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Factors Associated With Variation in Long-term Acute Care Hospital vs Skilled Nursing Facility Use Among Hospitalized Older Adults
JAMA Internal Medicine ( IF 22.5 ) Pub Date : 2018-03-01 , DOI: 10.1001/jamainternmed.2017.8467
Anil N. Makam 1, 2 , Oanh Kieu Nguyen 1, 2 , Lei Xuan 2 , Michael E. Miller 2 , James S. Goodwin 3 , Ethan A. Halm 1, 2
Affiliation  

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.

中文翻译:

与住院老年人中长期急性护理医院与熟练护理设施使用差异相关的因素

重要性 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移到长期急症护理医院 (LTAC) 而不是成本较低的熟练护理机构 (SNF) 进行急诊后护理。目的检查与住院老年人中 LTAC 与 SNF 转移变异相关的因素。设计、设置和参与者 我们使用全国 5% 的医疗保险数据对 2012 财年期间转入 LTAC 与 SNF 的住院老年人(≥65 岁)进行了这项回顾性观察队列研究。主要结果和措施 LTAC 转移的预测因素使用多级混合效应模型进行评估,该模型针对患者、医院和区域级因素进行调整。我们使用序列模型估计了变异分配系数并调整了医院和地区特定的 LTAC 转移率。结果 在转入 LTAC 或 SNF 的 65 525 名住院老年人(42 461 [64.8%] 名女性;39 908 [60.9%] 名≥85 岁)中,3093 名(4.7%)转入 LTAC。我们确定了 29 个患者、3 个医院和 5 个区域级别的独立预测因子。LTAC 转移的最强预测因素是接受气管切开术(调整后的比值比 [aOR],23.8;95% CI,15.8-35.9)和在 LTAC 附近住院(0-2 与 >42 英里;aOR,8.4, 95% 置信区间,6.1-11.5)。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%)和地区差异(32.9%;95% CI,27。6%-38.3%)。与太平洋西北部、北部和东北部 (<2.2%) 相比,南部 (17%-37%) 的案例组合调整后 LTAC 使用率非常高。从完整的多水平模型来看,调整后的医院 LTAC 转移率中位数为 2.1%(第 10-90 个百分位数,0.24%-10.8%)。即使在一个区域内,调整后的医院 LTAC 转移率也有很大差异(组内相关系数 [ICC],0.26;95% CI,0.23-0.30)。结论和相关性 尽管许多患者层面的因素与 LTAC 的使用有关,但 LTAC 与 SNF 转移的一半变化与患者的疾病严重程度或临床复杂性无关,并且可以通过患者的住院地点和地区来解释在南方使用得更多。即使在具有类似 LTAC 接入的地区的医院中,LTAC 的使用也存在相当大的差异。
更新日期:2018-03-01
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