Abstract
BackgroundThe use of post-acute care (PAC) for cardiovascular conditions is highly variable across geographical regions. Although PAC benefits include lower readmission rates, better clinical outcomes, and lower mortality, referral patterns vary widely, raising concerns about substandard care and inflated costs. The objective of this study is to identify factors associated with PAC referral decisions at acute care discharge.MethodsThis study is a retrospective Electronic Health Records (EHR) based review of a cohort of patients with coronary artery bypass graft (CABG) and valve replacement (VR). EHR records were extracted from the Cerner Health-Facts Data warehouse and covered 49 hospitals in the United States of America (U.S.) from January 2010 to December 2015. Multinomial logistic regression was used to identify associations of 29 variables comprising patient characteristics, hospital profiles, and patient conditions at discharge.ResultsThe cohort had 14,224 patients with mean age 63.5 years, with 10,234 (71.9%) male and 11,946 (84%) Caucasian, with 5827 (40.96%) being discharged to home without additional care (Home), 5226 (36.74%) to home health care (HHC), 1721 (12.10%) to skilled nursing facilities (SNF), 1168 (8.22%) to inpatient rehabilitation facilities (IRF), 164 (1.15%) to long term care hospitals (LTCH), and 118 (0.83%) to other locations. Census division, hospital size, teaching hospital status, gender, age, marital status, length of stay, and Charlson comorbidity index were identified as highly significant variables (p- values < 0.001) that influence the PAC referral decision. Overall model accuracy was 62.6%, and multiclass Area Under the Curve (AUC) values were for Home: 0.72; HHC: 0.72; SNF: 0.58; IRF: 0.53; LTCH: 0.52, and others: 0.46.ConclusionsCensus location of the acute care hospital was highly associated with PAC referral practices, as was hospital capacity, with larger hospitals referring patients to PAC at a greater rate than smaller hospitals. Race and gender were also statistically significant, with Asians, Hispanics, and Native Americans being less likely to be referred to PAC compared to Caucasians, and female patients being more likely to be referred than males. Additional analysis indicated that PAC referral practices are also influenced by the mix of PAC services offered in each region.
Highlights
The use of post-acute care (PAC) for cardiovascular conditions is highly variable across geographical regions
First, it is imperative to understand prevailing PAC referral practices across the dimensions of geographic region and patient acuity. Considering this target and the gaps as mentioned above in the literature, the objective of this study is to examine the geographic variations in PAC referral pattern and identify the associated risk factors related to hospital characteristics, patient demographics, and clinical information for the decision of discharge location for coronary artery bypass graft (CABG) and valve replacement (VR)
To assess the contribution of comorbid conditions in the discharge location (PAC referral), we examined if the patient had suffered from atrial fibrillation (ICD9–427.31), hypertension (ICD9–401.9), coronary atherosclerosis (ICD9–414.01), intermediate coronary syndrome (ICD9–411.1), hyperlipidemia (ICD9–272.4), acute posthemorrhagic anemia (ICD9–285.1), acute myocardial infarction (ICD9–410.71), tobacco use disorder (ICD9– 305.1), diabetes mellitus without complication (ICD9–250), acute kidney failure (ICD9–584.9), pulmonary collapse (ICD9–518), congestive heart failure (ICD9–428) and unspecified anemia (ICD9–285.9)
Summary
The use of post-acute care (PAC) for cardiovascular conditions is highly variable across geographical regions. Post-acute care (PAC) facilities provide treatment for acute-care patients following hospital discharge and are known to improve patient outcomes, readmission rates, mortality, and functional disability [1, 2]. Services are provided to these patients through various settings, which include long-term acute care hospitals (LTCH, 428 facilities in the U.S.), inpatient rehabilitation facilities (IRF, 1165 in the U.S.), skilled nursing facilities (SNF, 16,000 in U.S.), and Certified Home Health Agencies (HHA, 33,000 in U.S.) [7] These facilities play an essential role in improving acute-care patient outcomes, they are somewhat heterogeneous, poorly coordinated with acute-care hospitals, and exhibit high regional variations in usage and availability [8]. PAC is perhaps the least understood portion of the U.S healthcare continuum, and limited research was completed on PACs’ effectiveness for the conditions and settings mentioned above
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