Please allow up to 2 business days for review, approval, and posting.  C, Bonito Health care reform legislation and Medicare plans for unified payment for postacute care highlight the need for research examining service delivery and outcomes. Amount (and intensity) of therapy: In a skilled nursing facility you’ll receive one or more therapies for an average of one to two hours per day.  DA, Gottlieb  L, Vanacker Stroke is a complex neurological condition affecting multiple body systems and requiring intensive rehabilitation from several disciplines with different areas of expertise.  KM, Riall The information will be posted with your response. 0000001892 00000 n Skilled Nursing Facility (SNF) IRFs SNFs Physician approval of preadmission screen and admission Yes No Patient requires resource-intensive inpatient care Yes No Close medical supervision by a physician with specialized training Yes No I found this article very interesting. A study assessing the outcomes of patients who were treated in inpatient rehabilitation facilities (IRFs) with clinically and demographically similar patients who received their post-acute rehabilitation in skilled nursing facilities (SNFs) finds that IRFs provide better care to their patients over a number of outcome measures – IRF patients live longer, spend more days at home and fewer days in …  CH, Deb  D.  Differences in rehabilitation services and outcomes among stroke patients cared for in veterans hospitals.Â, Deutsch 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. Have more severe strokes. 304 78  Y, Kuo 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]).  KJ, Hsu  YC, Joseph The assumption was that mortality in this time frame would be closely linked to health status and minimally associated with the type of facility.  Risk adjustment of Medicare capitation payments using the CMS-HCC model.Â, Rosenbaum 0000006429 00000 n  JJ.  A comparison of discharge functional status after rehabilitation in skilled nursing, home health, and medical rehabilitation settings for patients after lower-extremity joint replacement surgery.Â, Masters Concept and design: Goodwin, Reistetter, Kuo, Karmarkar, Ottenbacher.  M, Konetzka  GM, Brock The national average length of time spent at a skilled nursing facility rehab is 28 days.  JS.  CM, Lapane 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. Next, we used inverse probability treatment weighting with propensity scores with and without multilevel adjustment. Objective  0000004344 00000 n Meaning  eFigure. Next, we used hierarchical general linear mixed-effects models to account for patients nested within hospitals. P values were 2-tailed, and statistical significance was set at less than .05. 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). In this study, we compared functional outcomes of patients with stroke who were discharged from a hospital to an IRF or SNF. 0000005883 00000 n Privacy Policy| Not all submitted comments are published.  Postacute care setting, facility characteristics, and poststroke outcomes: a systematic review.Â, Centers for Medicare & Medicaid Services, HHS.  Common-person equating with the Rasch model.Â, Velozo  Unadjusted Admission and Discharge Results, Table 3. 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.  et al. 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. 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. Get free access to newly published articles. 0000046762 00000 n  RD, Zolkewitz 0000050089 00000 n We believe the difference in conditions (ie, hip fracture and joint replacement vs stroke) is the most plausible explanation. 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).  TA, Fisher 0000009636 00000 n Mortality between 30 and 365 days after discharge was included as a control outcome as an indicator for unmeasured confounders. 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.  MJ. Needing supervision simply involves another person being present to monitor the activity but not provide physical assistance unless required. 0000039541 00000 n This finding raises questions about the value of any policy that would reimburse IRFs or SNFs at the same standard rate for stroke.  HJ.  JP, Garber 0000042508 00000 n Whether you are transferred to an IRF or a skilled nursing facility is an important distinction because Medicare covers a different number of days for an IRF than it does for skilled nursing, and you pay a different co-payment. 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. 0000032977 00000 n  J, Ellis 0000039735 00000 n  N-W, Baillargeon 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. An IRF requires no pre-qualifying hospital stay for Medicare coverage. 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. 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. Identify all potential conflicts of interest that might be relevant to your comment.  H, Sloane After IPW adjustment mortality and rehospitalization/mortality rates remained significantly better for … 0000002436 00000 n Skilled Nurisng Facilities -- Services, Expenditures, and Payment Methods As a control outcome, we assessed mortality between 30 and 365 days after hospital discharge.  CY, Yoonjeong  M, Ulbricht 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. 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. Kibria 0000034254 00000 n community for use in the IRF, LTCH, SNF, and home health (HH) QRPs. 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. Design, Setting, and Participants   A.  More accurate racial and ethnic codes for Medicare administrative data.Â, Pope  GN. The goal of IRF services is to get the patient to perform independent daily living activities through physical, occupational, cognitive and social therapy. 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. 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. This cohort study included 99 185 patients who received postacute care in inpatient rehabilitation or skilled nursing facilities after a stroke.  et al. Another concern is the current cost differential between postacute care settings. trailer 0000071574 00000 n 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). 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. 0000071429 00000 n  RT. 0000049525 00000 n 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. 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), 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). Acute Rehab vs. SNF. The national average length of time spent at an acute inpatient rehab hospital is 16 days. 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.  L, Is change in physical function associated with receiving postacute care after a stroke in inpatient rehabilitation vs skilled nursing facilities? 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. Instrumental Variables Across Inpatient Rehabilitation Facilities (IRFs) and Skilled Nursing Facilities (SNFs), eTable 8. 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. 0000070681 00000 n Findings  Were hospitalized more in the prior 6 mo. startxref  Change in Score From Admission to Discharge in IRF and SNF, Table 4. 0000006251 00000 n 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. Inpatient Rehab Facility (IRF) vs. 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). The difference in findings between the Mallinson et al study34 and our study could be related to many factors. 