For patients who have very serious illnesses one option is to receive care in a long-term acute care hospital, which has a separate reimbursement scheme under Medicare. Researchers examined the effects of LTCH use on cost and quality outcomes, with the results reported in Medical Care. (MC Article) To be certified as an LTCH, a hospital unit must have mean length of stays over 25 days, which indicates that these are very ill, complex patients being treated. LTCH use tends to be expensive and has substantial geographic variation, partly due to availability of the units. Congress has recently required CMS to better define what patients qualify for LTCH stays, and has reduced payment for cases not meeting the criteria. The researchers sought to identify which types of patients may benefit from LTCH use by looking at overall costs compared to other settings and at mortality outcomes. They examined patient records for the five most common patient diagnoses in LTCH, other than mechanical ventilation, from the time period of 2009 to 2011. These diagnoses accounted for over half of the major reasons for an LTCH stay. A sub-analysis looked at patients who had at least 3 days in an intensive care unit as part of their acute hospital stay prior to the LTCH transfer.
The results varied by diagnostic category. In general male and African-American patients were more likely to end up in LTCH and patients in an LTCH had longer stays in ICUs and were more likely to have multiple organ failure, stroke or traumatic brain injury. On an adjusted basis, patients in LTCH with digestive major diagnostic conditions had 2.9% lower 365 day mortality rates than patients in other settings, but there was no significant difference in mortality for the other four studied diagnostic groups. But subgroups did show further mortality improvement, for example, for patients with major organ failure. All the mortality findings, however, were weakened when some patients were excluded from the analysis on the basis that they may not have been appropriate LTCH users. In terms of cost, for patients with respiratory, musculoskeletal and infectious disease diagnoses there was higher spending in an LTCH setting, but for the circulatory and digestive diagnoses, spending was lower. Sub-group analysis showed additional differences in both spending directions. Examining LTCH use is valuable, because these patients are among the most expensive and account for a substantial fraction of all Medicare spending. Deciphering which subsets of patients benefit, from a cost and mortality perspective, by using LTCH can help policymakers set better guidelines on who should be admitted to the units.