Date Presented 04/04/19
The study findings revealed significant differences in the outcomes of inpatient and skilled-nursing stroke rehabilitation within US stroke rehabilitation services. Researchers need to investigate patient and facility factors associated with skilled-nursing stroke rehabilitation.
Primary Author and Speaker: Timothy Reistetter
Additional Authors and Speakers: Ickpyo Hong, Trudy Mallinson, Clark Anderson, Yong-Fang Kuo, Kenneth Ottenbacher, James Goodwin
PURPOSE: Stroke rehabilitation is provided in several types of rehabilitation settings within the United States (US). The previous comparative effectiveness study of self-care and mobility outcomes (Reistetter et al., 2018) revealed that the patients with stroke admitted to inpatient rehabilitation facilities (IRF) had higher functional status outcomes compared to similar patients who received rehabilitation services from skilled nursing facilities (SNF). However, it is unclear if unmeasured confounders influence the stroke outcomes between the two post-acute care (PAC) settings and if the differences are greater than the minimal clinically important difference (MCID). Therefore, the purposes of the study was to 1) examine unmeasured confounders and compare the effectiveness of across types of stoke rehabilitation outcomes (Inpatient Rehabilitation: IRF, Skilled Nursing: SNF) in the United States (US) using a national sample of older adults and 2) test if the stroke outcome differences between IRFs and SNFs are greater than MCID.
DESIGN: This study was a cross-sectional design.
METHODS: We retrieved 103,475 patients who discharged to IRF (n=66,083) or SNF (n=39,392) following acute hospitalization for stroke using the 2012-2014 Medicare administrative database. The study sample included patients with the diagnoses of stroke based on Medical Severity Diagnosis Related Groups (MS-DRG) codes 061-066. Additional inclusion criteria included age >65 years, alive at least 10 days after hospital discharge, and living at community settings prior to index acute hospitalization. Stroke rehabilitation outcomes at admission and discharge for IRF and SNF were measured by Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) and Minimum Dataset 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 PAC settings (Mallinson, Deutsch, Heinemann, & Bateman, 2012). Instrument variable analysis was used to examine uncontrolled confounders for the stroke outcomes (Stel et al., 2012). The MCID values were calculated using the values of the pooled standard deviation and standard error of measurement in the self-care and mobility scores.
RESULTS: The majority of the sample was female (58.9%, n=46,221), non-Hispanic white (83.1%, n=86,008), with an ischemic stroke (88.8%, n=91,871). The MCID value of the self-care and mobility was 5.98 and 5.11, respectively. A traditional regression model controlling 37 covariates indicated that there were significant and meaningful outcome differences in self-care (IRF=61.1 vs. SNF=51.3, delta=9.8, p<0.001) and mobility (IRF=57.7 vs. SNF=49.6, delta=8.1, p<0.001) exist at discharge from IRF and SNF. After applying instrumental variable analysis controlling differential distance between patients’ ZIP codes and nearest IRF/SNF ZIP codes, these differences between IRF and SNF decreased in self-care (delta=7.6, p<0.001) and mobility (delta=5.6, p<0.001) which were greater than MCID values.
CONCLUSION: The findings indicate differences in the use and outcomes of IRF and SNF stroke rehabilitation within US stroke rehabilitation services even after controlling for unmeasured confounder. Clinicians and researchers need to investigate patient and facility factors associated with skilled nursing stroke rehabilitation. US policy makers need to explore programs that enhance rehabilitation quality within skilled nursing setting.
IMPACT STATEMENT: The study findings indicated that the patients with stroke admitted to IRF had higher functional status outcomes compared to those who received rehabilitation services from SNF. Clinicians and researchers need to improve stroke rehabilitation outcomes in SNF.
References
Mallinson, T. R., Deutsch. A., Heinemann, A. W., & Bateman. J. (2012). Comparing function across post-acute rehabilitation settings after co-calibration of self-care and mobility items. ACRM-ASNR Annual Conference. Vancouver, Canada: American Congress of Rehabilitation Medicine.
Reistetter, T. A., Hong, I., Mallinson, T., Anderson, C., Kuo, Y-F., & Goodwin, J. S. (2018). Comparative effectiveness of stroke rehabilitation services across inpatient rehabilitation and skilled nursing facilities in the United States. April 19-22. 2018 AOTA Annual Conference & Expo. Salt Lake City, UT.
Stel, V. S., Dekker, F. W., Zoccali, C., & Jager, K. J. (2012). Instrumental variable analysis. Nephrology Dialysis Transplantation, 28(7), 1694-1699. doi:10.1093/ndt/gfs310
