Gerben DeJong

Poststroke Rehabilitation: Outcomes and Reimbursement of Inpatient Rehabilitation Facilities and Subacute Rehabilitation Programs

Background and Purpose— To assess whether poststroke rehabilitation outcomes and reimbursement for Medicare beneficiaries differ across inpatient rehabilitation facilities (IRFs) and skilled nursing facility (SNF) subacute rehabilitation programs. Methods— Clinical data were linked with Medicare claims for 58 724 Medicare beneficiaries with a recent stroke who completed treatment in 1996 or 1997 in IRFs and subacute rehabilitation SNFs that subscribed to the Uniform Data System for Medical Rehabilitation. Outcome measures were discharge destination, discharge FIM ratings and Medicare Part A reimbursement during the institutional stay. Results— IRF patients that were more likely to have a community-based discharge, compared with rehabilitation SNF patients, were patients with mild motor disabilities and FIM cognitive ratings of 23 or greater (adjusted odds ratio [AOR]=2.19; 95% CI: 1.52 to 3.14), patients with moderate motor disabilities (AOR=1.98; 95% CI: 1.49 to 2.61), patients with significant motor disabilities (AOR=1.26; 95% CI: 1.01 to 1.57) and patients younger than 82 with severe motor disabilities (AOR=1.43; 95% CI: 1.25 to 1.64). IRF patients with significant and severe motor disabilities achieved greater motor function of 2 or more FIM units compared with rehabilitation SNF patients. Medicare Part A payments for IRFs were higher than rehabilitation SNF payments across all subgroups. Conclusions— For most patients, poststroke rehabilitation in the more costly and intensive IRFs resulted in higher functional outcomes compared with care in a SNF-based rehabilitation program. IRF and SNF outcomes were similar for patients with minimal motor disabilities and patients with mild motor disabilities and significant cognitive disabilities. Cost-effectiveness analyses require considering the costs of the full episode of care.

Predicting the stroke patient's ability to live independently.

The objective of this paper is to identify those variables that best predict a stroke patients ability to live independently following his/her discharge from medical rehabilitation. The paper draws heavily on a formal research model grounded in independent living (IL) theory. Independent living is defined and operationalized as (1) the patients ability to live in a nonrestrictive environment and (2) the patients ability to live productively–not only in terms of gainful employment but also in terms of other contributions to community and family life. The main data source for the study is an extensive computer file of 84 stroke patients discharged from 8 medical rehabilitation centers. The multivariate statistical analysis indicates that 56 to 80 percent of the variance in a patients ability to live independently can be explained or predicted mainly by the patients marital status, age, Barthel score, communication impairments, and the ability to get into a motor vehicle. The paper concludes by discussing the implications of the findings for medical rehabilitation and public policy.

Practice-Based Evidence Research in Rehabilitation: An Alternative to Randomized Controlled Trials and Traditional Observational Studies

Sound rigorous methods are needed by researchers and providers to address practical questions about risks, benefits, and costs of interventions as they occur in routine clinical practice such as: Are treatments used in daily practice associated with intended outcomes? For whom does an intervention work best? With limited clinical resources, what are the best interventions to use for specific types of patients? Answers to such questions can help clinicians, patients, researchers, and health care administrators learn from, and improve, real-world everyday clinical practice. In this article, we describe existing research designs to demonstrate clinical usefulness and comparative effectiveness of rehabilitation treatments. We compare randomized controlled trials and observational cohort studies of various types, including those that use instrumental variables or propensity scores to control for potential patient or treatment selection effects. We argue that practice-based evidence (PBE) study designs include features that address limitations inherent in both randomized trials and traditional observational studies, and also reduce the need for instrumental variables and propensity scores methods. We give examples of how PBE designs have been used in various rehabilitation areas to determine better treatments for specific types of patients.

America's neglected health minority: working-age persons with disabilities.

Debates on health policy at the national level often overlook categorically the 19 million working-age persons with disabilities. Although this heterogeneous population with significantly diverse health statuses has higher than average rates of health care utilization, it remains questionable whether the demographic subgroup sufficiently receives needed types of care. As such, particular targeted solutions in health services delivery are warranted to meet the special requirements of working-age disabled persons. At the same time, access to mainstream health care financing is crucial for a population already excluded frequently from private health insurance coverage.

An Overview of the Problem1

This article outlines the ongoing health care needs of people with disabilities and how organized health care, particularly primary care, often fails to address these needs in a timely fashion. The articles central argument is that managed care and the ferment present in health care today present eThis article outlines the ongoing health care needs of people with disabilities and how organized health care, particularly primary care, often fails to address these needs in a timely fashion. The articles central argument is that managed care and the ferment present in health care today present enormous opportunities for rehabilitation providers and others to develop creative solutions to address the shortcomings of the present health care system.

Toward a National Personal Assistance Program: The Independent Living Model of Long-Term Care for Persons with Disabilities

Long-term care for people with disabilities in this country traditionally has been provided through family members and friends. Federal and state policy has focused primarily on financing professional health care services provided through nursing homes and home health agencies. An alternative to these models of long-term care is the independent living model, which is based on the provision of services by nonprofessional personal assistants in the disabled persons home. We describe the model and consider why it is not the dominant approach to long-term care in the United States. We go on to assess options for developing a national personal assistance services program based on the independent living framework, discussing how covered services should be defined, how the program should be financed, whether the program should use means testing, how eligibility and level of benefits should be determined, and what role government should play in implementing the program. Several legislative approaches to developing a national program are explored.

