LTAC transfers are creating biased, gamed hospital-stay stats (AJRCCM)

Are you a hospital administrator, obsessed with improving “quality” and “performance” of your institution according to flawed, arbitrary criteria that lack a proven relationship to real-world outcomes, but are imposed by large governing and regulatory authorities who hold a sword of Damocles over your head threatening a crippling reduction of payments to your hospital at some unspecified point in the future if you fail to achieve these measures?

First, I’m sorry.

But here’s a bright spot: check out an article by William Hall, Laura Willis, Sofia Medvedev and Shannon Carson in the January Blue Journal. It shows that you can artificially reduce your hospital and ICU length of stay and mortality metrics by becoming more aggressive at transferring patients to long-term acute care hospitals (LTACs).

This is a “win-win” for you. Your LTAC-worthy patients are the sickest in the hospital: those on vents at the time of LTAC transfer require another 25 days to wean on average, and have a ~70% mortality within one year. Are you kidding me? If you let them stay in your ICU, they’ll destroy your length of stay and mortality stats. And get this: if you get them out, you get to count them as a 0% weighted mortality to your overall mix.

Trust me, other hospitals are already doing this. If you don’t, you’ll just end up looking bad by comparison.

Hall and friends crunched the numbers for you, using the University HealthSystem Consortium’s database to take a cross-sectional snapshot of 137 U.S. hospitals (nonprofit and academic), including all discharges 2008-2009 among patients who received mechanical ventilation for more than 4 days.

Great news: the data shows that just by increasing your transfers to LTACs, you can markedly reduce your LOS and mortality stats. In fact, 14% of the variation in hospital mortality index, and 37% of the variation in length of stay were determined by the hospitals’ relative success at transferring patients to LTACs.

These academic authors point out a few nagging public policy problems that this could cause, what with the statistics being misleading and incorrect, and with the National Quality Forum pushing to have every hospital report them publicly, at which point hospitals would unfairly be compared to each other.

But that’s for the eggheads and wonks to quibble about. These authors suggest the LTAC-transferred patients be censored out of the reporting data for the acute care hospitals; maybe that will happen at some point. What you can do now is hire another social worker to expedite placements — that one you have, Mr. Bigglesby, leaves at 3 every day. Also, send out some snazzy flyers to LTACs, maybe send Karen out there to bring them lunch. Remember, LTACs are almost all for-profit businesses. They might not provide very good care, but boy, do they make money. Maybe you and St. Elsewhere should open one, sir — who knows how long till the financial party’s over!

Hall WB et al. The Implications of Long-Term Acute Care Hospital Transfer Practices for Measures of In-Hospital Mortality and Length of Stay. Am J Respir Crit Care Med 2012;185:53-57.