Many critically ill patients survive their initial episode of acute illness but go on to develop persistent organ failures necessitating prolonged life support, a syndrome known as chronic critical illness. Increasingly, patients with chronic critical illness receive care in long---termacute care hospitals (LTACs), specialized facilities for the care of these high---risk, high---cost patients. In our prior work we demonstrated that LTACs play an important role in the care of chronic critical illness, producing similar outcomes at lower costs compared to traditional intensive care units (ICUs). Yet our work also demonstrated wide variation in survival across LTACs, with significant differences in long---term mortality that are not explained by differences in case---mix. This work affirmed the essential position of LTACs in the US health system, but also highlighted a pressing need for research on how to best organize and manage care within LTACs in order to optimize care for patients with chronic critical illness. Analogous care settings such as ICUs and nursing homes have a rich evidence base informing their organization and management, but to date no such data exist for LTACs. In this project we will address this fundamental knowledge gap by identifying the key clinical and organizational factors associated with LTAC performance. Our central hypothesis is that objective clinical and organizational factors will distinguish high performing LTACs from low performing ones. Building off a novel hierarchical risk---adjustment model for measuring LTAC---specific mortality, we will first perform site visits at five US LTACs with the lowest risk---adjusted mortality and five LTACs with highest risk--- adjusted mortality. During these site visits we will conduct in---depth ethnography and semi---structured interviews to identify the clinical and organizational factors associated with positive outcomes. Second, we will develop and field a quantitative survey of physician and nurse managers at all US LTACs, linking the survey back to patient---level outcomes data and empirically defining LTAC clinical and organizational best practices. By shifting the paradigm of LTAC evaluation away from whether they work to how and where they work best, this project will be the first rigorous examination of the factors that define effective LTACs, as well as effective care for chronic critical illness. Ultimately, these results will provide clinicins, hospital administrators and policy makers with immediate, actionable data about how to use LTACs most effectively and efficiently, leading to improved survival for patients with chronic critical illness.

Public Health Relevance

Approximately 230,000 Americans are admitted to a long---term acute care hospital (LTAC) each year, with an estimated annual cost to Medicare exceeding $5 billion. By identifying the ways to best deliver care in LTACs, this project will uncover important tools to improve survival for these high---risk, high---cost patients.

Agency
National Institute of Health (NIH)
Institute
National Heart, Lung, and Blood Institute (NHLBI)
Type
Research Project (R01)
Project #
5R01HL096651-09
Application #
9386754
Study Section
Health Services Organization and Delivery Study Section (HSOD)
Program Officer
Aggarwal, Neil Raj
Project Start
2009-08-01
Project End
2018-11-30
Budget Start
2017-12-01
Budget End
2018-11-30
Support Year
9
Fiscal Year
2018
Total Cost
Indirect Cost
Name
University of Pittsburgh
Department
Internal Medicine/Medicine
Type
Schools of Medicine
DUNS #
004514360
City
Pittsburgh
State
PA
Country
United States
Zip Code
15213
Kahn, Jeremy M; Barnato, Amber E; Lave, Judith R et al. (2015) A Comparison of Free-Standing versus Co-Located Long-Term Acute Care Hospitals. PLoS One 10:e0139742
Kahn, Jeremy M; Le, Tri; Angus, Derek C et al. (2015) The epidemiology of chronic critical illness in the United States*. Crit Care Med 43:282-7
Reineck, Lora A; Le, Tri Q; Seymour, Christopher W et al. (2015) Effect of public reporting on intensive care unit discharge destination and outcomes. Ann Am Thorac Soc 12:57-63
Reineck, Lora A; Pike, Francis; Le, Tri Q et al. (2014) Hospital factors associated with discharge bias in ICU performance measurement. Crit Care Med 42:1055-64
Reineck, Lora A; Kahn, Jeremy M (2014) The authors reply. Crit Care Med 42:e685-6
Kahn, Jeremy M; Cicero, Brandon D; Wallace, David J et al. (2014) Adoption of ICU telemedicine in the United States. Crit Care Med 42:362-8
Reineck, Lora A; Wallace, David J; Barnato, Amber E et al. (2013) Nighttime intensivist staffing and the timing of death among ICU decedents: a retrospective cohort study. Crit Care 17:R216
Kahn, Jeremy M; Werner, Rachel M; David, Guy et al. (2013) Effectiveness of long-term acute care hospitalization in elderly patients with chronic critical illness. Med Care 51:4-10
Wallace, David J; Angus, Derek C; Barnato, Amber E et al. (2012) Nighttime intensivist staffing and mortality among critically ill patients. N Engl J Med 366:2093-101
Schenker, Yael; White, Douglas B; Asch, David A et al. (2012) Health-care system distrust in the intensive care unit. J Crit Care 27:3-10

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