Program evaluation of physical medicine and rehabilitation departments using self-report Barthel

The Barthel Index measures performance of personal care (feeding, dressing, hygiene) and mobility (transferring, walking/wheeling) activities. Since its inception, several revisions of this index have increased its accuracy in measuring functional ability of patients during medical rehabilitation. However, this activities of daily living (ADL) scale is rarely used to determine the abilities of individuals after discharge, leaving assessment of functional outcome incomplete. In this study this index has been converted to a self-report format, which can be completed easily by the patient or family member both during the rehabilitation stay and after discharge. The reliability of the self-report version is examined, by comparing the assessments of patients to those made by the health professionals. A sample of persons at an inpatient rehabilitation facility, who could both read and write, completed the self-report during the week before discharge. Results comparing the assessment of professionals and patients showed a statistically significant difference with p less than 0.001. This paper will suggest reasons for the difference and explore the possibility of using this self-report version as a means to evaluate both the short-and long-term outcomes of rehabilitation programs.

Rehospitalization in the First Year of Traumatic Spinal Cord Injury After Discharge From Medical Rehabilitation

OBJECTIVEnTo determine rates of rehospitalization among discharged rehabilitation patients with traumatic spinal cord injury (SCI) in the first 12 months postinjury, and to identify factors associated with rehospitalization.nnnDESIGNnProspective observational cohort study.nnnSETTINGnSix geographically dispersed rehabilitation centers in the U.S.nnnPARTICIPANTSnConsecutively enrolled individuals with new traumatic SCI (N=951), who were discharged from participating rehabilitation centers and participated in a 1-year follow-up survey.nnnINTERVENTIONSnNot applicable.nnnMAIN OUTCOME MEASURESnOccurrence of postrehabilitation rehospitalization within 1 year of injury, length of rehospitalization stays, and causes of rehospitalizations.nnnRESULTSnMore than one third (36.2%) of participants were rehospitalized at least once in the 12-month follow-up period; 12.5% were rehospitalized at least twice. The average number of rehospitalizations among those rehospitalized at least once was 1.37 times, with an average length of stay (LOS) of 15.5 days across all rehospitalization episodes. The 3 most common health conditions associated with rehospitalization were those related to the genitourinary system (eg, urinary tract infection), respiratory system (eg, pneumonia), and skin and subcutaneous tissue (eg, pressure ulcer). Being a woman (95% confidence interval [CI], 1.034-2.279), having Medicaid as the main payer (95% CI, 1.303-2.936), and more severe case mix were associated with increased odds of rehospitalization. Those who had more intensive physical therapy (95% CI, .960-.981) had lower odds of rehospitalization. Some center-to-center variation in rehospitalization rates remained unexplained after case mix and practice differences were considered. The 6 SCI rehabilitation centers varied nearly 2-fold in rates at which their former SCI patients were rehospitalized--from 27.8% to 50%. Center-to-center variation diminished when patient case mix was considered.nnnCONCLUSIONSnCompared with earlier studies, rehospitalization rates among individuals with SCI in the first postinjury year remain high and vary by level and completeness of injury. Rehospitalization risk was associated with younger age, being a woman, unemployment and retirement, and Medicaid coverage. Those who had more intensive physical therapy had lower odds of rehospitalization. Future studies should examine center-to-center variations in rehospitalization rates and availability of patient education and community resources.

Predicting long-term outcome among post-rehabilitation stroke patients.

This paper examines correlates of long-term outcome in a sample of 89 stroke patients discharged from medical rehabilitation. Patients in this study were recruited in 1984 and followed prospectively for a 12-month period postdischarge. This analysis builds on previous studies which have called researchers to move beyond single-outcome studies which use only bivariate analysis. Multivariate techniques are used to evaluate the influence of a number of predictor variables on three measures of long-term outcome: 1) a composite variable that includes functional status, mortality and discharge disposition (home v nursing home); 2) life satisfaction; and 3) medical charges. The results show that 1) multivariate analyses present a different picture from that obtained when using bivariate analysis; and 2) the same predictor variables are not equally important in predicting different outcome variables. From 30-42% of the variance in the three dependent variables is explained by severity of illness, function at admission, age, wheelchair use and in- and out-of-house social supports.

Outcomes and reimbursement of inpatient rehabilitation facilities and subacute rehabilitation programs for Medicare beneficiaries with hip fracture.

Objective:We sought to assess whether outcomes and reimbursement differ for Medicare beneficiaries with hip fracture when treated in an inpatient rehabilitation facility (IRF) compared with a skilled nursing facility (SNF) subacute rehabilitation program. Participants:Clinical data were linked with Medicare claims for 29,793 Medicare fee-for-service beneficiaries with a recent hip fracture who completed treatment in 1996 or 1997 in rehabilitation facilities that subscribed to the Uniform Data System for Medical Rehabilitation. Outcome Measures:We measured discharge destination, change in motor FIM™ rating, and Medicare Part A reimbursement. Results:For patients with moderate-to-severe and severe disabilities, case mix groups (CMGs) 704 and 705, the percentage of patients discharged to the community from IRFs was lower than for patients treated in subacute rehabilitation SNFs, after controlling for covariates. Adjusted odds ratios were 0.71 (95% confidence interval 0.55–0.92) for CMG 704 and 0.72 (95% confidence interval 0.63–0.83) for CMG 705. For patients in the 3 other CMGs, no significant differences were detected. Improvement in motor functional status was roughly equivalent for patients treated in IRFs and those treated in the subacute rehabilitation programs across all 5 CMGs, after controlling for covariates. Medicare Part A payments for IRFs were significantly higher than SNF payments across all CMGs. Conclusion:SNF-based subacute rehabilitation was less costly and outcomes were in most, but not all, instances similar or better than IRF-based rehabilitation for Medicare fee-for-service beneficiaries who had a recent hip fracture.