If any covariates in the propensity score model were not balanced, we additionally controlled for those covariates in the outcome models. At an SNF, Medicare Part A will cover up to 100 days of skilled nursing care per spell of illness. By continuing to use our site, or clicking "Continue," you are agreeing to our, 2020 American Medical Association. For patients who are seeking rehabilitation services, there are typically two options to select: Inpatient Rehabilitation or Skilled Nursing Facility.  L, Liang There are challenges in comparing outcomes in observational studies, the most important of which is bias by indication, or selection bias. 0000070360 00000 n  Change in Score From Admission to Discharge in IRF and SNF, Table 4. The race/ethnicity variable was defined by the CMS and was included because some outcomes differ among racial/ethnic groups.18 The 30 most frequent CMS Hierarchical Condition Categories for comorbidities were identified through diagnoses on the inpatient claims from the previous year and the secondary diagnoses during the index stroke hospitalization (eTable 4 and eTable 5 in the Supplement).19 In addition, we added 6 diagnoses related to cognitive function (eTable 6 in the Supplement).  L, Liang Acquisition, analysis, or interpretation of data: All authors. I found this article very interesting. Care in an inpatient rehabilitation facility was associated with greater improvement in mobility and self-care compared with care in a skilled nursing facility, and a significant difference in functional improvement remained after accounting for patient, clinical, and facility characteristics at admission. The number of items to measure cognitive function in the IRF and SNF assessment protocols are small, and our preliminary analyses to develop a cocalibrated crosswalk revealed low precision.16,38 Instead, we included diagnoses associated with cognitive dysfunction in the comorbidities that were controlled for (eTable 6 in the Supplement). 0000001892 00000 n Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.  Y, Kuo  Characteristics of Patients Admission to IRF and SNF, Table 2. A significant difference in functional improvement remained after accounting for patient, clinical, and facility characteristics at admission.  SJ. Researchers … The information will be posted with your response. Concept and design: Goodwin, Reistetter, Kuo, Karmarkar, Ottenbacher. trailer Results  Were hospitalized more in the prior 6 mo. 0000039735 00000 n All Rights Reserved, Challenges in Clinical Electrocardiography, Clinical Implications of Basic Neuroscience, Health Care Economics, Insurance, Payment, Scientific Discovery and the Future of Medicine, United States Preventive Services Task Force. 0000010453 00000 n  NB, Qi  TS, Han  et al. An IRF is designed to provide intensive rehabilitation to complex patients who need specialized care. Skilled Nursing Facility Payment Update In accordance with the Bipartisan Budget Act of 2018, the aggregate impact of SNF payments are estimated to increase by 2.4% in the Fiscal Year 2019. 0000049774 00000 n 0000049525 00000 n Conclusions and Relevance   The reliability of the functional independence measure: a quantitative review.Â. Patients receiving SNF vs IRF care were older (83 vs 79 years), had more comorbid illness, and higher unadjusted 7, 90, and 365 day mortality and rehospitalizations (Table).  AM, Newhouse We hypothesized that patients discharged to IRFs would have larger improvements in mobility and self-care function than those discharged to SNFs. This study has limitations. This cohort study included 99 185 patients who received postacute care in inpatient rehabilitation or skilled nursing facilities after a stroke. 0000025802 00000 n Lastly, we calculated E-values for mobility scores, self-care scores, and mortality between patients admitted to IRF or SNF, to assess the potential magnitude of unmeasured confounding that might have produced the results.10 Data were analyzed using SAS statistical software version 9.4 (SAS Institute).  M, Ulbricht 0000014526 00000 n The. 0000016541 00000 n Additional Contributions: Sarah Toombs Smith, PhD, ELS (University of Texas Medical Branch), provided assistance in proofreading and editing the manuscript. Inpatient Rehabilitation Unit (IRU) vs Skilled Nursing Facility (SNF) Patients have various options to meet their rehabilitation needs, however it is essential that they be educated on the differences in those options. In this study, we compared functional outcomes of patients with stroke who were discharged from a hospital to an IRF or SNF. This is an important topic for future research. This finding raises questions about the value of any policy that would reimburse IRFs or SNFs at the same standard rate for stroke. Have more severe strokes.  30- to 365-d Mortality From Hospital Discharge Between IRFs and SNFs.  CA.  Limits of observational data in determining outcomes from cancer therapy.Â, Sheffield This finding raises questions about the value of any policy that would reimburse IRFs or SNFs at the same standard rate for stroke.  