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

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).

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.