Abstract

Health care reform legislation and Medicare plans for unified payment for postacute care highlight the need for research examining service delivery and outcomes. To compare functional outcomes in patients with stroke after postacute care in inpatient rehabilitation facilities (IRF) vs skilled nursing facilities (SNF). 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. Inpatient rehabilitation received in IRFs vs SNFs. 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. 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. 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.

Highlights

  • More than 40% of Medicare beneficiaries are discharged from acute care hospitals to postacute care each year

  • Compared with patients admitted to inpatient rehabilitation facilities (IRF), patients admitted to skilled nursing facilities (SNF) were older and had longer hospital length of stay than those admitted to IRFs

  • Multivariable, propensity score, and instrumental variable analyses showed a similar magnitude of better improvements in patients admitted to IRF vs those admitted to SNF

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Summary

Introduction

More than 40% of Medicare beneficiaries are discharged from acute care hospitals to postacute care each year. The 2014 Improving Medicare Post-Acute Care Transformation (IMPACT) Act[3] requires the Secretary of the Department of Health and Human Services to establish a unified payment system for postacute care. As a step in this process, the Medicare Payment Advisory Commission recommended that inpatient rehabilitation facilities (IRFs) and skilled nursing facilities (SNFs) explore similar episode-based reimbursement for a given condition. The purpose of our study was to examine changes in functional status in a national sample of Medicare beneficiaries with stroke who received inpatient rehabilitation at an IRF or SNF following acute hospital discharge. We selected stroke because it is a major cause of disability in the United States and an important public health issue, patients with stroke have complex neurological disorders that require a range of treatments and expertise, and stroke represents the largest impairment group treated in IRFs.[6]

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