Date Presented 4/21/2018
The study findings revealed significant differences in self‐care and mobility outcomes for inpatient and skilled nursing stroke rehabilitation in the United States. Clinicians and researchers need to investigate patient and facility factors associated with skilled nursing stroke rehabilitation outcomes.
Primary Author and Speaker: Timothy Reistetter
Additional Authors and Speakers: Ickpyo Hong, Trudy Mallinson
Contributing Authors: Clark Anderson, Young‐Fang Kuo, James S. Goodwin
PURPOSE: Stroke rehabilitation is provided in several types of rehabilitation settings in the United States. Comparative effectiveness studies of self‐care and mobility outcomes provide occupational therapy practitioners and policymakers with information about factors that influence functional recovery. The purpose of this study was to compare the effectiveness of skilled nursing facility (SNF) and inpatient rehabilitation facility (IRF) outcomes across the United States using a national sample of older adults.
METHOD: This study was a cross–sectional design with 112,114 patients discharged to an IRF (n = 66,237) or SNF (n = 44,392) after acute hospitalization for stroke using 2013–2014 Medicare data. The study sample included patients with stroke diagnoses based on Medical Severity Diagnosis Related Groups codes 061–066. Additional inclusion criteria were age >65, alive ≥10 days after hospital discharge, and living in community settings before index acute hospitalization.
Stroke rehabilitation outcomes at admission and discharge for IRFs and SNFs were measured using the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF–PAI) and Minimum Data Set 3.0 (MDS), respectively. We used a crosswalk for IRF–PAI and MDS assessments to construct comparable admission and discharge functional scores between these two postacute care settings (Mallinson et al., 2012). Propensity score matching (inverse probability weighting [IPW] for covariate adjustment) was used to balance stroke covariate differences between IRFs and SNFs. Multilevel regression models with the IPW method were used to evaluate the difference in self‐care and mobility outcomes at discharge between IRFs and SNFs after adjusting for client and facility covariates.
RESULTS: The majority of the sample was female (59.3%) and non‐Hispanic White (82.8%) and had had ischemic stroke (88.7%). Significant differences were found in 43 of 46 client and facility covariates between patients with stroke in IRF and SNF settings. After applying the IPW method, 41 covariates were balanced across IRFs and SNFs. The remaining unbalanced covariates (teaching hospital, bed count, number of stroke discharges, self‐care, and motor scores) were controlled with IPW in multilevel regression models. Comparison of self‐care and mobility across settings suggests that functional abilities at admission to IRFs (self‐care = 43.9, mobility = 43.3) and SNFs (self‐care = 44.1, mobility = 43.7) were similar; however, there were significant and meaningful outcome differences at discharge in self‐care (IRF = 56.8 vs. SNF = 46.7, p < .001) and mobility (IRF = 54.3 vs. SNF = 46.0, p < .001), even after adjusting for stroke covariates.
CONCLUSION: The findings indicate differences in the use and outcomes of IRF and SNF stroke rehabilitation services within the United States. Clinicians and researchers need to investigate patient and facility factors associated with skilled nursing stroke rehabilitation outcomes. U.S. policymakers need to explore programs that enhance rehabilitation quality in skilled nursing settings.
IMPACT STATEMENT: The study indicates that patients with stroke admitted to IRFs had higher functional outcomes compared with those receiving rehabilitation in SNFs, even after adjusting for covariates and the likelihood of receiving IRF services. Clinicians and researchers need to improve rehabilitation outcomes in SNFs. This study aligns with the American Occupational Therapy Association’s health services research priority and highlights the need for effectiveness studies examining real–world delivery of rehabilitation services across the United States.
References
Mallinson, T. R., Deutsch. A., Heinemann, A. W., & Bateman. J. (2012, October). Comparing function across post‐acute rehabilitation settings after co‐calibration of self‐care and mobility items. Paper presented at the meeting of the American Congress of Rehabilitation Medicine and American Society of Neurorehabilitation, Vancouver, British Columbia.
