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Ventilator-Associated Pneumonia among Elderly Medicare
Beneficiaries in Long-Term Care Hospitals
William Buczko, Ph.D.
Ventilator-associated pneumonia (VAP)
is a complication of ventilator care that
produces excess, avoidable resource use and
treatment costs. Control of VAP is an impor-
tant aspect of quality of care improvement
for long-term care hospitals (LTCHs) since
they provide post-acute ventilator care for
many Medicare beneficiaries. Data for
Medicare patients discharged from LTCHs
during CY 2004 who received contin-
uous mechanical ventilation are exam-
ined (N=13,759). Nearly 25% of Medicare
LTCH ventilator patients acquired VAR
Despite having lower mortality and less
co-morbidity than non-VAP patients, length
of stay (LOS) and total charges were both
higher for VAP patients. Some of this excess
is avoidable.
INTRODUCTION
Ventilator-associated pneumonia (VAP)
refers to nosocomial pneumonia occur-
ring in patients receiving mechanical
ventilation 48 hours or more 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) LOS, mortality and
treatment costs (Kollef, 2005; Chastre and
Fagon, 2002). VAP is the leading cause
of nosocomial mortality for patients with
respiratory failure (Kollef, 2005). Early
onset VAP cases generally occur within 4
The author is with the Centers for Medicare & Medicaid Ser-
vices (CMS). The statements expressed in this article are those
of the author and do not necessarily reflect the views or policies
of CMS.
days of hospitalization and usually carry
a better prognosis than late onset cases
occurring later than 4 days from admis-
sion (Chastre and Fagon, 2002). Previous
studies in acute care settings indicate
that males, trauma patients and severely
ill patients are at increased risk for VAP
(Chastre and Fagon, 2002; Kollef, 2005).
Kollef (2005) reviews the pathogenesis of
VAP (an avoidable, hospital-acquired infec-
tion) and states that many VAP cases are
preventable if appropriate interventions
are in place.
Several studies have examined the
effects of VAP in inpatient facilities. Rello
et al. (2002) and Bregeon et al. (2001)
found that there was no significant dif-
ference in inpatient mortality among
ventilator patients with and without VAP.
Several studies have found that the pres-
ence of VAP substantially increased dura-
tion of mechanical ventilation compared
to patients without VAP. This, in turn,
increased patient ICU days, inpatient
LOS and billed charges for patients with
VAP (Chastre and Fagon, 2002; Rello et
al., 2002; Kollef, 2005; Safdar et al., 2005;
Hugonnet et al., 2007). These studies
suggest that control of VAP would save
hospital resources and costs and improve
outcomes. The incidence and outcomes of
VAP in post acute settings have not been
extensively examined. The largest study
of mechanical ventilation in LTCHs (Ven-
tilator Outcomes [Barlow] Study) found
that 31% of the 1,419 study patients in 23
LTCHs were treated for pneumonia or tra-
cheobronchitis in 2003 but did not discuss
HEALTH CARE FINANCING REVIEW/Fall 2009/Volume 31, Number 1
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