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1.  Effectiveness of long-term acute care hospitalization in elderly patients with chronic critical illness 
Medical care  2013;51(1):4-10.
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.
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 to patients who remained in an intensive care unit (adjusted hazard ratio = 0.99, 95% CI: 0.96 to 1.01, p=0.27). Total hospital-related costs in the 180 days following 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: 6,343 to 24,842, p=0.001).
Conclusions
Patients with chronic critical illness transferred to LTACs experience similar survival compared with patients who remain in intensive care units, incur fewer health care costs driven by a reduction in post-acute care utilization, but invoke higher overall Medicare payments.
doi:10.1097/MLR.0b013e31826528a7
PMCID: PMC3500575  PMID: 22874500
mechanical ventilation; costs; Medicare; patient readmission; intensive care
2.  The Effect of Insurance Status on Mortality and Procedural Use in Critically Ill Patients 
Rationale: Lack of health insurance may be an independent risk factor for mortality and differential treatment in critical illness.
Objectives: To determine whether uninsured critically ill patients had differences in 30-day mortality and critical care service use compared with those with private insurance and to determine if outcome variability could be attributed to patient-level or hospital-level effects.
Methods: Retrospective cohort study using Pennsylvania hospital discharge data with detailed clinical risk adjustment, from fiscal years 2005 and 2006, consisting of 167 general acute care hospitals, with 138,720 critically ill adult patients 64 years of age or younger.
Measurements and Main Results: Measurements were 30-day mortality and receipt of five critical care procedures. Uninsured patients had an absolute 30-day mortality of 5.7%, compared with 4.6% for those with private insurance and 6.4% for those with Medicaid. Increased 30-day mortality among uninsured patients persisted after adjustment for patient characteristics (odds ratio [OR], 1.25 for uninsured vs. insured; 95% confidence interval [CI], 1.04–1.50) and hospital-level effects (OR, 1.26; 95% CI, 1.05–1.51). Compared with insured patients, uninsured patients had decreased risk-adjusted odds of receiving a central venous catheter (OR, 0.84; 95% CI, 0.72–0.97), acute hemodialysis (OR, 0.59; 95% CI, 0.39–0.91), and tracheostomy (OR, 0.43; 95% CI, 0.29–0.64).
Conclusions: Lack of health insurance is associated with increased 30-day mortality and decreased use of common procedures for the critically ill in Pennsylvania. Differences were not attributable to hospital-level effects, suggesting that the uninsured have a higher mortality and receive fewer procedures when compared with privately insured patients treated at the same hospitals.
doi:10.1164/rccm.201101-0089OC
PMCID: PMC3208649  PMID: 21700910
insurance; intensive care unit; critical care; mortality
3.  Long-term acute care hospital utilization after critical illness 
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 growth of their activity at the national level is 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 ≥ 65 years of age.
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, non-federal 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 38.1/100,000 in 1997 to 99.7/100,000 in 2006, with greater use among male individuals and black individuals in all time periods. Over time, transferred patients had higher numbers of comorbidities (5.0 in 1997–2000 versus 5.8 in 2004–2006, p<0.001), and were more likely to receive mechanical ventilation at the long-term acute care hospital (16.4% in 1997–2000 versus 29.8% in 2004–2006, p<0.001). 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.
doi:10.1001/jama.2010.761
PMCID: PMC3094575  PMID: 20530778

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