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Background: Long-term acute care hospital (LTACH) use varies considerably across the U.S., which may reflect uncertainty about the effectiveness of LTACHs vs. skilled nursing facilities (SNF), the principal post-acute care alternative. Given that LTACHs provide more intensive care and thus receive over triple the reimbursement of SNFs for comparable diagnoses, we sought to compare outcomes and spending between LTACH versus SNF transfer., Methods: Using Medicare claims linked to electronic health record (EHR) data from six Texas Hospitals between 2009 and 2010, we conducted a retrospective cohort study of patients hospitalized on a medicine service in a high-LTACH use region and discharged to either an LTACH or SNF and followed for one year. The primary outcomes included mortality, 60-day recovery without inpatient care, days at home, and healthcare spending RESULTS: Of 3503 patients, 18% were transferred to an LTACH. Patients transferred to LTACHs were younger (median 71 vs. 82 years), less likely to be female (50.5 vs 66.6%) and white (69.0 vs. 84.1%), but were sicker (24.3 vs. 14.2% for prolonged intensive care unit stay; median diagnosis resource intensity weight of 2.03 vs. 1.38). In unadjusted analyses, patients transferred to an LTACH vs. SNF were less likely to survive (59.1 vs. 65.0%) or recover (62.5 vs 66.0%), and spent fewer days at home (186 vs. 200). Adjusting for demographic and clinical confounders available in Medicare claims and EHR data, LTACH transfer was not significantly associated with differences in mortality (HR, 1.12, 95% CI, 0.94-1.33), recovery (SHR, 1.07, 0.93-1.23), and days spent at home (IRR, 0.96, 0.83-1.10), but was associated with greater Medicare spending ($16,689 for one year, 95% CI, $12,216-$21,162)., Conclusion: LTACH transfer for Medicare beneficiaries is associated with similar clinical outcomes but with higher healthcare spending compared to SNF transfer. LTACH use should be reserved for patients who require complex inpatient care and cannot be cared for in SNFs.

Objectives: Long-term acute care (LTAC) hospitals provide extended complex post-acute care to more than 120 000 Medicare beneficiaries annually, with the goal of helping patients to regain independence and recover. Because little is known about patients' long-term outcomes, we sought to examine the clinical course after LTAC admission., Design: Nationally representative 5-year cohort study using 5% Medicare data from 2009 to 2013., Setting: LTAC hospitals., Participants: Hospitalized Medicare fee-for-service beneficiaries 65 years of age or older who were transferred to an LTAC hospital., Measurements: Mortality, recovery (defined as achieving 60 consecutive days alive without inpatient care), time spent in an inpatient facility following LTAC hospital admission, receipt of an artificial life-prolonging procedure (feeding tube, tracheostomy, hemodialysis), and palliative care physician consultation., Results: Of 14 072 hospitalized older adults transferred to an LTAC hospital, median survival was 8.3 months, and 1- and 5-year survival rates were 45% and 18%, respectively. Following LTAC admission, 53% never achieved a 60-day recovery. The median time of their remaining life a patient spent as an inpatient after LTAC admission was 65.6% (interquartile range = 21.4%-100%). More than one-third (36.9%) died in an inpatient setting, never returning home after the LTAC admission. During the preceding hospitalization and index LTAC admission, 30.9% received an artificial life-prolonging procedure, and 1% had a palliative care physician consultation., Conclusion: Hospitalized older adults transferred to LTAC hospitals have poor survival, spend most of their remaining life as an inpatient, and frequently undergo life-prolonging procedures. This prognostic understanding is essential to inform goals of care discussions and prioritize healthcare needs for hospitalized older adults admitted to LTAC hospitals. Given the exceedingly low rates of palliative care consultations, future research is needed to examine unmet palliative care needs in this population. J Am Geriatr Soc 67:2282-2288, 2019., (© 2019 The American Geriatrics Society.)

