Long-term acute care hospital utilization after critical illness

Abstract

Context: Long-term acute care hospitals have emerged as a novel approach for the care of patients recovering from severe acute illness, but the extent and increases in their activity at the national level are unknown.

Objective: To examine temporal trends in long-term acute care hospital utilization after an episode of critical illness among fee-for-service Medicare beneficiaries aged 65 years or older.

Design, setting, and patients: Retrospective cohort study using the Medicare Provider Analysis and Review files from 1997 to 2006. We included all Medicare hospitalizations involving admission to an intensive care unit of an acute care, nonfederal hospital within the continental United States.

Main outcome measures: Overall long-term acute care utilization, associated costs, and survival following transfer.

Results: The number of long-term acute care hospitals in the United States increased at a mean rate of 8.8% per year, from 192 in 1997 to 408 in 2006. During that time, the annual number of long-term acute care admissions after critical illness increased from 13,732 to 40,353, with annual costs increasing from $484 million to $1.325 billion. The age-standardized population incidence of long-term acute care utilization after critical illness increased from 38.1 per 100,000 in 1997 to 99.7 per 100,000 in 2006, with greater use among male individuals and black individuals in all periods. Over time, transferred patients had higher numbers of comorbidities (5.0 in 1997-2000 vs 5.8 in 2004-2006, P < .001) and were more likely to receive mechanical ventilation at the long-term acute care hospital (16.4% in 1997-2000 vs 29.8% in 2004-2006, P < .001). One-year mortality after long-term acute care hospital admission was high throughout the study period: 50.7% in 1997-2000 and 52.2% in 2004-2006.

Conclusions: Long-term acute care hospital utilization after critical illness is common and increasing. Survival among Medicare beneficiaries transferred to long-term acute care after critical illness is poor.

Figure 1

Temporal trends in long-term acute care hospitals (panel A), long-term acute care beds (panel B) and long-term acute care -associated costs after critical illness (panel C).^{a a} P-values for linear trends <0.001 for all panels.

Figure 2

Population-adjusted incidence of long-term acute care hospital transfer after critical illness over time, for entire United States population (panel A), population by gender (panel B) and population by race (panel C). ^{a a} P-values for linear trends <0.001 for all panels.

Figure 3

Kaplan-Meier curves for one-year survival after transfer to a long-term acute care hospital, both for all patients (panel A) and for patients by ventilation status at originating hospital and long-term acute care hospital (panel B).