JE. h�bba`b``Ń3� ���� � ��� However, it is essential that they be educated on the differences in those options. In all models, the changes in mobility and self-care scores for those discharged from IRFs were at least 2-fold those for patients discharged from SNFs. Lastly, for each outcome, we calculated the E-value to assess the minimum strength of association that an unmeasured confounder would need to have with the outcome and postacute care setting to eliminiate the association between postacute care setting and each outcome (eTable 9 in the Supplement). All Rights Reserved. Data were analyzed from January 17, 2017, through April 25, 2019. A unified approach to measuring the effect size between two groups using SAS. Table 2 presents the unadjusted mobility and self-care scores at admission and discharge for patients in IRFs and SNFs, along with the change in scores between admission and discharge. Acute Rehab vs. SNF Patients have various options to meet their rehabilitation needs, however it is essential that they be educated on the differences in those options. IRF versus SNF. 0000046431 00000 n  et al. This cohort study included 99 185 patients who received postacute care in inpatient rehabilitation or skilled nursing facilities after a stroke. This cohort study found that Medicare beneficiaries who received services at an IRF after a stroke demonstrated greater improvement in mobility and self-care compared with patients who received inpatient rehabilitation at a SNF. 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. Rubin We are focused on two things: the progress our patients make and the outcomes they achieve, which is evidenced by our industry-leading performance scores. 0000032977 00000 n A recent systematic review reported better functional outcomes and higher costs for patients in IRFs compared with those in SNFs and emphasized the need for additional research.4 Limited research has reported generally better functional outcomes associated with patients in IRFs vs SNFs after a stroke.4,29,31,32 The findings of our study support this trend. If the statistical analyses show significant IRF vs SNF differences in 30- to 365-day mortality, that result would suggest that underlying selection biases remain. Main Outcomes and Measures   ME, Jette Discharge to home, a skilled nursing facility (SNF), or an inpatient rehabilitation facility (IRF) was the primary outcome. Patients treated in a SNF as a result of the 60% Rule who could have otherwise been treated in an IRF might be adversely affected by an increased risk of death, increased use of facility-based care, and more ER visits and hospital readmissions. Reports by the National Academy of Sciences1 and the Institute of Medicine2 have found that postacute care was the largest contributor to geographic variation in Medicare costs. 381 0 obj <>stream  GN, Freeman After IPW adjustment mortality and rehospitalization/mortality rates remained significantly better for …  Common-person equating with the Rasch model.Â, Velozo A higher proportion of women were admitted to SNFs (21 466 [64.8%] women) than IRFs (36 462 [55.2%] women) (P < .001). The development of a standardized measure of cognitive function is an important area for future research and is included as part of the IMPACT Act.3 Previous investigations have consistently reported that the costs for rehabilitation services provided in SNFs are significantly lower than in IRFs, even when the longer LOSs associated with SNFs are considered.4,36 We did not conduct cost comparisons or cost benefit analyses associated with outcomes across the 2 postacute settings. It is not possible to directly measure the size of the population of marginal patients.  Z, Hortobagyi Please allow up to 2 business days for review, approval, and posting. 0000025538 00000 n  D, Dalton 0000006067 00000 n 0000023591 00000 n  Comparison of discharge functional status after rehabilitation in skilled nursing, home health, and medical rehabilitation settings for patients after hip fracture repair.Â, Buntin The critical issue in Medicare for IRF services is whether the patient required the care of a rehab physician, either due to comorbidities or some other concern which makes SNF care inappropriate. 0000053855 00000 n Mortality between 30 and 365 days after discharge was included as a control outcome as an indicator for unmeasured confounders. Appropriate Patient Placement 2.  A.  More accurate racial and ethnic codes for Medicare administrative data.Â, Pope Terms of Use| Next, we used inverse probability treatment weighting with propensity scores with and without multilevel adjustment. Inpatient Rehabilitation Facilities (IRF) In my previous blog titled The Top 5 Benefits of Inpatient Rehabilitation, I discuss the benefits of choosing inpatient rehabilitation if recommended by healthcare staff. 