Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas.
Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas.
JAMA Intern Med. 2018 Mar 1;178(3):399-405. doi: 10.1001/jamainternmed.2017.8467.
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.
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.
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.
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).
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.
尽管提供了重叠的护理水平，但尚不清楚为什么住院的老年人会被转往长期急性护理医院（LTAC）而不是成本较低的熟练护理设施（SNF）进行康复护理。
研究与住院老年人转往 LTAC 与 SNF 之间差异相关的因素。
设计、地点和参与者：我们使用国家 5%的医疗保险数据，对 2012 财年转往 LTAC 与 SNF 的住院老年人（≥65 岁）进行了回顾性观察队列研究。
使用多水平混合效应模型评估 LTAC 转院的预测因素，并调整患者、医院和地区水平的因素。我们使用序贯模型估计变异划分系数和调整医院和地区特定的 LTAC 转院率。
在 65525 名转往 LTAC 或 SNF 的住院老年人中（42461 名[64.8%]女性；39908 名[60.9%]≥85 岁），3093 名（4.7%）被转往 LTAC。我们确定了 29 个患者、3 个医院和 5 个地区水平的独立预测因素。LTAC 转院的最强预测因素是接受气管切开术（调整后的优势比[OR]，23.8；95%置信区间[CI]，15.8-35.9）和靠近 LTAC 住院（0-2 英里与>42 英里；OR，8.4，95%CI，6.1-11.5）。在调整病例组合后，患者之间的差异解释了 LTAC 使用差异的 52.1%（95%CI，47.7%-56.5%）。其余部分归因于医院（15.0%；95%CI，12.3%-17.6%）和区域差异（32.9%；95%CI，27.6%-38.3%）。病例组合调整后的 LTAC 使用在南部（17%-37%）非常高，而在太平洋西北、北部和东北部（<2.2%）则非常低。从完整的多水平模型来看，调整后的医院 LTAC 转院率中位数为 2.1%（第 10 百分位数至第 90 百分位数，0.24%-10.8%）。即使在一个地区内，调整后的医院 LTAC 转院率也存在很大差异（组内相关系数[ICC]，0.26；95%CI，0.23-0.30）。
尽管许多患者水平因素与 LTAC 使用相关，但 LTAC 与 SNF 转院差异的一半独立于患者的疾病严重程度或临床复杂性，并且由患者住院的地点和所在地区决定，南部地区的使用量要大得多。即使在具有类似 LTAC 通道的地区内的医院中，LTAC 的使用也存在很大差异。鉴于 LTAC 比 SNF 的费用更高，需要更加关注 LTAC 在老年人康复护理中的最佳作用。
