Factors associated with variation in long-term acute care hospital vs skilled nursing facility use among hospitalized older adults

Anil N. Makam, Oanh Kieu Nguyen, Lei Xuan, Michael E. Miller, James Goodwin, Ethan A. Halm

Research output: Contribution to journalArticle

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Abstract

IMPORTANCE Despite providing an overlapping level of care, it is unknown why hospitalized older adults are transferred to long-term acute care hospitals (LTACs) vs less costly skilled nursing facilities (SNFs) for postacute care. OBJECTIVE To examine factors associated with variation in LTAC vs SNF transfer among hospitalized older adults. DESIGN, SETTING, AND PARTICIPANTS We conducted this retrospective observational cohort study of hospitalized older adults (65 years) transferred to an LTAC vs SNF during fiscal year 2012 using national 5% Medicare data. MAIN OUTCOMES AND MEASURES Predictors of LTAC transfer were assessed using a multilevel mixed-effects model adjusting for patient-, hospital-, and region-level factors. We estimated variation partition coefficients and adjusted hospital- and region-specific LTAC transfer rates using sequential models. RESULTS Among 65 525 hospitalized older adults (42 461 [64.8%] women; 39 908 [60.9%] 85 years) transferred to an LTAC or SNF, 3093 (4.7%) were transferred to an LTAC. We identified 29 patient-, 3 hospital-, and 5 region-level independent predictors. The strongest predictors of LTAC transfer were receiving a tracheostomy (adjusted odds ration [aOR], 23.8; 95% CI, 15.8-35.9) and being hospitalized in close proximity to an LTAC (0-2 vs >42 miles; aOR, 8.4, 95% CI, 6.1-11.5). After adjusting for case-mix, differences between patients explained 52.1% (95% CI, 47.7%-56.5%) of the variation in LTAC use. The remainder was attributable to hospital (15.0%; 95% CI, 12.3%-17.6%), and regional differences (32.9%; 95% CI, 27.6%-38.3%). Case-mix adjusted LTAC use was very high in the South (17%-37%) compared with the Pacific Northwest, North, and Northeast (<2.2%). From the full multilevel model, the median adjusted hospital LTAC transfer rate was 2.1% (10th-90th percentile, 0.24%-10.8%). Even within a region, adjusted hospital LTAC transfer rates varied substantially (intraclass correlation coefficient [ICC], 0.26; 95% CI, 0.23-0.30). CONCLUSIONS AND RELEVANCE Although many patient-level factors were associated with LTAC use, half of the variation in LTAC vs SNF transfer is independent of patients’ illness severity or clinical complexity, and is explained by where the patient was hospitalized and in what region, with far greater use in the South. Even among hospitals in regions with similar LTAC access, there was considerable variation in LTAC use. Given the higher expense associated with LTACs vs SNFs, greater attention is needed to define the optimal role of LTACs in the postacute care of older adults.

Original languageEnglish (US)
Pages (from-to)399-405
Number of pages7
JournalJAMA Internal Medicine
Volume178
Issue number3
DOIs
StatePublished - Mar 1 2018

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Skilled Nursing Facilities
Long-Term Care
Subacute Care
Diagnosis-Related Groups

ASJC Scopus subject areas

  • Internal Medicine

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Factors associated with variation in long-term acute care hospital vs skilled nursing facility use among hospitalized older adults. / Makam, Anil N.; Nguyen, Oanh Kieu; Xuan, Lei; Miller, Michael E.; Goodwin, James; Halm, Ethan A.

In: JAMA Internal Medicine, Vol. 178, No. 3, 01.03.2018, p. 399-405.

