jueves, 20 de febrero de 2020

Outcomes Better When Stroke Patients Receive Inpatient Rehab Care

Stroke patients who received care at inpatient rehabilitation facilities were more likely to experience better mobility and improved self-care than stroke patients at skilled nursing facilities, according to a study funded by AHRQ and the National Institutes of Health. Researchers examined records of nearly 100,000 Medicare patients who received post-acute care following strokes in 2013 and 2014. Two-thirds received inpatient rehabilitation care while the remaining received care at skilled nursing facilities. Researchers asserted that the findings raise questions about the value of policies that reimburse inpatient facilities and nursing facilities at the same rate. Access the abstract of the study published in JAMA Network Open.

https://pubmed.ncbi.nlm.nih.gov/31800069-comparison-of-functional-status-improvements-among-patients-with-stroke-receiving-postacute-care-in-inpatient-rehabilitation-vs-skilled-nursing-facilities/?from_single_result=Comparison+of+Functional+Status+Improvements+Among+Patients+With+Stroke+Receiving+Postacute+Care+in+Inpatient+Rehabilitation+vs+Skilled+Nursing+Facilities
AHRQ News Now

Comparison of Functional Status Improvements Among Patients With Stroke Receiving Postacute Care in Inpatient Rehabilitation vs Skilled Nursing Facilities

Ickpyo Hong 1, James S Goodwin 2, Timothy A Reistetter 3, Yong-Fang Kuo 4, Trudy Mallinson 5, Amol Karmarkar 6, Yu-Li Lin 7, Kenneth J Ottenbacher 8

Affiliations

PMID: 31800069
PMCID: PMC6902754
DOI: 10.1001/jamanetworkopen.2019.16646

Abstract

Importance: Health care reform legislation and Medicare plans for unified payment for postacute care highlight the need for research examining service delivery and outcomes.

Objective: To compare functional outcomes in patients with stroke after postacute care in inpatient rehabilitation facilities (IRF) vs skilled nursing facilities (SNF).

Design, setting, and participants: This cohort study included patients with stroke who were discharged from acute care hospitals to IRF or SNF from January 1, 2013, to November 30, 2014. Medicare claims were used to link to IRF and SNF assessments. Data analyses were conducted from January 17, 2017, through April 25, 2019.

Exposures: Inpatient rehabilitation received in IRFs vs SNFs.

Main outcomes and measures: Changes in mobility and self-care measures during an IRF or SNF stay were compared using multivariate analyses, inverse probability weighting with propensity score, and instrumental variable analyses. Mortality between 30 and 365 days after discharge was included as a control outcome as an indicator for unmeasured confounders.

Results: Among 99 185 patients who experienced a stroke between January 1, 2013, and November 30, 2014, 66 082 patients (66.6%) were admitted to IRFs and 33 103 patients (33.4%) were admitted to SNFs. A higher proportion of women were admitted to SNFs (21 466 [64.8%] women) than IRFs (36 462 [55.2%] women) (P < .001). Compared with patients admitted to IRFs, patients admitted to SNFs were older (mean [SD] age, 79.4 [7.6] years vs 83.3 [7.8] years; P < .001) and had longer hospital length of stay (mean [SD], 4.6 [3.0] days vs 5.9 [4.2] days; P < .001) than those admitted to IRFs. In unadjusted analyses, patients with stroke admitted to IRF compared with those admitted to SNF had higher mean scores for mobility on admission (44.2 [95% CI, 44.1-44.3] points vs 40.8 [95% CI, 40.7-40.9] points) and at discharge (55.8 [95% CI, 55.7-55.9] points vs 44.4 [95% CI, 44.3-44.5] points), and for self-care on admission (45.0 [95% CI, 44.9-45.1] points vs 41.8 [95% CI, 41.7-41.9] points) and at discharge (58.6 [95% CI, 58.5-58.7] points vs 45.1 [95% CI, 45.0-45.2] points). Additionally, patients in IRF compared with those in SNF had larger improvements for mobility score (11.6 [95% CI, 11.5-11.7] points vs 3.5 [95% CI, 3.4-3.6] points) and for self-care score (13.6 [95% CI, 13.5-13.7] points vs 3.2 [95% CI, 3.1-3.3] points). Multivariable, propensity score, and instrumental variable analyses showed a similar magnitude of better improvements in patients admitted to IRF vs those admitted to SNF. The differences between SNF and IRF in odds of 30- to 365-day mortality (unadjusted odds ratio, 0.48 [95% CI, 0.46-0.49]) were reduced but not eliminated in multivariable analysis (adjusted odds ratio, 0.72 [95% CI, 0.69-0.74]) and propensity score analysis (adjusted odds ratio, 0.75 [95% CI, 0.72-0.77]). These differences were no longer statistically significant in the instrumental variable analyses.

Conclusions and relevance: In this cohort study of a large national sample, inpatient rehabilitation in IRFs for patients with stroke was associated with substantially improved physical mobility and self-care function compared with rehabilitation in SNFs. This finding raises questions about the value of any policy that would reimburse IRFs or SNFs at the same standard rate for stroke.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Reistetter reported receiving grants from the Agency for Healthcare Research and Quality (AHRQ) during the conduct of the study. Dr Kuo reported receiving grants from the AHRQ during the conduct of the study and grants from the National Institute on Drug Abuse outside the submitted work. Dr Mallinson reported receiving grants from National Institute on Disability and Rehabilitation Research outside the submitted work. Dr Karmarkar reported receiving grants from the National Institutes of Health (NIH) and being an employee of RTI International outside the submitted work. Y.-L. Lin reported grants from National Institutes of Health during the conduct of the study. Dr Ottenbacher reported receiving grants from the NIH during the conduct of the study and personal fees from the Kessler Foundation outside the submitted work. No other disclosures were reported.