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Schumacher RC, Chiu M, de Leon J, Krause K, Makam AN. Appropriateness of Long-Term Acute Care Hospital Transfer: A Multicenter Study of Medicare ACO Beneficiaries. J Am Med Dir Assoc 2021; 22:1767-1771.e5. [PMID: 33617790 PMCID: PMC9094673 DOI: 10.1016/j.jamda.2021.01.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 01/11/2021] [Accepted: 01/18/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES There is wide variation in long-term acute care hospital (LTACH) use nationwide, the most intensive and expensive post-acute care setting, although appropriateness of use is uncertain. Therefore, we examined the appropriateness and reasons for transfer in a high-use region, and how Medicare criteria for LTACH payment identifies appropriate transfers. DESIGN Multicenter retrospective observational cohort. SETTING AND PARTICIPANTS Consecutive hospitalized Medicare beneficiaries transferred to an LTACH from 2017 to 2018 from an accountable care organization in Texas. METHODS The primary outcome was clinical appropriateness of transfer ascertained by 2 physician reviewers. We abstracted patients' characteristics and primary reasons for transfer. We examined the positive predictive value (PPV) of meeting Medicare criteria for full LTACH payment [preceding intensive care unit (ICU) stay ≥3 days or prolonged mechanical ventilation] for identifying appropriate transfers, and how this differed if Medicare adopted an 8-day minimum ICU stay criterion recommended by the Medicare Payment Advisory Commission (MedPAC). RESULTS Of 105 LTACH transfers, 33 (31.4%) were clinically appropriate. The most common reason among appropriate transfers was respiratory care (58%), but 42% had other indications. Inappropriate transfers most commonly were for wound care (28%), intravenous medication infusions (28%), or patient (17%) and physician preference (26%). The PPV for meeting Medicare LTACH payment criteria was 55%. The PPV improved to 77% if Medicare adopted the 8-day minimum ICU stay criterion, with only a modest absolute increase in appropriate transfers not meeting the more stringent criteria (12% to 17%). CONCLUSIONS AND IMPLICATIONS Two-thirds of LTACH transfers in a high-LTACH-use region are clinically inappropriate, and are most commonly transferred for wound care, intravenous infusions, or patient and physician preference. Medicare payment criteria modestly distinguished between appropriate and inappropriate transfers. Adoption of MedPAC's recommended 8-day minimum ICU stay criterion could safely reduce inappropriate transfers, although generalizability to low LTACH-use regions is uncertain.
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Affiliation(s)
- Ross C Schumacher
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA; Division of Pulmonary, Allergy, and Critical Care Medicine, The University of Alabama at Birmingham, AL, USA
| | - Michael Chiu
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Jean de Leon
- Department of Physical Medicine and Rehabilitation, UT Southwestern Medical Center, Dallas, TX, USA
| | - Kate Krause
- UT Southwestern Medical School, Dallas, TX, USA
| | - Anil N Makam
- Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX, USA; Division of Hospital Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, CA, USA; Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, CA, USA.
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Makam AN, Nguyen OK, Miller ME, Shah SJ, Kapinos KA, Halm EA. Comparative effectiveness of long-term acute care hospital versus skilled nursing facility transfer. BMC Health Serv Res 2020; 20:1032. [PMID: 33176767 PMCID: PMC7656509 DOI: 10.1186/s12913-020-05847-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 10/21/2020] [Indexed: 12/02/2022] Open
Abstract
Background Long-term acute care hospital (LTACH) use varies considerably across the U.S., which may reflect uncertainty about the effectiveness of LTACHs vs. skilled nursing facilities (SNF), the principal post-acute care alternative. Given that LTACHs provide more intensive care and thus receive over triple the reimbursement of SNFs for comparable diagnoses, we sought to compare outcomes and spending between LTACH versus SNF transfer. Methods Using Medicare claims linked to electronic health record (EHR) data from six Texas Hospitals between 2009 and 2010, we conducted a retrospective cohort study of patients hospitalized on a medicine service in a high-LTACH use region and discharged to either an LTACH or SNF and followed for one year. The primary outcomes included mortality, 60-day recovery without inpatient care, days at home, and healthcare spending Results Of 3503 patients, 18% were transferred to an LTACH. Patients transferred to LTACHs were younger (median 71 vs. 82 years), less likely to be female (50.5 vs 66.6%) and white (69.0 vs. 84.1%), but were sicker (24.3 vs. 14.2% for prolonged intensive care unit stay; median diagnosis resource intensity weight of 2.03 vs. 1.38). In unadjusted analyses, patients transferred to an LTACH vs. SNF were less likely to survive (59.1 vs. 65.0%) or recover (62.5 vs 66.0%), and spent fewer days at home (186 vs. 200). Adjusting for demographic and clinical confounders available in Medicare claims and EHR data, LTACH transfer was not significantly associated with differences in mortality (HR, 1.12, 95% CI, 0.94–1.33), recovery (SHR, 1.07, 0.93–1.23), and days spent at home (IRR, 0.96, 0.83–1.10), but was associated with greater Medicare spending ($16,689 for one year, 95% CI, $12,216–$21,162). Conclusion LTACH transfer for Medicare beneficiaries is associated with similar clinical outcomes but with higher healthcare spending compared to SNF transfer. LTACH use should be reserved for patients who require complex inpatient care and cannot be cared for in SNFs. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-020-05847-6.