Research output: Contribution to journalArticle

Makam, Anil N. ; Nguyen, Oanh Kieu ; Xuan, Lei ; Miller, Michael E. ; Goodwin, James ; Halm, Ethan A. / Factors associated with variation in long-term acute care hospital vs skilled nursing facility use among hospitalized older adults. In: JAMA Internal Medicine. 2018 ; Vol. 178, No. 3. pp. 399-405.
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abstract = "IMPORTANCE Despite providing an overlapping level of care, it is unknown why hospitalized older adults are transferred to long-term acute care hospitals (LTACs) vs less costly skilled nursing facilities (SNFs) for postacute care. OBJECTIVE To examine factors associated with variation in LTAC vs SNF transfer among hospitalized older adults. DESIGN, SETTING, AND PARTICIPANTS We conducted this retrospective observational cohort study of hospitalized older adults (65 years) transferred to an LTAC vs SNF during fiscal year 2012 using national 5{\%} Medicare data. MAIN OUTCOMES AND MEASURES Predictors of LTAC transfer were assessed using a multilevel mixed-effects model adjusting for patient-, hospital-, and region-level factors. We estimated variation partition coefficients and adjusted hospital- and region-specific LTAC transfer rates using sequential models. RESULTS Among 65 525 hospitalized older adults (42 461 [64.8{\%}] women; 39 908 [60.9{\%}] 85 years) transferred to an LTAC or SNF, 3093 (4.7{\%}) were transferred to an LTAC. We identified 29 patient-, 3 hospital-, and 5 region-level independent predictors. The strongest predictors of LTAC transfer were receiving a tracheostomy (adjusted odds ration [aOR], 23.8; 95{\%} CI, 15.8-35.9) and being hospitalized in close proximity to an LTAC (0-2 vs >42 miles; aOR, 8.4, 95{\%} CI, 6.1-11.5). After adjusting for case-mix, differences between patients explained 52.1{\%} (95{\%} CI, 47.7{\%}-56.5{\%}) of the variation in LTAC use. The remainder was attributable to hospital (15.0{\%}; 95{\%} CI, 12.3{\%}-17.6{\%}), and regional differences (32.9{\%}; 95{\%} CI, 27.6{\%}-38.3{\%}). Case-mix adjusted LTAC use was very high in the South (17{\%}-37{\%}) compared with the Pacific Northwest, North, and Northeast (<2.2{\%}). From the full multilevel model, the median adjusted hospital LTAC transfer rate was 2.1{\%} (10th-90th percentile, 0.24{\%}-10.8{\%}). Even within a region, adjusted hospital LTAC transfer rates varied substantially (intraclass correlation coefficient [ICC], 0.26; 95{\%} CI, 0.23-0.30). CONCLUSIONS AND RELEVANCE Although many patient-level factors were associated with LTAC use, half of the variation in LTAC vs SNF transfer is independent of patients’ illness severity or clinical complexity, and is explained by where the patient was hospitalized and in what region, with far greater use in the South. Even among hospitals in regions with similar LTAC access, there was considerable variation in LTAC use. Given the higher expense associated with LTACs vs SNFs, greater attention is needed to define the optimal role of LTACs in the postacute care of older adults.",
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AU - Xuan, Lei

AU - Miller, Michael E.

AU - Goodwin, James

AU - Halm, Ethan A.

