irf vs snf

This is an important topic for future research. 0000006067 00000 n In contrast, the 4 instrumental variable models resulted in odds of mortality closer to 1.0, with ORs ranging from 0.92 (95% CI, 0.76-1.11) when adjusted for previous IRF or SNF assignment by stroke type within each hospital to 1.25 (95% CI, 0.88-1.76) when adjusted by differential distance from patient’s residence to the nearest IRF or SNF (Table 4).  YF, Duan  J, Goodwin In multivariate adjustment analysis, the mean (SE) difference in scores between patients from IRF vs SNF was 7.8 (0.05) points for mobility and 9.7 (0.06) points for self-care. 0000039735 00000 n 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). CMS developed the DTC-PAC measures to meet the IMPACT Act mandate and finalized them through rulemaking in Fiscal Year 2017 (IRF, LTCH, SNF) and Calendar Year 2017 (HH). Our findings indicate the need to carefully manage discharge to postacute care based on the patient’s needs and potential for recovery. The investigation included 99,185 stroke patients who received post-acute care services at a SNF or IRF between Jan. 2013 and Nov. 2014. 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 changes in mobility and self-care scores were substantially greater among IRF patients. 0000002436 00000 n 0000049774 00000 n 304 0 obj <> endobj The assumption was that mortality in this time frame would be closely linked to health status and minimally associated with the type of facility. 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. 0000004344 00000 n A unified approach to measuring the effect size between two groups using SAS. 0000018480 00000 n 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. 0000042411 00000 n Our responses appear below. An IRF is designed to provide intensive rehabilitation to complex patients who need specialized care.  P.  Predicting discharge destination after stroke: a systematic review.Â, Werner %%EOF Had a longer hospital LOS After IPW adjustment mortality and rehospitalization/mortality rates remained significantly better for … For patients who are seeking rehabilitation services, there are typically two options to select: Inpatient Rehabilitation Hospital or Skilled Nursing Facility. 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. 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. Additional Contributions: Sarah Toombs Smith, PhD, ELS (University of Texas Medical Branch), provided assistance in proofreading and editing the manuscript. 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. 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.  DB. 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.  DE, Alter doi:10.1001/jamanetworkopen.2019.16646.  et al. Skilled Nurisng Facilities -- Services, Expenditures, and Payment Methods However, it is essential that they be educated on the differences in those options. Next, we used hierarchical general linear mixed-effects models to account for patients nested within hospitals. Question  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. 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.  et al. Differences between inpatient rehabilitation & skilled nursing care 1.  L, Velozo Comparing “Apples to Oranges” is a long-standing concern in studies of functional outcomes involving IRFs and SNFs. What Constitutes an IRF vs. a Skilled Nursing Facility. 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.  TS, Han Theresa Sullivan 2 years ago. A significant difference in functional improvement remained after accounting for patient, clinical, and facility characteristics at admission.  ES, Wennberg 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. The difference in findings between the Mallinson et al study34 and our study could be related to many factors. As the IMPACT Act3 and unified payment are implemented, it will be important to accurately identify subgroups and target patients who would do better in one setting vs another.  H, Sloane  JP, Stein 0000070681 00000 n Our findings and the research of Buntin et al36 indicate that it may be possible to improve our ability to identify appropriate candidates for the high-intensity, specialized services provided in IRFs. A higher proportion of women were admitted to SNFs (21 466 [64.8%] women) than IRFs (36 462 [55.2%] women) (P < .001). 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. The 2014 Improving Medicare Post-Acute Care Transformation (IMPACT) Act3 requires the Secretary of the Department of Health and Human Services to establish a unified payment system for postacute care. • 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 … 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. Multivariable, propensity score, and instrumental variable analyses showed a similar magnitude of better improvements in patients admitted to IRF vs those admitted to SNF. Table 3 presents stroke outcomes by mobility and self-care discharge scores for patients in IRF or SNF. JAMA Netw Open. Dr Karmarkar reported receiving grants from the National Institutes of Health (NIH) and being an employee of RTI International outside the submitted work.  DA, Gottlieb 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. We began with unadjusted bivariate analyses of all variables compared across IRF and SNF settings. 