Comparative effectiveness of long-term acute care hospital versus skilled nursing facility transfer

Anil N Makam,Sachin J Shah,Ethan A Halm,Kandice A Kapinos,Michael E Miller,Oanh Kieu Nguyen

doi:10.1186/s12913-020-05847-6

Abstract

BackgroundLong-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.MethodsUsing 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 spendingResultsOf 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).ConclusionLTACH 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.

Highlights

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
Description of cohort Of 5603 potentially eligible hospitalizations to an internal medicine service at one of six hospitals in north Texas leading to an LTACH or SNF transfer, we included 3503 index episodes of care among unique Medicare beneficiaries
Patients transferred to an LTACH spent a median of 25 days in the LTACH and patients transferred to a SNF spent a median of 24 days (IQR, 12–50) in the SNF

Summary

Introduction

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 receive over triple the reimbursement of SNFs for comparable diagnoses, we sought to compare outcomes and spending between LTACH versus SNF transfer. LTACHs were initially intended to care for those requiring prolonged mechanical ventilation, but the only official Medicare requirement for LTACH certification is to maintain an average length of stay of at least 25 days [6]. LTACHs care for an expanded population with complex and prolonged illness, three-quarters of whom are not mechanically ventilated, but have a range of medical needs such as intravenous antibiotics, complex wound care, and dialysis [7,8,9]. LTACHs are the most expensive post-acute care provider, and cost the Medicare program $4.5 billion annually [10]

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Conclusion