1 does the supply of long-term acute care hospitals matter? geographic location and outcomes of care...
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Does the Supply of Long-term Acute Care Hospitals Matter? Geographic Location and Outcomes of Care
for Medicare Ventilator Cases
Presented byKathleen Dalton, PhD
Co-investigatorsSara Freeman, MS, and Barbara Gage, PhD
RTI International
Presented atAcademy Health, June 2008
Funding Source: Centers for Medicare and Medicaid Services
3040 Cornwallis Road ■ P.O. Box 12194 ■ Research Triangle Park, NC 27709Phone 919-541-5919 E-mail [email protected] 919-541-7384
Background
Definition: Acute facility w/ ALOS> 25 days
High-acuity, medically complex patients Ventilator support; other respiratory diseases;
wound care; sepsis Account for <2% Medicare discharges nationally
Post-discharge LTCH referral generates a new DRG payment
LTCHs have the highest costs and highest DRG rates of any Medicare PPS
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Background
Number of LTCH facilities is growing 281 in 2001 increased to 392 by 2006 (+40%) New facilities tend to be for-profit and specialize in
respiratory care
Great geographic variation in supply of LTCH facilities and beds Highest in South and Southwest Many geographic areas have none
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Background
Most common LTCH referrals from short-stay acute hospitals are ventilator support DRGs Vent cases can also be discharged to SNF and inpatient
rehab (IRF) Majority of non-LTCH vent cases finish their care in the
original acute setting Local vent LTCH referral rates are as high as 40% in parts
of Texas
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Study Question:
What happens in areas that have no LTCHs?
If we look at clinically similar vent patients, are there area-level differences in episode outcomes? Medicare inpatient days or costs? Mortality? Time to home discharge? Readmissions following a home discharge?
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Design: Sample
From licensure files: identify matched metropolitan study areas with and without LTCHs
From FY 2004 Medicare claims, identify all index cases with IPPS ventilator support DRGs(“Index” = no previous admission within 60 days)
From FY 2004 and 2005 hospital and SNF claims, follow beneficiary until episode is closed by: Discharge home followed by 60+ days without further admission Discharge into long-term care (non-Medicare, without further
readmission) Death
Exclude cases with death <=7 days from index admission
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Design: Analysis
1. From intervention area cases only, construct probability model for LTCH referral using patient-level predictors
2. Use coefficients to compute predicted pr(LTCH) for all vent episodes
3. Group all episodes into low, medium and high probability
4. By probability group, examine area-level differences in post-acute referral, utilization, cost and clinical outcomes.
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LTCH Locations at Time of Study Sample (2004)
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Matched Study Areas (1):
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New YorkMichigan
Matched Study Areas (2):
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North Carolina Virginia
Matched Study Areas (3):
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OregonWashington
Matched Study Areas (4):
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Southern California Northern California
Descriptive Statistics
Control areas LTCH areasN=1,571 N=5,147
Index admission disposition (verified):
Remain in index hospital 0.54 0.49
Transfer to other acute 0.15 0.15LTCH referral 0.01 0.16
IRF referral 0.08 0.04
SNF referral 0.22 0.17
Outcome measures:
Episode days 48.9 52.3
Part A days 41.7 44.3
Part A payments 61,291$ 73,151$
Mortality (episode + 30 days) 0.40 0.43
Home discharge within 30 days 0.27 0.24
Acute readmission within 30 days of home discharge (1 or more) 0.06 0.10
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LTCH Referral =f (demographics, pr_dx, co-morbidities, trach, other proc codes)
0 .1 .3 1probability
estimation sample(LTCH areas) Out-of-sample (control areas)
random effects logit (by hospital)
estimation sample compared to out-of-sample predictions on control groupDistribution of LTCH referral probabilities:
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Group Sizes by Predicted Referral Probabilities
Low: p <=.10
Medium (.10 <p <=.30)
High (p> .30)
LTCH Areas 3,401 557 1,189 5,147
Control Areas 1,038 204 329 1,571
Full sample 4,439 761 1,518 6,71866% 11% 23% 100%
Referral Probability Group
All
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Substitution Effects: What Levels of Care are LTCHs Replacing?
