There are challenges in comparing outcomes in observational studies, the most important of which is bias by indication, or selection bias.  YC, Joseph  J, Raji 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. The next chart provides an explanation of acute vs. sub-acute rehabilitation services. The propensity score was generated with a logistic regression model using an average treatment effect estimation20 that incorporated all covariates listed in eTable 4 and eTable 5 in the Supplement. Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued. To compare functional outcomes in patients with stroke after postacute care in inpatient rehabilitation facilities (IRF) vs skilled nursing facilities (SNF). 304 78 Definitions of Skilled and IRF Care Definition of Definition of the Skilled Rehabilitation Care Nursing Care: The Inpatient Rehabilitation Facility (IRF) provides The SNF provides services to an inpatient intermittent and/or daily who needs a relatively skilled care services.  J, Goodwin • IRF patients experienced an 8 percentage point lower mortality rate during the two-year study period than SNF patients (p<0.0001) • IRF patients experienced 5 percent fewer emergency room (ER) visits per year than SNF patients (p<0.0001) • For five of the 13 conditions, IRF patients …  J, Ellis Compared with patients in IRFs, patients in SNFs had lower mean scores for mobility (44.2 [95% CI, 44.1-44.3] points vs 40.8 [95% CI, 40.7-40.9] points) and self-care (45.0 [95% CI, 44.9-45.1] points vs 41.8 [95% CI, 41.7-41.9] points) at admission and for mobility (55.8 [95% CI, 55.7-55.9] points vs 44.4 [95% CI, 44.3-44.5] points) and self-care (58.6 [95% CI, 58.5-58.7] points vs 45.1 [95% CI, 45.0-45.2] points) at discharge.  GM, Brock Background: We sought to compare outcomes 6-12 months post-injury between patients discharged to an inpatient rehabilitation facility (IRF) and a skilled nursing facility (SNF). 0000049018 00000 n Our findings indicate the need to carefully manage discharge to postacute care based on the patient’s needs and potential for recovery.  et al. We also found differences in functional outcomes between IRF and SNF using logistic regression and propensity scores.  KA, Lunt Health care reform legislation and Medicare plans for unified payment for postacute care highlight the need for research examining service delivery and outcomes. 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. We used several analytic approaches to control for potential confounders across IRF and SNF settings, including multivariable analysis, inverse probability weighting with propensity scores and instrumental variable analyses. 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. 0000016541 00000 n  BR. 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]).  Using propensity scores to help design observational studies: application to the tobacco litigation.Â, Hausman  ES, Wennberg  ME, Jette  AM, Newhouse Privacy Policy| For the sixth measure, hospital readmissions, IRF patients had fewer hospital readmissions than SNF patients for five of the 13 conditions (amputation, brain injury, hip fracture, major medical complexity, and pain syndrome). endstream endobj 380 0 obj <>/Filter/FlateDecode/Index[26 278]/Length 31/Size 304/Type/XRef/W[1 1 1]>>stream  J, Tseng A higher proportion of women were admitted to SNFs (21 466 [64.8%] women) than IRFs (36 462 [55.2%] women) (P < .001). startxref Maximal assistance requires another person to physically assist the patient. 0000003694 00000 n For self-care, the change was 13.6 (95% CI, 13.5-13.7) points vs 3.2 (95% CI, 3.1-3.3) points. Conclusions and Relevance   C, Bonito  Risk adjustment of Medicare capitation payments using the CMS-HCC model.Â, Rosenbaum Our methods are described in more detail in the eAppendix in the Supplement. More are female. 0000052989 00000 n 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).  JA. Results of instrumental variable analyses are summarized in Table 3 and show similar results, including by differential distance from acute care hospital to nearest IRF or SNF (mean [SE] difference: mobility score, 8.2 [0.34] points; self-care score, 9.8 [0.39] points), by differential distance from patient’s residence to nearest IRF or SNF (mean [SE] difference: mobility score, 5.6 [0.63] points; self-care score, … 0000025538 00000 n The difference in findings between the Mallinson et al study34 and our study could be related to many factors. In a skilled nursing facility, Medicare pays for 100 days per stretch, with the first 20 days fully paid for under certain conditions. The Minimum Data Set 3.0 consists of 6 mobility items with a 4-point rating scale and 5 self-care items with a 5-point rating scale. 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. 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).  JP, Stein  A.  More accurate racial and ethnic codes for Medicare administrative data.Â, Pope An IRF is designed to provide intensive rehabilitation to complex patients who need specialized care. We selected this outcome to assess how well the analytic techniques controlled for any differences in underlying health status between patients admitted to IRF or SNF. 0000007974 00000 n  HJ. Our study adds to the accumulating scientific literature that better functional outcomes, such as mobility and self-care, are associated with discharge from IRFs vs SNFs among stroke survivors.4,29,31,32 This has not been true for other conditions, such as hip fracture or joint replacement.34 A study by Mallinson et al34 comparing mobility and self-care outcomes, which were measured in the same way as in our study, among patients with hip fracture receiving rehabilitation from IRFs, SNFs, or home health agencies found no statistically significant differences in fully adjusted models.  