Effectiveness of Long-term Acute Care Hospitalization in Elderly Patients With Chronic Critical Illness

Background: For patients recovering from severe acute illness, admission to a long-term acute care hospital (LTAC) is an increasingly common alternative to continued management in an intensive care unit (ICU). Objective: To examine the effectiveness of LTAC transfer in patients with chronic critical illness. Research Design: Retrospective cohort study in United States hospitals from 2002 to 2006. Subjects: Medicare beneficiaries with chronic critical illness, defined as mechanical ventilation and at least 14 days of intensive care. Measures: Survival, costs, and hospital readmissions. We used multivariate analyses and instrumental variables to account for differences in patient characteristics, the timing of LTAC transfer, and selection bias. Results: A total of 234,799 patients met our definition of chronic critical illness. Of these, 48,416 (20.6%) were transferred to an LTAC. In the instrumental variable analysis, patients transferred to an LTAC experienced similar survival compared with patients who remained in an ICU [adjusted hazard ratio = 0.99; 95% confidence interval (CI), 0.96 to 1.01; P = 0.27). Total hospital-related costs in the 180 days after admission were lower among patients transferred to LTACs (adjusted cost difference = -$13,422; 95% CI, -26,662 to -223, P = 0.046). This difference was attributable to a reduction in skilled nursing facility admissions (adjusted admission rate difference = -0.591; 95% CI, -0.728 to -0.454; P < 0.001). Total Medicare payments were higher (adjusted cost difference = $15,592; 95% CI, 6343 to 24,842; P = 0.001). Conclusions: Patients with chronic critical illness transferred to LTACs experience similar survival compared with patients who remain in ICUs, incur fewer health care costs driven by a reduction in postacute care utilization, however, invoke higher overall Medicare payments.