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Affiliation(s)
- Anil N Makam
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA. .,Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX, USA. .,Division of Hospital Medicine, Chan Zuckerberg San Francisco General Hospital, San Francisco, USA.
| | - Oanh Kieu Nguyen
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA.,Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX, USA.,Division of Hospital Medicine, Chan Zuckerberg San Francisco General Hospital, San Francisco, USA.,Division of Hospital Medicine, University Hospital of UCSF, San Francisco, USA
| | - Michael E Miller
- Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX, USA
| | - Sachin J Shah
- Division of Hospital Medicine, University of California San Francisco, San Francisco, USA
| | - Kandice A Kapinos
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA.,Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX, USA.,RAND Corporation, Arlington, VA, USA
| | - Ethan A Halm
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA.,Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX, USA
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Abstract
In the United States, we are blessed with many options for postacute care: inpatient rehabilitation facilities, long-term acute care hospitals, skilled nursing facilities, home health agencies, and outpatient rehabilitation. However, choosing the appropriate level of care can be a daunting task. It requires interdisciplinary input and involvement of all stakeholders. The decision should be informed by outcomes data specific to the patient's diagnosis, impairments, and psychosocial supports.
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Affiliation(s)
- Robert Samuel Mayer
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Phipps 174, Baltimore, MD 21287, USA.
| | - Amira Noles
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Phipps 174, Baltimore, MD 21287, USA
| | - Dominique Vinh
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, 5505 Hopkins Bayview Circle, Baltimore, MD 21224, USA
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Dawson A, Grigonis A. Comment on: The Clinical Course after Long-term Acute Care Hospital Admission among Older Medicare Beneficiaries. J Am Geriatr Soc 2020; 68:666-667. [PMID: 31903544 DOI: 10.1111/jgs.16320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 11/11/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Amanda Dawson
- Select Medical, Research Unit, Inpatient Hospital Division, Mechanicsburg, Pennsylvania
| | - Antony Grigonis
- Select Medical, Quality and Healthcare Analytics Department, Inpatient Hospital Division, Mechanicsburg, Pennsylvania
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Makam AN, Tran T, Miller ME, Xuan L, Nguyen OK, Halm EA. The Clinical Course after Long-Term Acute Care Hospital Admission among Older Medicare Beneficiaries. J Am Geriatr Soc 2019; 67:2282-2288. [PMID: 31449686 DOI: 10.1111/jgs.16106] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 07/03/2019] [Accepted: 07/05/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVES Long-term acute care (LTAC) hospitals provide extended complex post-acute care to more than 120 000 Medicare beneficiaries annually, with the goal of helping patients to regain independence and recover. Because little is known about patients' long-term outcomes, we sought to examine the clinical course after LTAC admission. DESIGN Nationally representative 5-year cohort study using 5% Medicare data from 2009 to 2013. SETTING LTAC hospitals. PARTICIPANTS Hospitalized Medicare fee-for-service beneficiaries 65 years of age or older who were transferred to an LTAC hospital. MEASUREMENTS Mortality, recovery (defined as achieving 60 consecutive days alive without inpatient care), time spent in an inpatient facility following LTAC hospital admission, receipt of an artificial life-prolonging procedure (feeding tube, tracheostomy, hemodialysis), and palliative care physician consultation. RESULTS Of 14 072 hospitalized older adults transferred to an LTAC hospital, median survival was 8.3 months, and 1- and 5-year survival rates were 45% and 18%, respectively. Following LTAC admission, 53% never achieved a 60-day recovery. The median time of their remaining life a patient spent as an inpatient after LTAC admission was 65.6% (interquartile range = 21.4%-100%). More than one-third (36.9%) died in an inpatient setting, never returning home after the LTAC admission. During the preceding hospitalization and index LTAC admission, 30.9% received an artificial life-prolonging procedure, and 1% had a palliative care physician consultation. CONCLUSION Hospitalized older adults transferred to LTAC hospitals have poor survival, spend most of their remaining life as an inpatient, and frequently undergo life-prolonging procedures. This prognostic understanding is essential to inform goals of care discussions and prioritize healthcare needs for hospitalized older adults admitted to LTAC hospitals. Given the exceedingly low rates of palliative care consultations, future research is needed to examine unmet palliative care needs in this population. J Am Geriatr Soc 67:2282-2288, 2019.
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Affiliation(s)
- Anil N Makam
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas.,Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas.,Division of Hospital Medicine, Chan Zuckerberg San Francisco General Hospital, University of California San Francisco, Dallas, Texas
| | - Thu Tran
- UT Southwestern Medical School, Dallas, Texas
| | - Michael E Miller
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas
| | - Lei Xuan
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas
| | - Oanh Kieu Nguyen
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas.,Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas.,Division of Hospital Medicine, Chan Zuckerberg San Francisco General Hospital, University of California San Francisco, Dallas, Texas
| | - Ethan A Halm
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas.,Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas
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