Patients receiving long-term mechanical ventilation present a serious financial challenge to hospitals. Depending on the case mix in a particular hospital of Medicare, Medicaid, managed-care contract, and fully insured patients, the financial picture in most hospitals is bleak. Depending on the level of state Medicaid reimbursement, Medicaid losses on these patients vary. Because acute care hospitals cannot be reimbursed for chronic ventilator units, hospitals have resorted to leasing space to separate entities, which, when separately incorporated, accredited, and staffed, can secure waivered status from the PPS and can be paid at a per diem rate based on their costs. Hospital patients who are ventilator dependent can be transferred to these PPS-waived units. There are states where no chronic ventilator facilities exist and where nursing homes do not accept ventilator-dependent patients. This situation is serious for the hospital if the patient does not have caregivers at home who are capable of caring for a ventilator-dependent patient. The problem of the large numbers of patients who are ventilated mechanically with endotracheal tubes but who do not fall into MDC 4 needs to be addressed by Medicare. Medicare needs to evaluate the cost and use of NIV in ICU practice and develop a system to reimburse for this modality at a reasonable level under Part A.
[Show abstract][Hide abstract] ABSTRACT: As the decision-making process in long-term respiratory care units often depends on time-based outcomes, we sought to identify independent predictors of time-to-weaning (TTW) in a hospital-based specialized respiratory care unit.
Characteristics that were identified in previous studies as predictors of weaning success in ICUs and long-term ventilator units were prospectively collected on 113 consecutive admissions to our unit. TTW analyses were performed with Kaplan-Meier curves, log rank test, and Cox proportional regression.
The TTW was shorter in patients with static lung compliance (Cst) of > 20 mL/cm H(2)O, a normal creatinine level (0.6 to 1.4 mg/dL), a rapid shallow breathing index (RSBI) of < or = 105, intact skin, and in those patients from a surgical referral source. We found an interaction between RSBI and Cst (p = 0.02) such that patients with an RSBI of < or = 105, regardless of Cst, had a median TTW of 11 days, those with an RSBI of > 105 and a Cst of > 20 had a median TTW of 31 days, and those with an RSBI of > 105 and a Cst of < or = 20 mL/cm H(2)O had not reached a median TTW by 60 days (p = 0.007 [log rank for linear trend]). In a Cox-proportional hazard model, both this categorization model of RSBI and Cst, and renal function had a significant impact on TTW.
In a multivariate model incorporating the variables reviewed, only the lung parameters (RSBI combined with Cst) and renal function remained independently associated with TTW.
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