Reviewing LTACH Transfers to Determine Appropriateness

Only a third of long-term acute care hospital (LTACH) transfers in a high-LTACH-use region were considered clinically appropriate by physician reviewers, according to study results published online ahead of print in the Journal of the American Medical Directors Association.

“There is wide variation in LTACH use nationwide, the most intensive and expensive post-acute care setting, although appropriateness of use is uncertain,” researchers explained. “Therefore, we examined the appropriateness and reasons for transfer in a high-use region, and how Medicare criteria for LTACH payment identifies appropriate transfers.”

For the study, two physician reviewers looked at patient characteristics and primary reasons for transfer for 105 consecutive Medicare beneficiaries moved from a hospital to an LTACH. The transfers occurred from 2017 to 2018, and patients were from an accountable care organization in Texas.

Just 31.4% of the transfers were clinically appropriate, according to the study. The most common reason for appropriate LTACH transfers were for respiratory care, which explained 58% of transfers. Among patients inappropriately transferred to LTACHs, the most common reasons were for wound care (28%), intravenous medication infusions (28%), and patient (17%) and physician preference (26%).

The positive predictive value (PPV) of meeting current Medicare criteria for full LTACH payment (a preceding intensive care unit [ICU] stay 3 days or more, or prolonged mechanical ventilation) was 55%, researchers reported. If Medicare adopted an 8-day minimum ICU stay recommended by the Medicare Payment Advisory Commission (MedPAC), the PPV for meeting Medicare LTACH payment criteria grew to 77%, with appropriate transfers not meeting the more stringent criteria increasing from 12% to 17%.

“Medicare payment criteria modestly distinguished between appropriate and inappropriate transfers,” researchers wrote. “Adoption of MedPAC’s recommended 8-day minimum ICU stay criterion could safely reduce inappropriate transfers, although generalizability to low LTACH-use regions is uncertain.”

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