title: The implications of long-term acute care hospital transfer practices for measures of in-hospital mortality and length of stay.
abstract: BACKGROUND
  The National Quality Forum recently endorsed in-hospital mortality and intensive care unit length of stay (LOS) as quality indicators for patients in the intensive care unit. These measures may be affected by transferring patients to long-term acute care hospitals (LTACs).
  
  
  OBJECTIVE
  To quantify the implications of LTAC transfer practices on variation in mortality index and LOS index for patients in academic medical centers.
  
  
  METHODS
  We used a cross-sectional study design using data reported to the University HealthSystem Consortium from 2008-2009. Data were from patients who were mechanically ventilated for more than 96 hours.
  
  
  RESULTS
  Using linear regression, we measured the association between mortality index and LTAC transfer rate, with the hospital as the unit of analysis. Similar analyses were conducted for LOS index and cost index. A total of 137 hospitals were analyzed, averaging 534 transfers to LTAC per hospital during the study period. Mean±SD in-hospital mortality was 24±6.4%, and observed LOS was 30.4±8.2 days. The mean LTAC transfer rate was 15.7±13.7%. Linear regression demonstrated a significant correlation between transfer rate and mortality index (R2=0.14; P<0.0001) and LOS index (R2=0.43; P<0.0001).
  
  
  CONCLUSIONS
  LTAC hospital transfer rate has a significant impact on reported mortality and LOS indices for patients requiring prolonged acute mechanical ventilation. This is an example of factors unrelated to quality of medical care or illness severity that must be considered when interpreting mortality and LOS as quality indicators.
authors.affiliation: Pulmonary and Critical Care Medicine, University of North Carolina at Chapel Hill, 4134 Bioinformatics Building, CB#7020, Chapel Hill, NC 27599, USA.
authors.forename: William B
authors.initials: WB
authors.lastname: Hall
authors.forename: Laura E
authors.initials: LE
authors.lastname: Willis
authors.forename: Sofia
authors.initials: S
authors.lastname: Medvedev
authors.forename: Shannon S
authors.initials: SS
authors.lastname: Carson
mesh_terms: D003430:Cross-Sectional Studies; D005260:Female; D017052:Hospital Mortality; D006763:Hospitals, Chronic Disease / Q000706:statistics & numerical data*; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data*; D008134:Long-Term Care; D008297:Male; D008875:Middle Aged; D010360:Patient Transfer / Q000706:statistics & numerical data*; D012121:Respiration, Artificial