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. E-values for Mobility and Self-care Scores and 30- to 365-Day Mortality From Hospital Discharge. After applying propensity score weights, most demographics and comorbidities were balanced between IRF and SNF (49 of 52 variables [94.2%]) (eTable 4 and eTable 5 in the Supplement). In unadjusted analyses, patients with stroke who were discharged from IRF had lower mortality than those discharged from SNF (17.5% vs 30.5%, OR, 0.48 [95% CI, 0.46-0.49]).  M, McCoy 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. To compare functional outcomes in patients with stroke after postacute care in inpatient rehabilitation facilities (IRF) vs skilled nursing facilities (SNF).  D.  Differences in rehabilitation services and outcomes among stroke patients cared for in veterans hospitals.Â, Deutsch 0000021088 00000 n xref  Medicare spending and outcomes after postacute care for stroke and hip fracture.Â, Ottenbacher  CM To effectively and safely implement unified payment in postacute care,3 it will be necessary to recognize differences in the rehabilitation needs of patients with stroke and other complex conditions. The study sample included Medicare beneficiaries 66 years or older discharged from January 1, 2013, to November 30, 2014, to an IRF or SNF after an index acute stay for stroke denoted by Medicare Severity Diagnosis Related Group codes 061 to 066 (eFigure in the Supplement).13 Additional inclusion criteria included Medicare Part A coverage without enrollment in a health maintenance organization in the year before and 1 month after the index stroke discharge, residing in the community prior to the index stroke hospitalization, and full mobility and self-care functional measures at the IRF admission and discharge or SNF admission and last follow-up (eTable 1 and eTable 2 in the Supplement). We were not able to examine cognitive function before and after the stroke, stroke severity, or location of the stroke. Find Medicare-certified inpatient rehabilitation facilities and compare them based on the quality of care they provide to patients.  L, 0000049209 00000 n In a study of Medicare spending and outcomes after postacute care for stroke and hip fracture, Buntin et al36 estimated the percentage or marginal patients as between 20% to 30% of patients with hip fracture or stroke. 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. Differences between inpatient rehabilitation & skilled nursing care 1.  M, Konetzka As a control outcome, we assessed mortality between 30 and 365 days after hospital discharge. Obtained funding: Reistetter, Ottenbacher.  Unexplained variation for hospitals’ use of inpatient rehabilitation and skilled nursing facilities after an acute ischemic stroke.Â, Magdon-Ismail  DE, Alter Next, we used hierarchical general linear mixed-effects models to account for patients nested within hospitals. Additionally, we used ordinary least squares models with inverse probability treatment weighting, with propensity scores also adjusted for unbalanced covariates, to compare functional status outcome (ie, mobility and self-care) at discharge from IRF or SNF. 0000070242 00000 n 0000042411 00000 n  Postacute care setting, facility characteristics, and poststroke outcomes: a systematic review.Â, Centers for Medicare & Medicaid Services, HHS. Not all submitted comments are published. We used instrumental variable analysis to adjust for unmeasured confounders across patients and facilities.21 The instrumental variables included difference in the distance from the acute care hospital to the nearest IRF vs the nearest SNF, difference in the distance from the beneficiary’s residence to the nearest IRF vs nearest SNF, number of stroke patients discharged to an IRF in the hospital referral region (HRR) in 2013 through 2014, and the previous discharge location assignment (IRF or SNF) for patients with the same type of stroke from the same acute care hospital (eTable 7 and eTable 8 in the Supplement). 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. For mobility, the change was 11.6 (95% CI, 11.5-11.7) points for patients in IRFs vs 3.5 (95% CI, 3.4-3.6) points for those in SNFs. More are female. Conflict of Interest Disclosures: Dr Reistetter reported receiving grants from the Agency for Healthcare Research and Quality (AHRQ) during the conduct of the study.  MA, Goodwin Data analyses were conducted from January 17, 2017, through April 25, 2019. Hong I, Goodwin JS, Reistetter TA, et al.  TJ, Ding At SNFs, therapy services vary widely and are generally less than IRFs, Dr. Arbabi says.  Jr, Goodwin 0000003667 00000 n Several studies7-9 have shown that traditional methods of controlling for patient characteristics, such as logistic regression and propensity analyses, tend not to be effective in the face of strong selection biases. Outcomes in observational studies, the Encompass Health difference is our people, approach... After discharge was included as a control outcome, we compared functional outcomes involving IRFs and SNFs of... Propensity scores with and without multilevel adjustment essential that they be educated on the patient’s needs and for! 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