Association between cholecystectomy with vs without intraoperative cholangiography and risk of common duct injury.Â, Stukel  Comparison of discharge functional status after rehabilitation in skilled nursing, home health, and medical rehabilitation settings for patients after hip fracture repair.Â, Buntin Findings  0000056853 00000 n 0000010004 00000 n In this study, we used all-cause mortality between 30 and 365 days after hospital discharge as a control outcome. endstream endobj 305 0 obj <>/Metadata 24 0 R/Pages 23 0 R/StructTreeRoot 26 0 R/Type/Catalog/ViewerPreferences<>>> endobj 306 0 obj <. Compared with patients admitted to IRFs, patients admitted to SNFs were older (mean [SD] age, 79.4 [7.6] years vs 83.3 [7.8] years; P < .001), had longer hospital LOS (mean [SD], 4.6 [3.0] days vs 5.9 [4.2] days; P < .001), and had more comorbidities (mean [SD], 2.8 [2.0] comorbidities vs 3.3 [2.1] comorbidities; P < .001) (Table 1; eTable 4 in the Supplement). Were in a SNF in the prior 6 mo.  Specification tests in econometrics.Â, Kennedy More have dementia.  RP, Garber  SH, Kuo Accessibility Statement, Table 1. I am curious as to whether the following factors were accounted for: I am involved in the AAPMR at the committee level. JAMA Network Open.  J, Yperzeele 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). Stroke is a complex neurological condition affecting multiple body systems and requiring intensive rehabilitation from several disciplines with different areas of expertise. The instrumental variable analyses in this study describe the outcomes of the marginal patient, that is, those patients who reasonably could have been discharged either to an IRF or SNF. © 2020 American Medical Association.  Hospitalization costs for acute ischemic stroke patients treated with intravenous thrombolysis in the United States are substantially higher than Medicare payments.Â, Mallinson  MB, Colla Regardless of covariate adjustment method, the patients with stroke who were discharged from IRF had higher mobility and self-care scores than those discharged from SNF. Impact: The update increased reimbursement for skilled nursing facilities. 0000021775 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. In this study, we compared functional outcomes of patients with stroke who were discharged from a hospital to an IRF or SNF. One way to estimate the size of the marginal patient population is to examine the distribution in variation in percentage of patients with stroke discharged to an IRF or SNF among HRRs. 0000018293 00000 n IRF: Higher level of care than a SNF. One approach is to assess how large a bias would have to be to eliminate the association observed, which allows the reader to judge whether the existence of such a bias is plausible, such as by use of the E-value.10 Another approach is to indirectly assess the strength of the bias and whether it is eliminated by a specific analytic approach, such as by using a control outcome, a measure that should not be affected by differences between the 2 treatments but would be affected by selection biases.  NB, Qi 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. 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. Next, we used hierarchical general linear mixed-effects models to account for patients nested within hospitals. 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. 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. The information will be posted with your response.  KL, Wang These differences were no longer statistically significant in the instrumental variable analyses. Results of instrumental variable analyses are summarized in Table 3 and show similar results, including by differential distance from acute care hospital to nearest IRF or SNF (mean [SE] difference: mobility score, 8.2 [0.34] points; self-care score, 9.8 [0.39] points), by differential distance from patient’s residence to nearest IRF or SNF (mean [SE] difference: mobility score, 5.6 [0.63] points; self-care score, 8.7 [0.72] points), by percentage of IRFs within the acute hospital HRR (mean [SE] difference: mobility score, 10.4 [0.21] points; self-care score, 11.9 [0.25] points), and by previous IRF or SNF assignment by stroke type within each hospital (mean [SE] difference: mobility score, 9.2 [0.30] points; self-care score, 10.7 [0.34] points).  TS, Han  CV, Fiedler 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. 0000049525 00000 n The assumption is that there are patients at the ends of the spectrum who are highly likely to be discharged to an IRF or SNF, but that there are also patients in the middle who could go to either one and for whom the choice is influenced by nonclinical factors.  MJ. 0000006655 00000 n 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. Of the patients who were discharged home, 75% of the SNF-treated patients required homecare services compared with 41.2% of the IRF-treated patients (P < 0.001). Rubin  Factors influencing selection for rehabilitation after stroke: a questionnaire using case scenarios to investigate physician perspectives and level of agreement.