L, Vanacker 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. Objective To compare functional outcomes in patients with stroke after postacute care in inpatient rehabilitation facilities (IRF) vs skilled nursing facilities (SNF).  Jr, Goodwin Functional Measures: Mobility and Self-Care. Inpatient rehabilitation received in IRFs vs SNFs. Conflict of Interest Disclosures: Dr Reistetter reported receiving grants from the Agency for Healthcare Research and Quality (AHRQ) during the conduct of the study.  TS, Han  HY, Instrumental Variables Across Inpatient Rehabilitation Facilities (IRFs) and Skilled Nursing Facilities (SNFs), eTable 8. These differences were no longer statistically significant in the instrumental variable analyses. In this study, we compared functional outcomes of patients with stroke who were discharged from a hospital to an IRF or SNF. Geographic variation in health care spending in the United States: insights from an Institute of Medicine report. Unadjusted Admission and Discharge Results, Table 3. Main Outcomes and Measures 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. Risk adjustment of Medicare capitation payments using the CMS-HCC model. The assumption was that mortality in this time frame would be closely linked to health status and minimally associated with the type of facility.  |   RP, Garber Comparison of Functional Status Improvements Among Patients With Stroke Receiving Postacute Care in Inpatient Rehabilitation vs Skilled Nursing Facilities. Dr Karmarkar reported receiving grants from the National Institutes of Health (NIH) and being an employee of RTI International outside the submitted work. An IRF requires no pre-qualifying hospital stay for Medicare coverage. Case-mix classification system used under the SNF PPS The new SNF Patient-Driven-Payment-Model (PDPM) will become effective on October 1, 2019.  KJ, Hsu Hong Please see our commenting policy for details.  MA, Graham Christopher Martinez was leading a normal life for a 23-year-old, going to college, working full time, out with his friends having a good time when on October 18, … A total of 99 185 patients with stroke from 3405 hospitals were included in the study, including 66 082 patients (66.6%) who received stroke rehabilitation in an IRF and 33 103 patients (33.4%) who received stroke rehabilitation in an SNF.  L, Velozo Statistical analysis: Hong, Kuo, Karmarkar, Lin. Postacute care reform based on the IMPACT Act3 must avoid a payment system that shifts patients with stroke who could benefit from intensive inpatient rehabilitation to lower cost settings. In the multilevel multivariate propensity score inverse probability of treatment weighting model, the mean (SE) difference in scores between patients from IRF vs SNF was 8.0 (0.04) points for mobility and 9.9 (0.05) points for self-care. An SNF requires a 3-day pre-qualifying hospital stay for Medicare coverage. Crit Care Nurs Clin North Am.  Y, Granger Magdon-Ismail  GM, Brock Ickpyo Hong, PhD, OTR, and Kenneth J. Ottenbacher, PhD, OTR. We estimated the parameters using 2-stage least square regression.22-24 For the control outcome of 30- to 365-day mortality, the parameters were estimated from 2-stage residual inclusion models because the outcome was dichotomous. Under PPS, SNF patients may be receiving less rehabilitation therapy, 16 and IRF patients may have shorter stays. Results:  I, Woo  HS, Shim JAMA.  Z, Sicklick Centers for Medicare & Medicaid Services. On this page, you will find descriptions of each measure, links to measure specifications, measure updates, and other measure-related information. Exposures Inpatient rehabilitation received in IRFs vs SNFs. 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. Privacy Policy| These findings suggest that there is room for payment reform in postacute care and highlight the need to target decision-making regarding discharge to postacute facilities based on patient needs and potential for recovery. 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.  Z, Hortobagyi In this study, we used all-cause mortality between 30 and 365 days after hospital discharge as a control outcome. Drafting of the manuscript: Hong, Goodwin, Ottenbacher. 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]). Our methods are described in more detail in the eAppendix in the Supplement. To compare functional outcomes in patients with stroke after postacute care in inpatient rehabilitation facilities (IRF) vs skilled nursing facilities (SNF).  CY, Yoonjeong 2013;310(12):-. Werner She was not compensated for her contribution. Epub 2019 Dec 24. USA.gov. 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).  et al. 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).  TR, Bateman Terms of Use| sub-acute care. The proposal is based, in part, on the substantial overlap in patient populations served by IRFs and SNFs.4,5, 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. 