Impact of Long-Term Acute Care Hospital Closures on Patient Care Patterns and Outcomes

A study published in JAMA Network Open examines the impact of long-term acute care hospital closures on care patterns and outcomes for patients requiring mechanical ventilation, revealing changes in discharge patterns and advanced directive decisions without affecting mortality rates.

In the US, patients surviving critical illness may go to short-stay hospitals, skilled nursing facilities, or long-term acute care hospitals for post-acute care. Long-term acute care hospitals offer advanced interdisciplinary care with higher nurse-to-patient ratios, historically receiving higher reimbursement rates until CMS reforms in 2005. Closing many LTCHs due to financial pressures could impact upstream hospital care patterns for patients at risk for prolonged mechanical ventilation.

Data from Medicare files from 2011 to 2019 were used, including demographic and clinical data on hospital admissions and comorbidities. Patients aged 66 and older hospitalized with intensive care unit admission and receiving prolonged mechanical ventilation were analyzed. LTCH closures from 2012 to 2018 were studied, with hospital-level exposures and outcomes associated with the near-total loss of LTCH availability.

Researchers analyzed two groups of outcomes related to hospitalization, including measures such as do-not-resuscitate orders, palliative care delivery, tracheostomy rates, and disposition at the end of hospitalization. Patient outcomes evaluated included hospital length of stay, days alive and institution-free within 90 days of admission, spending per days alive within 90 days of admission, and mortality within 90 days of admission. Difference-in-differences analyses were used to compare outcomes between exposed hospitals with a closure-affected LTCH and control hospitals. Models adjusted for various hospital and patient characteristics to reduce potential confounding. Sensitivity analyses and falsification tests were conducted to validate the findings and consider additional factors affecting outcomes.

Between 2011 and 2019, almost 600 000 eligible patients on mechanical ventilation were admitted to hospitals, with nearly 100 000 of them transferred to long-term care hospitals. A study conducted between 2012 and 2018 found that 84 long-term care hospitals closed, impacting hospitals that had previously discharged patients to these facilities. Subsequent analysis focused on patient outcomes before and after long-term care hospital closures, showing trends in tracheostomy rates, palliative care, and other care patterns among patients.

“In this cohort study, LTCH closure was associated with changes in discharge patterns in patients receiving mechanical ventilation for at least 96 hours and advanced directive decisions in the subgroup receiving a tracheostomy, without change in mortality,” said researchers. “Further studies are needed to understand how LTCH availability may be associated with other important outcomes, including functional outcomes and patient and family satisfaction.”

Reference
Law AC, Bosch NA, Song Y, et al. Patient Outcomes After Long-Term Acute Care Hospital Closures. JAMA Netw Open. 2023;6(11):e2344377. doi:10.1001/jamanetworkopen.2023.44377