Abstract
Introduction: Hospitals strongly influence whether acute stroke patients receive stroke rehabilitation at Inpatient Rehabilitation Facilities (IRFs) or Skilled Nursing Facilities (SNFs), but little is known about drivers of variation. Our objective was to quantify the impact of hospital-level factors on discharge decisions. Methods: A cohort of acute stroke patients who were discharged to IRFs or SNFs was generated from Medicare data (2011-2014). A multi-level random effects logistic regression model that included patient- and hospital-level predictors (fixed effects) of discharge to an IRF (vs. SNF) was constructed. From this model, the amount of variation in discharge decisions due to hospitals was estimated from the intraclass correlation coefficient (ICC). Average effect sizes of hospital-level factors were estimated by adjusted odds ratios (aORs). Variations in effect sizes of factors between hospitals was estimated using 80% Interval Odds Ratios (80% IORs) which reflects a range of estimated effect sizes of factors across individual hospitals. Results: The cohort included 1,816 acute care hospitals which discharged 66,548 patients to IRFs and 68,867 patients to SNFs. Acute hospitals accounted for a quarter of the variation in IRF (vs. SNF) discharge (ICC=0.26). Important hospital-level factors associated with IRF discharge included IRF affiliation (aOR=2.53, 95% CI: 2.25-2.84), urban setting (aOR=1.71 95%CI:1.44-2.03) and Southern vs. Mid-west CMS region (aOR=3.12 95% CI: 2.55-3.83). All 80% IORs were wide which indicates substantial variation in the effects of these factors across hospitals which suggests that despite several significant aORs, much of the hospital-level variability remains poorly explained. Conclusion: Hospitals account for a quarter of the variation in use of IRFs (vs. SNFs). Several hospital-level factors were associated with IRF discharge but there was wide variation in the effects of these factors across hospitals.
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