Elderly have poor prognosis after recovery in long-term acute care hospitals

While long-term acute care hospitals (LTACHs) are designed to help patients recover and regain independence, fewer than 1-in-5 older adults who were transferred to such facilities were alive five years later, leaving them with a worse prognosis than terminal illnesses such as advanced cancer, according to research at UC San Francisco and The University of Texas Southwestern Medical Center.

In a study of 14,072 hospital patients admitted to an LTACH, the researchers found that the average patient spent 65.6 percent of his or her remaining life in a hospital or inpatient setting, and more than a third (36.9 percent) died in one, never returning home. Only 16 percent ever enrolled in hospice for an average of 10 days, which is far lower than Medicare beneficiaries not cared for in LTACHs, indicating a potential missed opportunity to improve care at the end of life.

The researchers said the results shed light on more realistic expectations for patients entering LTACHs and could give patients and their physicians the information they need in choosing care consistent with their values and preferences. Findings appear Aug. 26, 2019, in Journal of the American Geriatrics Society (JAGS).

"Understanding the clinical course after LTACH admission can inform goals of care discussions, planning for care at the end of life and prioritizing health care needs," said lead author Anil Makam, MD, MAS, assistant professor of medicine at UCSF. "It also may lead some patients to shift from intensive life-sustaining and rehabilitative treatment to hospice care, with a focus on managing their symptoms and improving the quality of their remaining life."

LTACHs provide extended, complex, post-acute care to more than 120,000 Medicare beneficiaries annually. They differ from acute-care hospitals and skilled-nursing facilities by focusing on treating patients who require extended inpatient care, typically for three to five weeks after initial hospitalization.

In the JAGS study, Makam and his UT Southwestern colleagues reviewed a portion of national Medicare data from 2009 to 2013 on hospitalized patients at least 65 years old who were transferred to an LTACH to recover. They examined patient mortality, recovery (60 consecutive days without inpatient care), time spent in an inpatient facility after LTACH admission, receipt of an artificial life-prolonging procedure such as a feeding tube or tracheostomy, and palliative care physician consultation.

Of 14,072 qualifying patients, 40 percent were admitted to an LTACH for a respiratory diagnosis. The average survival was 8.3 months, with one- and five-year survival rates of 45 percent and 18 percent, respectively. Almost 53 percent of patients never achieved 60-day recovery, the researchers said.

By comparison, the five-year survival rates for the most common adult cancers are breast, 75 percent; prostate, 69 percent; lung, 13 percent; colorectal, 51 percent; and bladder, 74 percent.

The study found that the youngest group (65-69 years old) and those with a musculoskeletal diagnosis had the most favorable prognosis, with an average survival of 17.3 months among the 65-69 age group and 25.9 months for those with musculoskeletal conditions. Patients 85 years or older had the worst prognosis, with an average survival of 4 months, and spent an average of 97.7 percent of the remainder of their lives as inpatients. Those with a primary respiratory diagnosis were close behind, with an average survival of 5.3 months and 88.8 percent of their remaining lives as inpatients.

During their hospital and subsequent LTACH stay, 30.9 percent of patients received an artificial life-prolonging procedure, with feeding tubes being the most common (22.3 percent). A startlingly low 1 percent were consulted by a palliative care physician, and 3.2 percent by a geriatrician, leading the researchers to advocate further study to examine their unmet palliative care needs.

"As we didn't interview or survey individuals, we don't know if they desired life-sustaining or intensive care, were informed of their prognosis, received palliative care from their primary physician in the LTACH, or the extent of their symptom burden or quality of life," Makam said. "But, in many ways, LTACHs are a more ideal setting for palliative care interventions than acute care hospitals given their much longer length of stay, higher concentration of very ill patients and less focus on diagnostic evaluation."

To prevent unnecessary harm and avoid additional burdensome care in these patients, the researchers also recommend that clinicians strongly consider waiving non-vaccination preventive care treatments for asymptomatic conditions or modifying risk factors to prevent adverse outcomes in the distant future.