0000049580 00000 n 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). 0000049018 00000 n 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. 0000057261 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), 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).  Poststroke rehabilitation: outcomes and reimbursement of inpatient rehabilitation facilities and subacute rehabilitation programs.Â, Mallinson 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.  30- to 365-d Mortality From Hospital Discharge Between IRFs and SNFs. This finding raises questions about the value of any policy that would reimburse IRFs or SNFs at the same standard rate for stroke. Patient Comorbidities Between Skilled Nursing Facility (SNF) Stays Included in the Cohort and Those Excluded Due to Incomplete Data for Function Scores, eTable 3.  L, Liang 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. 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. 0000071342 00000 n Our findings are based on Medicare files for IRF and SNF settings only and are not applicable to stroke rehabilitation in other postacute venues (eg, home health care, long-term care hospitals, or outpatient care). 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.  SH, Kuo Design, Setting, and Participants  The information will be posted with your response.  Specification tests in econometrics.Â, Kennedy  Translating measures across the continuum of care: using Rasch analysis to create a crosswalk between the Functional Independence Measure and the Minimum Data Set.Â, Hong © 2020 American Medical Association. The researchers found that IRF patients had better clinical outcomes than patients treated in SNFs on five of six measures. Exposures  It is not possible to directly measure the size of the population of marginal patients.  ME, Jette Administrative, technical, or material support: Mallinson.  Unexplained variation for hospitals’ use of inpatient rehabilitation and skilled nursing facilities after an acute ischemic stroke.Â, Magdon-Ismail 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. 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. 0000007455 00000 n  C, Bonito 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. h�b``d`��������� �� @1v�'/S�1�G�$L$>aT��Д�tjZ�R)�4���^W�U����Wt A������l!F ��>`i>� ���}�́��L%��� � endstream endobj 380 0 obj <>/Filter/FlateDecode/Index[26 278]/Length 31/Size 304/Type/XRef/W[1 1 1]>>stream 0000006541 00000 n  M, Konetzka Researchers …  J, Yperzeele Adjustment for patient and hospital characteristics in a multivariate adjustment model increased the OR to 0.72 (95% CI, 0.69-0.74), which was similar to results of the inverse probability weighted propensity models (adjusted odds ratio, 0.75 [95% CI, 0.72-0.77]).  P.  Sensitivity analysis in observational research: introducing the E-Value.Â, Centers for Medicare & Medicaid Services. In order to assess the ability of the various analytic techniques to adjust for unmeasured confounders, we assessed mortality between 30 and 365 days as a control outcome (Table 4). 0000003694 00000 n  GN, Freeman  Y, Thomas The. 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.  P, Sood  MJ.  PR, Rubin IRF versus SNF.  Association between cholecystectomy with vs without intraoperative cholangiography and risk of common duct injury.Â, Stukel 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]).  W, Rabinstein  AW, Black 0000070603 00000 n doi:10.1001/jamanetworkopen.2019.16646. Concept and design: Goodwin, Reistetter, Kuo, Karmarkar, Ottenbacher.  Jr, Goodwin  Postacute care setting, facility characteristics, and poststroke outcomes: a systematic review.Â, Centers for Medicare & Medicaid Services, HHS. Data were analyzed from January 17, 2017, through April 25, 2019. Terms of Use| These resources will help determine what is best for you or your loved one. 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. 0000049525 00000 n 0000053855 00000 n Dr Ottenbacher reported receiving grants from the NIH during the conduct of the study and personal fees from the Kessler Foundation outside the submitted work. 0000023591 00000 n If the IRF is a part of the acute care hospital, the patient will have their primary physician and any clinical specialists that followed the patient in the hospital available to them during their IRF stay. The lower confidence limit of the E-value was 4.0 for the change in mobility and 4.2 for self-care scores. Effective administrative oversight will be required to ensure patients receive the appropriate care in the right setting. 0000014349 00000 n 0000021591 00000 n 0000046762 00000 n  TR, Bateman 0000053395 00000 n 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. 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. The national average length of time spent at a skilled nursing facility rehab is 28 days. Health care reform legislation and Medicare plans for unified payment for postacute care highlight the need for research examining service delivery and outcomes.  Medicare spending and outcomes after postacute care for stroke and hip fracture.Â, Ottenbacher  J, Tseng 0000007974 00000 n Discharge to home, a skilled nursing facility (SNF), or an inpatient rehabilitation facility (IRF) was the primary outcome. 