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N2 - IMPORTANCE Despite providing an overlapping level of care, it is unknown why hospitalized older adults are transferred to long-term acute care hospitals (LTACs) vs less costly skilled nursing facilities (SNFs) for postacute care. OBJECTIVE To examine factors associated with variation in LTAC vs SNF transfer among hospitalized older adults. DESIGN, SETTING, AND PARTICIPANTS We conducted this retrospective observational cohort study of hospitalized older adults (65 years) transferred to an LTAC vs SNF during fiscal year 2012 using national 5% Medicare data. MAIN OUTCOMES AND MEASURES Predictors of LTAC transfer were assessed using a multilevel mixed-effects model adjusting for patient-, hospital-, and region-level factors. We estimated variation partition coefficients and adjusted hospital- and region-specific LTAC transfer rates using sequential models. RESULTS Among 65 525 hospitalized older adults (42 461 [64.8%] women; 39 908 [60.9%] 85 years) transferred to an LTAC or SNF, 3093 (4.7%) were transferred to an LTAC. We identified 29 patient-, 3 hospital-, and 5 region-level independent predictors. The strongest predictors of LTAC transfer were receiving a tracheostomy (adjusted odds ration [aOR], 23.8; 95% CI, 15.8-35.9) and being hospitalized in close proximity to an LTAC (0-2 vs >42 miles; aOR, 8.4, 95% CI, 6.1-11.5). After adjusting for case-mix, differences between patients explained 52.1% (95% CI, 47.7%-56.5%) of the variation in LTAC use. The remainder was attributable to hospital (15.0%; 95% CI, 12.3%-17.6%), and regional differences (32.9%; 95% CI, 27.6%-38.3%). Case-mix adjusted LTAC use was very high in the South (17%-37%) compared with the Pacific Northwest, North, and Northeast (<2.2%). From the full multilevel model, the median adjusted hospital LTAC transfer rate was 2.1% (10th-90th percentile, 0.24%-10.8%). Even within a region, adjusted hospital LTAC transfer rates varied substantially (intraclass correlation coefficient [ICC], 0.26; 95% CI, 0.23-0.30). CONCLUSIONS AND RELEVANCE Although many patient-level factors were associated with LTAC use, half of the variation in LTAC vs SNF transfer is independent of patients’ illness severity or clinical complexity, and is explained by where the patient was hospitalized and in what region, with far greater use in the South. Even among hospitals in regions with similar LTAC access, there was considerable variation in LTAC use. Given the higher expense associated with LTACs vs SNFs, greater attention is needed to define the optimal role of LTACs in the postacute care of older adults.

AB - IMPORTANCE Despite providing an overlapping level of care, it is unknown why hospitalized older adults are transferred to long-term acute care hospitals (LTACs) vs less costly skilled nursing facilities (SNFs) for postacute care. OBJECTIVE To examine factors associated with variation in LTAC vs SNF transfer among hospitalized older adults. DESIGN, SETTING, AND PARTICIPANTS We conducted this retrospective observational cohort study of hospitalized older adults (65 years) transferred to an LTAC vs SNF during fiscal year 2012 using national 5% Medicare data. MAIN OUTCOMES AND MEASURES Predictors of LTAC transfer were assessed using a multilevel mixed-effects model adjusting for patient-, hospital-, and region-level factors. We estimated variation partition coefficients and adjusted hospital- and region-specific LTAC transfer rates using sequential models. RESULTS Among 65 525 hospitalized older adults (42 461 [64.8%] women; 39 908 [60.9%] 85 years) transferred to an LTAC or SNF, 3093 (4.7%) were transferred to an LTAC. We identified 29 patient-, 3 hospital-, and 5 region-level independent predictors. The strongest predictors of LTAC transfer were receiving a tracheostomy (adjusted odds ration [aOR], 23.8; 95% CI, 15.8-35.9) and being hospitalized in close proximity to an LTAC (0-2 vs >42 miles; aOR, 8.4, 95% CI, 6.1-11.5). After adjusting for case-mix, differences between patients explained 52.1% (95% CI, 47.7%-56.5%) of the variation in LTAC use. The remainder was attributable to hospital (15.0%; 95% CI, 12.3%-17.6%), and regional differences (32.9%; 95% CI, 27.6%-38.3%). Case-mix adjusted LTAC use was very high in the South (17%-37%) compared with the Pacific Northwest, North, and Northeast (<2.2%). From the full multilevel model, the median adjusted hospital LTAC transfer rate was 2.1% (10th-90th percentile, 0.24%-10.8%). Even within a region, adjusted hospital LTAC transfer rates varied substantially (intraclass correlation coefficient [ICC], 0.26; 95% CI, 0.23-0.30). CONCLUSIONS AND RELEVANCE Although many patient-level factors were associated with LTAC use, half of the variation in LTAC vs SNF transfer is independent of patients’ illness severity or clinical complexity, and is explained by where the patient was hospitalized and in what region, with far greater use in the South. Even among hospitals in regions with similar LTAC access, there was considerable variation in LTAC use. Given the higher expense associated with LTACs vs SNFs, greater attention is needed to define the optimal role of LTACs in the postacute care of older adults.

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