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Design and Participants: This retrospective cohort study described survival, functional, and cognitive status post-LTCH and identified factors associated with adverse outcomes among participants aged older than 50 years enrolled in the Health and Retirement Study (HRS) with linked fee-for-service Medicare claims. Participants had an LTCH admission between 2003 and 2016, with interviews available preadmission, and function and cognition were ascertained from interviews conducted every 2 years. The primary outcome was death or severe impairment in the 2.5 years post-LTCH hospitalization, defined as dependencies in more than two activities of daily living or dementia. Multivariable logistic regression evaluated associations with a priori selected risk factors including pre-LTCH survival prognosis (Lee index score), pre-LTCH impairment status, and illness severity characterized by receipt of mechanical ventilation and intensive care unit stay of 3 or more days.
Results: Participants (N=396) were aged median 75 years (IQR=68-82); 51% women; and 15% Black, 12% Hispanic or other, and 74% White. Twenty-eight percent had severe impairment. Participants who died or survived with severe functional/cognitive impairment (79%; time-to-death median=94 [IQR=29-306] days post-LTCH) were older (median=76yrs [IQR=70-83] vs 71 [66-77]), with lower income (median=$19,474 [IQR=10,800-34,928] vs $25,930 [14,400-54,765]), vs those who survived with no or mild impairment. After accounting for acute illness characteristics, prehospitalization survival prognosis and severe baseline impairment were associated with an increased likelihood of death or severe impairment (adjusted odds ratio [AOR]=3.2 [95% CI=1.7-6.0] for a 5-point increase in Lee index score; and AOR=4.5 [1.3-15] for severe vs no impairment).
Commentary: Many older adults want to know how their functional status and independence will be impacted by their disease. This study provides critical prognostic and outcome information to inform serious illness conversations with older adults preceding or during an LTCH stay. Four of five participants died or survived with severe impairment within 2.5 years of an LTCH hospitalization, and prehospitalization health and functional status was more important than prolonged ICU stay or mechanical ventilation in determining prognosis and outcome. Prior studies were not representative of older adults; therefore, this study provides new data on important outcomes. Specialist palliative care consultation should be considered prior to LTHC hospitalization or during LTHC stay due to poor outcomes for this population to ensure that being admitted to a LTHC is goal concordant.
Bottom Line: The majority of Medicare beneficiaries who require LTCH stays will have severe impairment (dependencies in two or more activities of daily living or dementia) or death within 2.5 years of hospitalization; pre-illness health status influences outcomes more than the acute hospital stay.
Reviewer: Adi Shafir, MD, OHSU, Portland, OR
References:
1. Medicare Payment Advisory Commission. Report to the Congress: Medicare Payment Policy: Chapter 10: Long-Term Care Hospital Services. Medicare Payment Advisory Committee. March 2022. https://www.medpac.gov/wp-content/uploads/2022/03/Mar22_MedPAC_ReportToCongress_v3_SEC.pdf.
2. Eskildsen MA. Long-term acute care: a review of the literature. J Am Geriatr Soc. 2007;55(5):775-779. doi:10.1111/j.1532-5415.2007.01162.x.
3. Carson SS. Know your long-term care hospital. Chest. 2007;131(1):2-5. doi:10.1378/chest.06-2513.
Source: Jain S, Gan S, Nguyen OK, et al. Survival, function, and cognition after hospitalization in long-term acute care hospitals. JAMA Netw Open. 2024;7(5):e2413309. doi:10.1001/jamanetworkopen.2024.13309.
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