Insurance and racial differences in long-term acute care utilization after critical illness

Objectives: To determine whether insurance coverage and race are associated with long-term acute care hospital utilization in critically ill patients requiring mechanical ventilation. Design: Retrospective cohort study. Setting: Nonfederal Pennsylvania hospital discharges from 2004 to 2006. Patients: Eligible patients were aged 18 yrs or older, of white or black race, and underwent mechanical ventilation in an intensive care unit during their hospital stay. Interventions: None. Measurements and Main Results: We used multivariable logistic regression with hospital-level random effects to determine the independent association between discharge to long-term acute care hospital, insurance status, and race after appropriate controls, including a chart-based measure of severity of illness. The primary outcome measure was discharge to long-term acute care hospital. Of 66,233 eligible patients, 84.7% were white and 15.3% were black. More white patients than black patients had commercial insurance (23.4% vs. 14.9%) compared to Medicaid (10.6% vs. 29.7%) or no insurance (1.3% vs. 2.2%). Long-term acute care hospital transfer occurred in 5.0% of patients. On multivariable analysis in patients aged younger than 65 yrs, black patients were significantly less likely to undergo long-term acute care hospital transfer (odds ratio, 0.71; p = .003), as were patients with Medicaid vs. commercial insurance (odds ratio, 0.17; p < .001). Analyzing race and insurance together and accounting for hospital-level effects, patients with Medicaid were still less likely to undergo long-term acute care hospital transfer (odds ratio, 0.18; p < .001), but race effects were no longer present (odds ratio, 1.06; p = .615). No significant race effects were seen in the Medicare-eligible population aged 65 yrs or older (odds ratio for transfer to long-term acute care hospital, 0.93; p = .359). Conclusions: Differences in long-term acute care hospital utilization after critical illness appear driven by insurance status and hospital-level effects. Racial variation in long-term acute care hospital use is not seen after controlling for insurance status and is not seen in a group with uniform insurance coverage. Differential access to postacute care may be minimized by expanding commercial or Medicare insurance availability and standardizing long-term acute care admission criteria across hospitals.