0.440 0.464] 1.174 0.043 [1.093 1.260] 0.329 0.008 [0.314 0.344]
General symptoms 1.669 0.019 [1.632 1.707] 1.708 0.024 [1.661 1.755] 1.463 0.096 [1.287 1.664] 1.612 0.036 [1.544 1.684]
N 394,920 394,920 394,920 394,920
Note: Hazard ratio are reported, 95% CIs in the parentheses.