title: Effectiveness of long-term acute care hospitalization in elderly patients with chronic critical illness.
abstract: 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.
  
  
  METHODS
  Retrospective cohort study in United States hospitals from 2002 to 2006.
  
  
  METHODS
  Medicare beneficiaries with chronic critical illness, defined as mechanical ventilation and at least 14 days of intensive care.
  
  
  METHODS
  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.
authors.affiliation: Department of Critical Care Medicine, Clinical Research, Investigation and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh School of Medicine, PA 15261, USA. kahnjm@upmc.edu
authors.forename: Jeremy M
authors.initials: JM
authors.lastname: Kahn
authors.forename: Rachel M
authors.initials: RM
authors.lastname: Werner
authors.forename: Guy
authors.initials: G
authors.lastname: David
authors.forename: Thomas R
authors.initials: TR
authors.lastname: Ten Have
authors.forename: Nicole M
authors.initials: NM
authors.lastname: Benson
authors.forename: David A
authors.initials: DA
authors.lastname: Asch
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002908:Chronic Disease / Q000191:economics* / Q000401:mortality; D016638:Critical Illness / Q000191:economics* / Q000401:mortality; D005260:Female; D017048:Health Care Costs / Q000706:statistics & numerical data; D006742:Hospital Bed Capacity; D017722:Hospital Charges / Q000706:statistics & numerical data; D006761:Hospitals / Q000706:statistics & numerical data*; D006801:Humans; D008134:Long-Term Care / Q000191:economics*; D008297:Male; D006278:Medicare / Q000706:statistics & numerical data; D010359:Patient Readmission / Q000191:economics; D010360:Patient Transfer; D012121:Respiration, Artificial / Q000191:economics; D012189:Retrospective Studies; D012959:Socioeconomic Factors; D016019:Survival Analysis; D014481:United States / Q000453:epidemiology