Ventilator-associated pneumonia among Medicare beneficiaries in long-term care hospitals

Ventilator-associated pneumonia (VAP) refers to nosocomial pneumonia occurring in patients receiving mechanical ventilation after airway intubation. It is a common complication of care that affects approximately one fourth of patients receiving mechanical ventilation and often produces excess (and likely avoidable) length of stay, mortality and treatment costs. While several studies have examined the effects of VAP in inpatient facilities, the incidence and outcomes of VAP in post acute settings have not been examined. Long-term Care Hospitals (LTCHs) provide post-acute ventilator care for many Medicare beneficiaries with complex conditions requiring long stays. Control of VAP is an important aspect of quality of care improvement for these facilities. MEDPAR discharge data for LTCHs are examined for Medicare fee-for-service beneficiaries who were discharged during CY 2004 with a procedure code of 96.72 (continuous mechanical ventilation for 96 consecutive hours or more) to avoid early onset infections that may have begun prior to the LTCH admission (N=13,759). Patients with a diagnosis of ICD-9-CM codes 481.xx – 486.xx were classified as having VAP present. Hospitalization patterns are examined by age, race, sex, presence of comorbidities (renal failure, diabetes, hypertension, stroke, chronic obstructive pulmonary disease (COPD), congestive heart failure) and discharge destination. In-hospital mortality and post-discharge survival are also examined. Nearly 25% of Medicare LTCH ventilator patients acquired VAP. The average age of patients with and without VAP was the same (72 years) and VAP incidence was proportionally distributed across age groups. Men were more likely than women to have acquired VAP. Blacks and Hispanics were less likely to have acquired VAP than whites. Patients acquiring VAP were more likely than other ventilator patients to have COPD as a comorbidity but tended to have fewer comorbidities than ventilator patients without VAP. Length of stay and total charges were both higher for VAP patients than for other ventilator patients. Patients with VAP were more likely to be discharged to skilled nursing facilities and hospices than ventilator patients without VAP. Ventilator patients with VAP had slightly lower rates of unadjusted in-hospital and post-discharge mortality. A proportional hazards model for survival at 2 years post discharge showed that VAP was not significantly associated with increased mortality. In this model, the effects of increasing age and presence of renal failure or diabetes had a greater effect on mortality than presence of VAP.