NEW YORK (Reuters Health) – Whether hospitalized older adults are discharged to long-term acute care hospitals (LTACs) or skilled nursing facilities (SNFs) is often unrelated to how sick they are, according to a retrospective study.
“For many patients there is often more than one choice for post-acute care,” Dr. Anil N. Makam from the University of Texas Southwestern Medical Center, in Dallas, told Reuters Health by email. “Physicians should understand the relative advantages of LTACs compared to SNFs and refer patients according to which site will be the best fit for their post-acute care needs.”
“LTACs may be best reserved for patients who are clinically stable enough to leave the hospital but will still require daily physician monitoring and/or intensive nursing care that may not be available in SNFs,” he explained.
Dr. Makam and colleagues used Medicare data from 65,525 patients hospitalized in 3,053 different hospitals across 304 hospital referral regions. They examined patient-, hospital-, and region-level factors associated with transferring hospitalized older adults to an LTAC versus an SNF.
Only 4.7% of these patients were transferred to an LTAC, with the rest transferred to an SNF, according to the February 5 JAMA Internal Medicine online report.
Receiving a tracheostomy and being hospitalized near an LTAC were the two strongest independent predictors of LTAC transfer.
After adjustment for case-mix, differences between patients explained 52.1% of the variation in LTAC use.
One-third of the variation between LTAC versus SNF transfer was explained by differences among regions, with a 16-fold difference in LTAC transfer rates between hospital referral regions “with the lowest 10th and highest 90th percentile transfer rate.”
LTAC use was very high in the South (17% to 37%) compared with the Pacific Northwest, North, and Northeast (<2.2%).
Differences among hospitals accounted for the remaining 15.6% of the variation in LTAC use, and hospital LTAC transfer rates varied substantially even within the same hospital referral region.
“The extreme regional variation in LTAC use suggests that there is overuse of LTACs in the South – particularly Oklahoma, Texas, and Louisiana – and underuse of LTACs in the Pacific Northwest, the North, and the North Northeast,” Dr. Makam said. “A key challenge is that no one knows what the ‘right’ rate of LTAC use is, or even who the ‘right’ person is to transfer to an LTAC.”
“Post-acute care accounts for the single largest increase in Medicare spending,” he said. “Although it may be tempting to dismiss the use of LTACs as wasteful or ‘low-value’ simply because they are expensive, there are many patients for whom LTACs are the best post-acute care option because of the complexity and/or severity of their medical conditions.”
“It is critical that we understand which individuals are most likely to benefit from LTACs versus SNFs for post-acute care so that we, as a society, can make the smartest decisions about how to allocate these resources,” Dr. Makam concluded.
SOURCE: http://bit.ly/2FO0AKn
JAMA Intern Med 2018.
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