PAC Referral: LOW group
0%
20%
40%
60%
80%
100%
control areas LTCH areas
LTCH
SNF
IRF
RemainAcute
``
PAC Referral: MEDIUM group
0%
20%
40%
60%
80%
100%
control areas LTCH areas
LTCH
SNF
IRF
RemainAcute
PAC referral: HIGH group
0%
20%
40%
60%
80%
100%
control areas LTCH areas
LTCH
SNF
IRF
RemainAcute
LTCHs substitute for some SNF and rehab referrals in all groups
In "high likelihood" group only substitute for extended acute-care stays
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Adjusted Episode Outcomes:
Y = f(LTCHarea, patient level variables, index hospital characteristics, location, other PAC) Stratified by low / medium / high Prob(LTCH) Coefficient on LTCH area indicator identifies average area-
level difference in outcomes Referent is case remaining in acute setting
Outcome measures: Episode length; Medicare days; Part A payments (all log-
linear) Mortality; home discharge; acute readmission (all as logit)
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Findings Summary
LTCH supply may be associated with Lower utilization per episode Similar Medicare Part A costs per episode
No significant differences between LTCH areas and non-LTCH areas in clinical outcomes Similar mortality and readmissions Marginal evidence suggesting more rapid discharge to
home
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Area-level Differences in Utilization:
EPISODE DAYS:Estimated differential, LTCH areas versus control areas
-30%
-25%
-20%
-15%-10%
-5%
0%
5%
10%
low (<0.1) med (0.1 to 0.3) high (>=0.3)
Probability of LTCH referral
diff
eren
ce w
/ 95%
CI
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Area-level Differences in Payments:
TOTAL PART A MEDICARE PAYMENTS:Estimated differential, LTCH areas versus control areas
-20%
-10%
0%
10%
20%
low (<0.1) med (0.1 to 0.3) high (>=0.3)
Probability of LTCH referral
diff
eren
ce w
/ 95%
CI
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Area-level Differences in Mortality:
30-DAY MORTALITYAdjusted Odds Ratios, LTCH areas versus control areas
0.00
0.50
1.00
1.50
2.00
2.50
low (<0.1) med (0.1 to 0.3) high (>=0.3)
Probability of LTCH referral
OD
DS
RA
TIO
w/ 9
5% C
I
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Area-level Differences in Home Discharge:
DISCHARGE HOME WITHIN 30 DAYSAdjusted Odds Ratios, LTCH areas versus control areas
0.00
1.00
2.00
3.00
4.00
5.00
6.00
low (<0.1) med (0.1 to 0.3) high (>=0.3)
Probability of LTCH referral
OD
DS
RA
TIO
w/ 9
5% C
I
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Area-level Differences in Readmissions:
30-DAY READMISSION (at least 1)Adjusted Odds Ratios, LTCH areas versus control areas
0.00
0.50
1.00
1.50
2.00
2.50
3.00
low (<0.1) med (0.1 to 0.3) high (>=0.3)
Probability of LTCH referral
OD
DS
RA
TIO
w/ 9
5% C
I
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Discussion
Unadjusted area-level differences are misleading
Lower utilization and no differences in episode costs for high-probability groups are both unexpected findings Possible policy implications would be to try to limit
LTCH referral for less complicated cases
Finding of no differences in mortality is at odds with previous work (Rand, MedPAC, RTI), associating LTCH referral with lower mortality
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Limitations / Other Design Issues
Referral model lacks important clinical information not found on claims Needs consistent patient assessment tool across
inpatient settings
Average area-level differences is a blunt measure of impact
Time-to-event model might be better for assessing differences in clinical outcomes
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