Utilization of Long-Term Acute Care Hospitals Increasing

In recent years, patients recovering from critical illness have received care in long-term acute care hospitals, and, according to researchers, with the combination of an aging population and advances in critical care, the incidence of chronic critical illness is expected to increase. Long-term acute care facilities could play a vital role in caring for these patients.

The Centers for Medicare & Medicaid Services (CMS) defines long-term acute care hospitals as acute care hospitals with a mean length of stay ≥25 days. These facilities act as specialized hospitals for patients who require prolonged mechanical ventilation, as well as patients with other types of chronic critical illness.

The researchers recently conducted a retrospective cohort study to determine the epidemiology of the use of long-term acute care hospitals following hospitalization for critical illness in fee-for-service Medicare beneficiaries ≥65 years of age. They reported results of the study in the Journal of the American Medical Association [2010;303(22):2253-2259].

Patient-level hospitalization data from the CMS Medicare Provider Analysis and Review files were used in the study. Fee-for-service Medicare beneficiaries represent approximately 70% of long-term acute care hospitalizations. Using resource utilization codes specific to admission to an intensive care unit (ICU), the researchers examined data that included admissions from 1997 to 2006 to general ICUs, specialty ICUs, and coronary care units; admissions to intermediate-care units were excluded. Other exclusion criteria were hospitalizations in Alaska and Hawaii and hospitalizations for patients <65 years of age.

The study’s primary outcome measures were overall use of long-term acute care, the costs associated with that care, and survival following transfer from the long-term acute care facility.

During the study period, there were 18,690,469 eligible hospitalizations involving a stay in the ICU. In 1997, there were 1,901,630 Medicare ICU admissions; in 2007, the number was 1,637,581.

The decline in ICU admissions was accompanied by an increase in the absolute number of transfers to a long-term acute care hospital; transfers as a proportion of all ICU discharges also steadily increased. In 1997, 0.7% (n=13,732) of ICU admissions resulted in transfer to a long-term acute care hospital; in 2006, 2.5% (n=40,353) of ICU admissions resulted in transfer to long-term acute care facilities (P<.001).

During the study period, the number of long-term acute care facilities increased at a mean rate of 8.8% per year. In 1997, there were 192 facilities; in 2006, the number was 408 (P<.001 for linear trend). The number of long-term acute care hospital beds increased from 16,523 in 1997 to 27,623 in 2006, a 5.9% per year mean rate of increase (P<.001).

The costs associated with utilization of long-term acute care hospitals were $484 million in 1997. In 2006, the total costs were $1.325 billion, a mean rate of increase of 12.1% (P<.001).

In age-adjusted analyses, the incidence of long-term acute care hospital transfer at the population level also increased. In 1997, transfers after critical illness were 38.1 per 100,000 capita; in 2006, there were 99.7 transfers after critical illness per 100,000 capita (P<.001). Throughout the study period, there was greater use of long-term acute care hospitals among male patients and black patients. Black patients experienced more than twice the transfer rate as white patients. There was no significant difference in the rate of increase by sex or race.

Over time, the incidence of comorbid conditions, the incidence of sepsis at the originating facility, and the percentage of patients requiring mechanical ventilation at the long-term acute care facility increased. In addition, over time the destination after discharge from the long-term acute care facility changed. More patients were discharged to a skilled nursing or rehabilitation facility (19.9% in 1997-2000, 34.9% in 2004-2006; P<.001) and fewer were discharged to home (32.3% in 1997-2000, 27.4% in 2004-2006; P<.001).

Finally, throughout the study period, the 1-year mortality rate following admission to a long-term acute care hospital was high: 50.7% in 1997-2000 and 52.2% in 2004-2006.

In conclusion, the researchers said, “our results underscore the capability of the medical system to adopt new organizational innovations and highlight the need for a diverse program of comparative effectiveness research to determine the optimal organization of care for patients recovering from critical illness, including the best way to maximize survival and control costs for this high-risk patient group.”—Tori Socha