Objectives: To determine why non-mechanically ventilated hospitalized older adults are transferred to long-term acute care (LTAC) hospitals rather than remaining in the hospital., Design: Observational cohort., Setting: National Medicare data., Participants: Non-mechanically ventilated hospitalized adults aged 65 and older with fee-for-service Medicare in 2012 who were transferred to an LTAC hospital (n=1,831) or had a prolonged hospitalization without transfer (average hospital length of stay or longer of those transferred to an LTAC hospital) and had one of the 50 most common hospital diagnoses leading to LTAC transfer (N=12,875)., Measurements: We assessed predictors of transfer using a multilevel model, adjusting for patient-, hospital-, and hospital referral region (HRR)-level factors. We estimated proportions of variance at each level and adjusted hospital- and HRR-specific LTAC transfer rates using sequential models., Results: The strongest predictor of transfer was being hospitalized near an LTAC hospital (<1.4 vs > 33.6 miles, adjusted odds ratio=6.2, 95% confidence interval (CI)=4.2-9.1). After adjusting for case mix, differences between hospitals explained 15.4% of the variation in LTAC use and differences between regions explained 27.8%. Case mix-adjusted LTAC use was high in the South, where many HRRs had rates between 20.3% and 53.1%, whereas many HRRs were less than 5.4% in the Pacific Northwest, North, and New England. From our fully adjusted model, the median adjusted hospital LTAC transfer rate was 7.2% (interquartile range 2.8-17.5%), with substantial within-region variation (intraclass coefficient=0.25, 95% CI=0.21-0.30)., Conclusions: Nearly half of the variation in LTAC use is independent of illness severity and is explained by which hospital and what region the individual was hospitalized in. Because of the greater fragmentation of care and Medicare spending with LTAC transfers (because LTAC hospitals generate a separate bundled payment from the hospital), greater attention is needed to define the optimal role of LTAC hospitals in caring for older adults. J Am Geriatr Soc 66:2112-2119, 2018., (© 2018, Copyright the Authors Journal compilation © 2018, The American Geriatrics Society.)

Objective: To describe the prevalence, characteristics, and predictors of safety-net use for primary care among non-Medicaid insured adults (i.e., those with private insurance or Medicare)., Methods: Cross-sectional analysis using the 2006-2010 National Ambulatory Medical Care Surveys, annual probability samples of outpatient visits in the U.S. We estimated national prevalence of safety-net visits using weighted percentages to account for the complex survey design. We conducted bivariate and multivariate logistic regression analyses to examine characteristics associated with safety-net clinic use., Results: More than one-third (35.0%) of all primary care safety-net clinic visits were among adults with non-Medicaid primary insurance, representing 6,642,000 annual visits nationally. The strongest predictors of safety-net use among non-Medicaid insured adults were: being from a high-poverty neighborhood (AOR 9.53, 95% CI 4.65-19.53), being dually eligible for Medicare and Medicaid (AOR 2.13, 95% CI 1.38-3.30), and being black (AOR 1.97, 95% CI 1.06-3.66) or Hispanic (AOR 2.28, 95% CI 1.32-3.93). Compared to non-safety-net users, non-Medicaid insured adults who used safety-net clinics had a higher prevalence of diabetes (23.5% vs. 15.0%, p<0.001), hypertension (49.4% vs. 36.0%, p<0.001), multimorbidity (≥2 chronic conditions; 53.5% vs. 40.9%, p<0.001) and polypharmacy (≥4 medications; 48.8% vs. 34.0%, p<0.001). Nearly one-third (28.9%) of Medicare beneficiaries in the safety-net were dual eligibles, compared to only 6.8% of Medicare beneficiaries in non-safety-net clinics (p<0.001)., Conclusions: Safety net clinics are important primary care delivery sites for non-Medicaid insured minority and low-income populations with a high burden of chronic illness. The critical role of safety-net clinics in care delivery is likely to persist despite expanded insurance coverage under the Affordable Care Act.