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). 0000057755 00000 n At an SNF, Medicare Part A will cover up to 100 days of skilled nursing care per spell of illness. 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. Not all submitted comments are published. 0000003831 00000 n 304 78  Z, Hortobagyi 0000006251 00000 n  Equating activities of daily living outcome measures: the Functional Independence Measure and the Korean version of Modified Barthel Index.Â, Eicheldinger Congress and CMS have set in motion an ambitious plan to significantly reform post-acute care, which includes long-term care hospitals (LTCH), inpatient rehabilitation facilities (IRF), skilled nursing facilities SNF) and home health (HH) agencies. Drafting of the manuscript: Hong, Goodwin, Ottenbacher. Table 1 presents the baseline differences in the patient characteristics between those admitted to IRFs or SNFs. Our data included Medicare files from 2012 to 2014. 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).  et al. 381 0 obj <>stream Acute vs. Sub-Acute Rehabilitation. 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). 0000014526 00000 n  JE. 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]). A 10-point difference in self-care in an IRF is the difference between a patient rating of needing maximal assistance vs needing supervision. |���_�m���6�A���4y���l6����2�p&�x���OU�!���� ���/87�:�1�`g�R@FjY�o����E�F����K��cf'�Ly��V���n�f��|��$c��f�m �F�  T, Deutsch Paper presented at: SAS Global Forum; April 22, 2012; Orlando, FL. 0000070360 00000 n 0000010004 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. 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.  N-W, Baillargeon The Manual Updates to Clarify Skilled Nursing Facility (SNF), Inpatient Rehabilitation Facility (IRF), Home Health (HH), and Outpatient (OPT) Coverage Pursuant to Jimmo vs. Sebelius can be found in CR 8458 (PDF) and in associated MLN Matters Article, MM8458 (PDF) MLN Connects Newsletter. 0000018293 00000 n If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. 0000021775 00000 n The Medicare Payment Advisory Commission reports6,37 consistently demonstrate that IRF costs are higher than those of SNF and home health. 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. We believe the difference in conditions (ie, hip fracture and joint replacement vs stroke) is the most plausible explanation. 0000049131 00000 n  The central role of the propensity score in observational studies for causal effects.Â, Kuo  Z, Sicklick  Risk adjustment of Medicare capitation payments using the CMS-HCC model.Â, Rosenbaum  Limits of observational data in determining outcomes from cancer therapy.Â, Sheffield  J.  Selection of Postacute stroke rehabilitation facilities: a survey of discharge planners from the northeast cerebrovascular consortium (NECC) region.Â, Bettger  KJ, Hsu  Hospital variation in functional recovery after stroke.Â, Mees  Hospitalization costs for acute ischemic stroke patients treated with intravenous thrombolysis in the United States are substantially higher than Medicare payments.Â, Mallinson 0000039660 00000 n startxref 0000050089 00000 n %PDF-1.4 %���� 0000025802 00000 n Another concern is the current cost differential between postacute care settings. eFigure. Objective: To compare functional outcomes in patients with stroke after postacute care in inpatient rehabilitation facilities (IRF) vs skilled nursing facilities (SNF). Dr Kuo reported receiving grants from the AHRQ during the conduct of the study and grants from the National Institute on Drug Abuse outside the submitted work.  M, Ulbricht Functional Measures: Mobility and Self-Care. 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.  R, Horner All Rights Reserved. Y.-L. Lin reported grants from National Institutes of Health during the conduct of the study.  D.  Differences in rehabilitation services and outcomes among stroke patients cared for in veterans hospitals.Â, Deutsch Inpatient rehabilitation received in IRFs vs SNFs. © 2019 Hong I et al.  Does postacute care site matter: a longitudinal study assessing functional recovery after a stroke.Â, Hoenig Accepted for Publication: October 9, 2019. More have dementia. We hypothesized that patients discharged to IRFs would have larger improvements in mobility and self-care function than those discharged to SNFs. 0000071429 00000 n trailer Brinjikji The next chart provides an explanation of acute vs. sub-acute rehabilitation services. Dr Mallinson reported receiving grants from National Institute on Disability and Rehabilitation Research outside the submitted work. 0000002254 00000 n 0000032977 00000 n 2019;2(12):e1916646. The assumption is that the underlying health of patients with stroke would vary somewhat among HRRs, but not markedly, and that the variation reflects local availability of the 2 types of facilities along with other medical cultural issues.  NB, Qi 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. Stays in skilled nursing facilities (SNFs) are also common. This finding raises questions about the value of any policy that would reimburse IRFs or SNFs at the same standard rate for stroke. 