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. 30- to 365-d Mortality From Hospital Discharge Between IRFs and SNFs. The Inpatient Rehabilitation Facility-Patient Assessment Instrument includes 5 mobility items and 6 self-care items, with a 7-point rating scale. Kibria Malcolm MP, Middleton A, Haas A, Ottenbacher KJ, Graham JE. We were not able to examine cognitive function before and after the stroke, stroke severity, or location of the stroke.  SH, Kuo  et al. The current CMS rules for identifying priority patients for IRFs are a good start, but challenges remain, such as the large disparity in the availability of IRFs vs SNFs.  RT. In the 4 instrumental variable models, the differences in improvement in mobility scores between IRF and SNF patients between 5 and 10 points and for self-care scores, the difference was between 8 and 12 points. For which patients is it more cost-effective to be placed in an IRF and which patients in a SNF taking into account outcomes both at discharge and rehospitalizations during the first 3-6 months following discharge? Kibria A, Mancher M, McCoy MA, Graham RP, Garber AM, Newhouse JP.  P, Sood We reported the study findings according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline. For patients who are seeking rehabilitation services, there are typically two options to select: Acute Rehab or Skilled Nursing Facility.  J, Tseng Significantly more of the SNF-treated patients required a walker (80.2%) for ambulation at discharge compared with patients treated at the IRF (38.3%, P < 0.001). Third, the higher proportion of SNF patients with apathy suggests that apathetic patients were selected for SNFs; randomization to IRF vs. SNF would be necessary to make a clearer inference that superior outcomes in IRFs are not due to selection of less ideal patients for SNFs. Dr Mallinson reported receiving grants from National Institute on Disability and Rehabilitation Research outside the submitted work. Medicare Costs. 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 site needs JavaScript to work properly.  M, Klein  PR, Rubin 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. Funding/Support: This study was supported with funding from the National Institutes of Health (R01-AG033134, P2C HD065702, R01-HD069443, K01-HD086290, P30-AG024832, K12 HD055929, and 1UL1TR001439) and the Agency for Healthcare Quality and Research (R01-HS024711, R24-HS022134).  P, Cras Patient Characteristics Between Skilled Nursing Facility (SNF) Stays Included in the Cohort and Those Excluded Owing to Incomplete Data for Function Scores, eTable 2. 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). Stroke is a complex neurological condition affecting multiple body systems and requiring intensive rehabilitation from several disciplines with different areas of expertise. Does postacute care site matter: a longitudinal study assessing functional recovery after a stroke. Ottenbacher JAMA Network Open.  et al. Epub 2017 Sep 28.  J, Goodwin  KL, Wang The control outcome should be strongly related to the underlying health of the patients but only minimally influenced by residence in an IRF vs SNF. As a control outcome, we assessed mortality between 30 and 365 days after hospital discharge. eFigure. The changes in mobility and self-care scores were substantially greater among IRF patients. Medicare spending and outcomes after postacute care for stroke and hip fracture.  et al. 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]). In a unified payment system, there would be financial incentives to shift high-cost patients, such as patients with stroke and other complex medical conditions, to lower-cost postacute care options. TriHealth Rehabilitation Hospital 2155 Dana Avenue Cincinnati, OH 45207 Phone: (513) 601-0600 Fax: (513) 601-0601 Pope Conclusions and Relevance  The control outcome should be strongly related to the underlying health of the patients but only minimally influenced by residence in an IRF vs SNF. Standardized Difference for Instrumental Variables, eTable 9. 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. Please allow up to 2 business days for review, approval, and posting. Association between cholecystectomy with vs without intraoperative cholangiography and risk of common duct injury.  CM, Lapane Published: December 4, 2019. doi:10.1001/jamanetworkopen.2019.16646. No other disclosures were reported. This study was approved by the institutional review board of the University of Texas Medical Branch and complies with the Centers for Medicare & Medicaid Services (CMS) Data Use Agreement requirements, which waived the need for informed consent for use of the study data because data were deidentified. Epub 2013 Jul 10.  et al. 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). 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