Some hospitals discharge significantly more of their patients to long-term acute care hospitals (LTACs) than others, according to a recent study.
The retrospective observational cohort study included 65,525 hospitalized patients ages 65 years or older who were transferred from an acute care hospital to an LTAC or a skilled nursing facility (SNF) during fiscal year 2012; 64.8% were women, and 60.9% were 85 years or older. Results were published by JAMA Internal Medicine on Feb. 5.
Overall, 4.7% of the patients were transferred to an LTAC. The study found 29 patient-level, three hospital-level, and five region-level independent predictors of LTAC transfer; the strongest predictors were having a tracheostomy (adjusted odds ratio [aOR], 23.8; 95% CI, 15.8 to 35.9) and being hospitalized in close proximity to an LTAC (aOR for 0 to 2 miles vs. >42 miles, 8.4; 95% CI, 6.1 to 11.5). After adjustment for case mix, differences between patients explained only 52.1% of the variation in LTAC use. Regional differences explained 32.9%, with use of LTACs being much higher in the South (17% to 37%) than the Pacific Northwest, North, and Northeast (<2.2%).The remainder of the variation (15.0%) was attributable to differences between hospitals. Even within a region, adjusted hospital LTAC transfer rates varied substantially.
The results support the findings of previous similar studies and “highlight opportunities to optimize the use of LTACs for patients who could not be effectively treated in less intensive settings, such as SNFs,” according to the authors. From a clinical perspective, LTACs do offer benefits to patients such as daily physician care and better nurse-to-patient ratios, but they also carry risks such as higher hospital-acquired infection rates. “The demand for LTACs is in part because of a perceived lack of adequately staffed, high-quality SNFs capable of providing complex nursing and medical therapy,” the authors said.
They noted that as of October 2018 LTACs will receive lower, site-neutral payments for patients who haven't had an ICU stay of at least three days or prolonged mechanical ventilation during hospitalization. However, it isn't clear whether this policy will lead to clinically appropriate reductions in LTAC use, according to the study authors, who called on payers and accountable care organizations to partner with high-quality SNFs and hospitals with low LTAC use to develop more efficient networks.
A separate study, published by Annals of Internal Medicine on Feb. 13, looked at the use of postacute care (PAC) facilities by Medicare beneficiaries at the end of life. Among more than 8 million patients who died between 2006 and 2011, 23.3% received care in a PAC facility in the last 90 days of life. Of those patients, 60.4% returned to an acute care hospital before death, most directly from the PAC facility. Among all studied patients, 39.0% used hospice services in the last year of life, and those patients had lower use of acute care and PAC facilities in the days and weeks before death.
The results show high rates of hospital readmission from PAC facilities at the end of life, which may lead to lower-quality end-of-life care for these patients and higher costs for the health care system, according to the study authors. The findings “could inform conversations with patients near the end of life about their setting and goals of care,” they said. “Policies that require documentation of advanced care planning before transfer to a PAC facility, including discussion of do-not-hospitalize orders, could help facilitate these conversations.”