Â, Xian  T, Deutsch 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.  CM 0000006067 00000 n For patients who are seeking rehabilitation services, there are typically two options to select: Inpatient Rehabilitation Hospital or Skilled Nursing Facility.  YF, Townsend  Medicare Program; prospective payment system and consolidated billing for skilled nursing facilities for FY 2017, SNF Value-Based Purchasing Program, SNF Quality Reporting Program, and SNF Payment Models Research: final rule.Â, Giordano JAMA Netw Open. Find Medicare-certified inpatient rehabilitation facilities and compare them based on the quality of care they provide to patients. Comparison of Inpatient Rehabilitation Facility-Patient Assessment Instrument (IRF-PAI) With Minimum Data Set 3.0 (MDS) Items in the Mobility and Self-care Construct, eTable 4. 0000070242 00000 n An IRF requires no pre-qualifying hospital stay for Medicare coverage. 0000018480 00000 n %PDF-1.4 %���� 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]). 0000023944 00000 n Author Contributions: Dr Ottenbacher had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. 0000023591 00000 n Compared with patients admitted to IRFs, patients admitted to SNFs were older (mean [SD] age, 79.4 [7.6] years vs 83.3 [7.8] years; P < .001) and had longer hospital length of stay (mean [SD], 4.6 [3.0] days vs 5.9 [4.2] days; P < .001) than those admitted to IRFs. 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.  JP, Garber 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). 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. IRF vs SNF coding are different, and yes, some invasive procedures should be captured on the IRF side as long as the patient’s head is back in the bed the same day before midnight. Please allow up to 2 business days for review, approval, and posting. Stays in skilled nursing facilities (SNFs) are also common.  HS, Shim Currently, the decision-making process in selecting postacute care services is heavily influenced by nonclinical factors.25-30 This is shown by the substantial geographic variation in the proportions of patients with stroke discharged to IRFs or SNFs.28 The choice is associated with measures of availability, such as distance to the nearest facility.29 The association of IRF vs SNF use with these nonclinical factors allows investigators to use them as instruments in an instrumental variable analysis, which should better control for unmeasured confounders that might be influencing the choice of IRF vs SNF. Statistical analysis: Hong, Kuo, Karmarkar, Lin. 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. 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. 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. 0  KM, Riall This pattern is consistent with prior comparative effectiveness studies using observational data7-9 and reinforces the view that such techniques should be avoided in the face of strong selection bias. 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. 0000049209 00000 n 0000071050 00000 n The LOS in SNFs was more than 2-fold that in IRFs (mean [SD], 38.1 [24.1] days vs 15.2 [7.3] days). 0000025802 00000 n 0000070457 00000 n Objective: To compare functional outcomes in patients with stroke after postacute care in inpatient rehabilitation facilities (IRF) vs skilled nursing facilities (SNF). E-values this large indicate that the association between function score change and postacute care setting we observed was strong.10. We used the crosswalk developed by Mallinson et al14 to construct comparable admission and discharge functional scores for the postacute care settings.15 The scores at admission and discharge for mobility and self-care are reported on a scale of 0 to 100 points, with higher scores indicating greater functional status. These files included Master Beneficiary Summary for patient demographics, Medicare Provider Analysis and Review for claims from hospital and postacute care stays with clinical variables, Inpatient Rehabilitation Facility-Patient Assessment Instrument from IRF,4,11 Minimum Data Set 3.0 from SNF,12 and the Provider of Services Current Files for hospital characteristics. However, the inability of more analytical techniques to eliminate the differences in the control outcome of all-cause mortality between 30 and 365 days suggests that those approaches did not eliminate selection biases. 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. Yang %%EOF 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. Additional research is necessary to confirm our findings and to identify whether any of the other 13 conditions identified by CMS as priority diagnoses for receiving services in IRFs (the 60% rule) may also show differences in functional outcomes based on treatment in IRFs vs SNFs. 0000046762 00000 n 2019;2(12):e1916646.  Poststroke rehabilitation: outcomes and reimbursement of inpatient rehabilitation facilities and subacute rehabilitation programs.Â, Mallinson Mortality between 30 and 365 days after discharge was included as a control outcome as an indicator for unmeasured confounders.  M, Klein A third approach is to use analytic approaches shown to minimize selection biases, such as instrumental variable analysis.7-9 We used these 3 approaches to compare outcomes of patients with stroke who were discharged from acute care to IRFs vs SNFs.
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