There is wide variation in long-term acute care hospital (LTACH) use nationwide, the most intensive and expensive post-acute care setting, although appropriateness of use is uncertain. Therefore, we examined the appropriateness and reasons for transfer in a high-use region, and how Medicare criteria for LTACH payment identifies appropriate transfers.
Multicenter retrospective observational cohort.
Setting and Participants
Consecutive hospitalized Medicare beneficiaries transferred to an LTACH from 2017 to 2018 from an accountable care organization in Texas.
The primary outcome was clinical appropriateness of transfer ascertained by 2 physician reviewers. We abstracted patients’ characteristics and primary reasons for transfer. We examined the positive predictive value (PPV) of meeting Medicare criteria for full LTACH payment [preceding intensive care unit (ICU) stay ≥3 days or prolonged mechanical ventilation] for identifying appropriate transfers, and how this differed if Medicare adopted an 8-day minimum ICU stay criterion recommended by the Medicare Payment Advisory Commission (MedPAC).
Of 105 LTACH transfers, 33 (31.4%) were clinically appropriate. The most common reason among appropriate transfers was respiratory care (58%), but 42% had other indications. Inappropriate transfers most commonly were for wound care (28%), intravenous medication infusions (28%), or patient (17%) and physician preference (26%). The PPV for meeting Medicare LTACH payment criteria was 55%. The PPV improved to 77% if Medicare adopted the 8-day minimum ICU stay criterion, with only a modest absolute increase in appropriate transfers not meeting the more stringent criteria (12% to 17%).
Conclusions and Implications
Two-thirds of LTACH transfers in a high-LTACH-use region are clinically inappropriate, and are most commonly transferred for wound care, intravenous infusions, or patient and physician preference. Medicare payment criteria modestly distinguished between appropriate and inappropriate transfers. 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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Published online: February 19, 2021
Anil N. Makam received travel expenses and a research grant from the National Association of Long-Term Hospitals (NALTH), and support from the National Institute on Aging (K23AG052603). The other authors declare no conflicts of interest.
© 2021 AMDA - The Society for Post-Acute and Long-Term Care Medicine.
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August 18, 2021
August 2021 Issue: Nursing Home Quality / Resident-to-Resident Mistreatment / POLST / LTACHs
Featuring Dr. Philip Sloane, Dr. Mallory Brown; Recorded: August 20, 2021.