The Role of Long-term Acute Care Hospitals in Treating the Critically Ill and Medically Complex: An Analysis of Nonventilator Patients

BACKGROUND: Little evidence exists on the effects of receiving care in a long-term acute care hospital (LTCH). OBJECTIVE: To examine LTCH effects on mortality and Medicare payments overall and among high-acuity patients. RESEARCH DESIGN: A retrospective cohort study of Medicare beneficiaries using probit and generalized linear models. An instrumental variable technique was used to adjust for selection bias. SUBJECTS: Medicare beneficiaries within 5 major diagnostic categories and not on prolonged mechanical ventilation. MEASURES: Mortality (365 d) and Medicare payments (180 d) during an episode of care. RESULTS: LTCH care is associated with increases in Medicare payments ranging from $3146 to $17,589 (P<0.01) with no mortality benefit for 3 categories and payment reductions of $5419 and $5962 (P<0.01) at lower or similar mortality for 2 categories. LTCH patients with multiple organ failure experience lower mortality at similar or lower payments (3 categories) or similar mortality at lower payments (1 category) compared with patients in other settings, with mortality benefits between 5.4 and 9.7 percentage points (P<0.05) and payment reductions between $13,806 and $20,809 (P<0.01). For 1 category, we found no difference in mortality or payments between LTCH and non-LTCH patients with multiple organ failure. For patients with ≥3 days in intensive care, LTCH care is associated with improved mortality and lower payments in 4 and 3 categories, respectively. CONCLUSIONS: Receiving care in an LTCH may improve outcomes for some patients. Further research is needed to better define patients for whom care in these hospitals is beneficial.