0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Research Letter |

Rise of Post–Acute Care Facilities as a Discharge Destination of US Hospitalizations FREE

Robert E. Burke, MD1,2; Elizabeth Juarez-Colunga, PhD3; Cari Levy, MD, PhD4; Allan V. Prochazka, MD, MSc1,2; Eric A. Coleman, MD, MPH4; Adit A. Ginde, MD, MPH5
[+] Author Affiliations
1Department of Veterans Affairs Medical Center, Eastern Colorado Health Care System, Denver
2Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora
3Department of Biostatistics and Informatics, University of Colorado School of Public Health, Aurora
4Division of Health Care Policy and Research, University of Colorado School of Medicine, Aurora
5Department of Emergency Medicine, University of Colorado School of Medicine, Aurora
JAMA Intern Med. 2015;175(2):295-296. doi:10.1001/jamainternmed.2014.6383.
Text Size: A A A
Published online

Medicare’s payment reforms in the 1990s significantly affected hospital length of stay and post–acute care (PAC) (eg, skilled nursing or rehabilitation) facility use.1,2 However, few studies describe contemporary length of stay and postdischarge care trends in a nationally representative sample of Medicare and non-Medicare patients. We sought to understand these trends using the National Hospital Discharge Survey (NHDS) from 1996 to 2010.

The NHDS is a nationally representative annual probability sample of discharges from hospitals in all 50 states.3 We included all hospital discharges of patients 18 years or older, excluding patients transferred to other hospitals, discharges against medical advice, discharges without a destination coded, or hospital lengths of stay more than 31 days (together, <7% of all discharges). We used NHDS definitions for discharge to home or a care facility.

We evaluated trends in discharges to PAC facilities as well as length of stay over the 15-year period, then calculated relative percentage changes for each year, using 1996 rates as a baseline. To account for the aging of the population, all trends were age-adjusted by the US Census population in 2003 (www.census.gov). The derived age-specific estimates for each individual year were weighted to reflect the age distribution in 2003, the midpoint of our analysis. Analyses were conducted using SAS statistical software (version 9.3; SAS Institute Inc) and graphics created in R (R Foundation for Statistical Computing). The study received approval by the Colorado Multiple Institutional Review Board (COMIRB).

The study population included 2.99 million sampled patient discharges, representing approximately 386 million discharges nationally during the 15-year study period. The proportion of hospitalizations resulting in discharges to PAC facilities increased from 9.2% in 1996 to 13.7% in 2010 (a 49.0% relative increase), while the proportion of discharges home decreased from 90.8% to 86.3% (a 5.0% relative decrease) (Figure 1). This corresponds to an absolute increase of 1.67 million discharges to PAC facilities in 2010, or 1.2 million more discharges to PAC facilities in 2010 than if the rate from 1996 had remained the same through 2010, adjusted for changes in the census. The mean length of stay decreased over this time period for patients being discharged to PAC facilities from 8.8 to 7.8 days; the trend for patients discharged home was 4.6 to 4.1 days (Figure 2).

Place holder to copy figure label and caption
Figure 1.
Trends in Discharges to Post–Acute Care (PAC) Facilities and Home

Trends in the percentage of patients discharged home or to PAC facilities are shown. Each year is compared with 1996 values to calculate a relative percentage change.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.
Trends in Length of Stay in Patients Discharged to Post–Acute Care (PAC) Facilities and Home

Concurrent trends in mean length of stay are presented; lengths of stay greater than 31 days were excluded from the analysis. Trends are calculated as a relative percentage change compared with 1996 levels. Length of stay is reported as mean number of days.

Graphic Jump Location

Discharges to PAC facilities rose nearly 50% over the 15 years, resulting in 1.2 million more discharges to PAC facilities in 2010 compared with 1996 rates. Concurrently, hospital lengths of stay progressively decreased, particularly for discharges to PAC facilities.

There are several potential explanations for these findings. Medicare’s prospective payment system may have influenced other payers leading to “quicker and sicker” discharges,4 and penalties for 30-day readmissions (currently assessed for readmissions from the community but not from PAC facilities) may have had the unintended consequence of increased discharges to PAC facilities. The rise in hospitalist care and changes in the epidemiology of diseases admitted to the hospital may also be significant contributors.

These findings have important implications for health care providers and policymakers. Health care providers have limited data regarding the most appropriate postdischarge care setting, and the “right” amount of PAC facility use is not defined.5 Clearly, high-quality transitional care from the hospital to a PAC facility is increasingly important.6

Policymakers must consider whether the increase in discharges to PAC facilities represents a positive phenomenon or unintended consequences of payment reform. The link between increased spending on PAC facilities and outcomes is not clear. The NHDS does not collect data on patient comorbidities, functional status, social support, or outcomes of postdischarge care. Further research is needed to identify which patients benefit from PAC facilities, which processes maximize this benefit, and which structures of care optimize important patient-centered outcomes.