0000009025 00000 n  Unadjusted Admission and Discharge Results, Table 3.  RP, Garber 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.  SJ.  JP, Garber 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. The CMS 60% rule identifies 13 diagnostic conditions that classify a facility as an IRF for Medicare reimbursement.35 Stroke is the largest category of these conditions, with 20.5% of all patients in IRFs in 2017.6.  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 Stroke Comorbidities Across Inpatient Rehabilitation Facilities (IRFs) and Skilled Nursing Facilities (SNFs) Before and After Inverse Probability of Treatment Weighting, eTable 6. 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. Medicare claims were used to link to IRF and SNF assessments.  KM, Riall Ickpyo Hong, PhD, OTR, and Kenneth J. Ottenbacher, PhD, OTR. 0000002595 00000 n 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). At SNFs, therapy services vary widely and are generally less than IRFs, Dr. Arbabi says. Comparative research related to functional outcomes for persons with stroke receiving rehabilitation in IRFs vs SNFs is limited, to our knowledge.  JP, Thomas 0000046580 00000 n Hong I, Goodwin JS, Reistetter TA, et al. 0000021088 00000 n 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). 0000034254 00000 n  Common-person equating with the Rasch model.Â, Velozo Identify all potential conflicts of interest that might be relevant to your comment.  YC, Joseph  MB, Colla Customize your JAMA Network experience by selecting one or more topics from the list below.  JJ. 0000001892 00000 n Appropriate Patient Placement 2.  Comparison of discharge functional status after rehabilitation in skilled nursing, home health, and medical rehabilitation settings for patients after hip fracture repair.Â, Buntin 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.  RM, Coe 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). 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). For patients who are seeking rehabilitation services, there are typically two options to select: Acute Rehab or Skilled Nursing Facility. I found this article very interesting. Our website uses cookies to enhance your experience. 0000070242 00000 n  CY, Yoonjeong Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Hong, Kuo, Karmarkar, Lin.  Potentially preventable hospitalizations in Medicare patients with diabetes: a comparison of primary care provided by nurse practitioners versus physicians.Â. Inpatient Rehab Facility (IRF) vs. 0000016541 00000 n  AM. Inpatient rehabilitation received in IRFs vs SNFs.  JS. 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. 0000006429 00000 n Obtained funding: Reistetter, Ottenbacher. 0000049209 00000 n 0000006655 00000 n We used mobility and self-care items from the Inpatient Rehabilitation Facility-Patient Assessment Instrument and the Minimum Data Set 3.0 (eTable 3 in the Supplement).  TJ, Ding I am curious as to whether the following factors were accounted for: I am involved in the AAPMR at the committee level. When it comes to inpatient rehabilitation, the Encompass Health difference is our people, our approach and our outcomes.  P, Cras There are several approaches to mitigating this problem.  S, Li  KL, Wang This cohort study included 99 185 patients who received postacute care in inpatient rehabilitation or skilled nursing facilities after a stroke. There are challenges in comparing outcomes in observational studies, the most important of which is bias by indication, or selection bias. This method has demonstrated efficacy in several settings.16,17. Medicare Requirements for Inpatient Rehabilitation Facility (IRF) vs.  MA, Goodwin Patients have various options to meet their rehabilitation needs. In a skilled nursing facility, Medicare pays for 100 days per stretch, with the first 20 days fully paid for under certain conditions.  JP. In this study, we compared functional outcomes of patients with stroke who were discharged from a hospital to an IRF or SNF. 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. Main Outcomes and Measures  Is change in physical function associated with receiving postacute care after a stroke in inpatient rehabilitation vs skilled nursing facilities?  L, Liang  JS. 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. 0000023767 00000 n  N, Escarce Newhouse 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. Conflict of Interest Disclosures: Dr Reistetter reported receiving grants from the Agency for Healthcare Research and Quality (AHRQ) during the conduct of the study.  CV, Heinemann 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. Yang 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.  RP,  CV, Fiedler 0000071574 00000 n 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. 0000070972 00000 n 0000039541 00000 n For patients who are seeking rehabilitation services, there are typically two options to select: Inpatient Rehabilitation or Skilled Nursing Facility.  L, Sandel 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. 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). Instrumental Variables Across Inpatient Rehabilitation Facilities (IRFs) and Skilled Nursing Facilities (SNFs), eTable 8.

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