Abstract 76: Estimating The Impact Of Hospital-level Variation In The Use Of Inpatient Rehabilitation Facilities Versus Skilled Nursing Facilities On Individual Stroke Patients

Abstract

Introduction: Observational studies indicate that stroke rehabilitation at Inpatient Rehabilitation Facilities (IRFs) is superior to Skilled Nursing Facilities (SNFs). Nationally, IRF vs. SNF use varies widely at the hospital level, but the impact on individual patients is unclear. Our objective was to quantify the effect of the admitting hospital on the probability of receiving IRF or SNF care for individual stroke patients. Methods: Medicare claims data (2011-2014) was used to generate a cohort of acute ischemic and hemorrhagic stroke patients who were discharged to IRFs or SNFs. We generated 2 multivariable effects logistic regression models. Model 1 predicted IRF admission (vs. SNF) using only patient-level factors as fixed effects, whereas Model 2 added a hospital random effect. The impact of the admitting hospital on an individual patients’ probability of IRF care was estimated by taking the difference in predicted probabilities (p^) between the 2 models. Hospital effects were categorized as moderate (10-19%) or large (>20%) based on the change in size of p^. The magnitude and direction of the random effect terms in Model 2 was used to categorize individual hospitals as being either neutral, SNF-, or IRF- favoring. Results: The cohort included 1,816 acute care hospitals which discharged 135,415 patients to IRFs (n=66,548) or SNFs (n= 68,867). Half of the hospitals were categorized as neutral (n=870, 47.9%) with the remaining being SNF- favoring (n=485, 26.7%) or IRF- favoring (n=461, 25.4%). For half of all patients, acute care hospital had a moderate influence on the type of rehabilitation that they received. For SNF and IRF-favoring hospitals, there were large (55% and 37% of patients) or moderate (30% and 42% of patients) hospital effects on discharge setting for the majority of patients. Conclusion: For the majority of stroke patients, which acute care hospital they happen to be admitted to meaningfully impacts the type of rehabilitation care they receive