Corresponding Author: Robert E. Burke, MD, Denver VA Medical Center, 1055 Clermont St, Denver, CO 80220 (robert.burke5@va.gov).

Published Online: December 1, 2014. doi:10.1001/jamainternmed.2014.6383.

Author Contributions: Dr Burke had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Burke, Coleman, Ginde.

Acquisition, analysis, or interpretation of data: Burke, Juarez-Colunga, Levy, Prochazka, Ginde.

Drafting of the manuscript: Burke.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Burke, Juarez-Colunga, Ginde.

Administrative, technical, or material support: Coleman.

Study supervision: Levy, Prochazka, Coleman, Ginde.

Conflict of Interest Disclosures: None reported.

Funding/Support: Drs Burke, Juarez-Colunga, Prochazka, and Ginde were supported by the Colorado Clinical Translational Science Institute (National Institutes of Health [NIH] UL1 TR001082), and Drs Burke and Prochazka by the Veterans Affairs Health Services Research and Development Service Center for Innovation: Value-Centered and Value-Driven Care. Dr Ginde was supported by NIH grant K23AG040708.

Role of the Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The views contained within are those of the authors and not necessarily representative of the US Department of Veterans Affairs.

Ackerly  DC, Grabowski  DC.  Post-acute care reform: beyond the ACA. N Engl J Med. 2014;370(8):689-691.
PubMed   |  Link to Article
Buntin  MB, Colla  CH, Escarce  JJ.  Effects of payment changes on trends in post-acute care. Health Serv Res. 2009;44(4):1188-1210.
PubMed   |  Link to Article
Dennison  C, Pokras  R.  Design and operation of the National Hospital Discharge Survey: 1988 redesign. Vital Health Stat 1. 2000;(39):1-42.
PubMed
Kosecoff  J, Kahn  KL, Rogers  WH,  et al.  Prospective payment system and impairment at discharge: the “quicker-and-sicker” story revisited. JAMA. 1990;264(15):1980-1983.
PubMed   |  Link to Article
Kane  RL.  Finding the right level of posthospital care: “We didn’t realize there was any other option for him.” JAMA. 2011;305(3):284-293.
PubMed   |  Link to Article
Mor  V, Intrator  O, Feng  Z, Grabowski  DC.  The revolving door of rehospitalization from skilled nursing facilities. Health Aff (Millwood). 2010;29(1):57-64.
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Figure 1.
Trends in Discharges to Post–Acute Care (PAC) Facilities and Home

Trends in the percentage of patients discharged home or to PAC facilities are shown. Each year is compared with 1996 values to calculate a relative percentage change.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.
Trends in Length of Stay in Patients Discharged to Post–Acute Care (PAC) Facilities and Home

Concurrent trends in mean length of stay are presented; lengths of stay greater than 31 days were excluded from the analysis. Trends are calculated as a relative percentage change compared with 1996 levels. Length of stay is reported as mean number of days.

Graphic Jump Location

Tables

References

Ackerly  DC, Grabowski  DC.  Post-acute care reform: beyond the ACA. N Engl J Med. 2014;370(8):689-691.
PubMed   |  Link to Article
Buntin  MB, Colla  CH, Escarce  JJ.  Effects of payment changes on trends in post-acute care. Health Serv Res. 2009;44(4):1188-1210.
PubMed   |  Link to Article
Dennison  C, Pokras  R.  Design and operation of the National Hospital Discharge Survey: 1988 redesign. Vital Health Stat 1. 2000;(39):1-42.
PubMed
Kosecoff  J, Kahn  KL, Rogers  WH,  et al.  Prospective payment system and impairment at discharge: the “quicker-and-sicker” story revisited. JAMA. 1990;264(15):1980-1983.
PubMed   |  Link to Article
Kane  RL.  Finding the right level of posthospital care: “We didn’t realize there was any other option for him.” JAMA. 2011;305(3):284-293.
PubMed   |  Link to Article
Mor  V, Intrator  O, Feng  Z, Grabowski  DC.  The revolving door of rehospitalization from skilled nursing facilities. Health Aff (Millwood). 2010;29(1):57-64.
PubMed   |  Link to Article

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.

Multimedia

Some tools below are only available to our subscribers or users with an online account.

1,837 Views
10 Citations
×

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Collections
PubMed Articles
Jobs