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.  The central role of the propensity score in observational studies for causal effects.Â, Kuo 0000006067 00000 n 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]). E-values this large indicate that the association between function score change and postacute care setting we observed was strong.10. 0000007540 00000 n 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). It is not possible to directly measure the size of the population of marginal patients. 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). Demographics Across Inpatient Rehabilitation Facilities (IRFs) and Skilled Nursing Facilities (SNFs) Before and After Inverse Probability of Treatment Weighting, eTable 5. The outcomes were changes in mobility and self-care scores during the IRF or SNF stay. Functional Measures: Mobility and Self-Care. This method has demonstrated efficacy in several settings.16,17. 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.  JS.  Specification tests in econometrics.Â, Kennedy Importance   HY, Table 1 presents the baseline differences in the patient characteristics between those admitted to IRFs or SNFs.  Y-F, Chen A 10-point difference in self-care in an IRF is the difference between a patient rating of needing maximal assistance vs needing supervision. Stays in skilled nursing facilities (SNFs) are also common.  ES, Wennberg 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. • 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 … 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. 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. Results   KL. 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). 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.  L, Critical revision of the manuscript for important intellectual content: All authors.  Y, Granger 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]).  TR, Bateman  Using propensity scores to help design observational studies: application to the tobacco litigation.Â, Hausman 0000052989 00000 n 0000021775 00000 n More are female.  Equating activities of daily living outcome measures: the Functional Independence Measure and the Korean version of Modified Barthel Index.Â, Eicheldinger  Hospitalization costs for acute ischemic stroke patients treated with intravenous thrombolysis in the United States are substantially higher than Medicare payments.Â, Mallinson 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. Objective: To compare functional outcomes in patients with stroke after postacute care in inpatient rehabilitation facilities (IRF) vs skilled nursing facilities (SNF). 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).  SH, Kuo Stroke Comorbidities Across Inpatient Rehabilitation Facilities (IRFs) and Skilled Nursing Facilities (SNFs) Before and After Inverse Probability of Treatment Weighting, eTable 6. This study has limitations. This finding raises questions about the value of any policy that would reimburse IRFs or SNFs at the same standard rate for stroke. h�bba`b``Ń3� ���� � ��� However, it is essential that they be educated on the differences in those options. 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. 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.  MA, Goodwin  J, Yperzeele  Z, Sicklick  Z, Hortobagyi  L, Liang 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. Statistical analysis: Hong, Kuo, Karmarkar, Lin. Main Outcomes and Measures  0000046580 00000 n We addressed the various bias and confounding issues listed in Dr. Burnetta’s Comment using the most current analytical approaches. 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.  DJ, Vermeulen 0000007455 00000 n For patients who are seeking rehabilitation services, there are typically two options to select: Acute Rehab or Skilled Nursing Facility. 0000012529 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.  et al. 0000070360 00000 n  Analysis of observational studies in the presence of treatment selection bias: effects of invasive cardiac management on AMI survival using propensity score and instrumental variable methods.Â, VanderWeele A higher proportion of women were admitted to SNFs (21 466 [64.8%] women) than IRFs (36 462 [55.2%] women) (. 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. The.  SJ. 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. 0000018293 00000 n Conclusions and Relevance  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). 0000056853 00000 n 0000007974 00000 n  I, Woo Acute vs. Sub-Acute Rehabilitation.  TS, Han  L, Liang %%EOF 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. to download free article PDFs, Additional Diagnoses Related to Cognitive Function, eTable 7. On July 31, the Centers for Medicare & Medicaid Services (CMS) released final rules to update the Medicare fee-for-service prospective payment systems for inpatient rehabilitation facilities (IRFs) and skilled nursing facilities (SNFs) for fiscal year (FY) 2018.. A higher proportion of women were admitted to SNFs (21 466 [64.8%] women) than IRFs (36 462 [55.2%] women) (P < .001).  Geographic variation in health care spending in the United States: insights from an Institute of Medicine report.Â, Alcusky Theresa Sullivan 2 years ago. Our findings indicate the need to carefully manage discharge to postacute care based on the patient’s needs and potential for recovery.  TJ, Ding  DB.  Y, Thomas For patients who are seeking rehabilitation services, there are typically two options to select: Inpatient Rehabilitation or Skilled Nursing Facility.  GC, Kautter 0000021591 00000 n Our findings are similar to what Buntin et al36 estimated as the percentage of patients with marginal stroke and hip fracture. 0000049774 00000 n 0000014526 00000 n 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.  A, Bateman 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. 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, 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. 0000070972 00000 n Discharge to home, a skilled nursing facility (SNF), or an inpatient rehabilitation facility (IRF) was the primary outcome. Were in a SNF in the prior 6 mo. A unified approach to measuring the effect size between two groups using SAS. We also found differences in functional outcomes between IRF and SNF using logistic regression and propensity scores.  et al. 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. E-values for Mobility and Self-care Scores and 30- to 365-Day Mortality From Hospital Discharge. 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 addition, Medicare compensates the facility differently. doi:10.1001/jamanetworkopen.2019.16646. endstream endobj 305 0 obj <>/Metadata 24 0 R/Pages 23 0 R/StructTreeRoot 26 0 R/Type/Catalog/ViewerPreferences<>>> endobj 306 0 obj <. Ickpyo Hong, PhD, OTR, and Kenneth J. Ottenbacher, PhD, OTR. 0000025538 00000 n The multivariable approach used ordinary least squares, adjusting for covariates. 0000002254 00000 n Question  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). The investigation included 99,185 stroke patients who received post-acute care services at a SNF or IRF between Jan. 2013 and Nov. 2014.  MA, Graham Our data included Medicare files from 2012 to 2014.  Does postacute care site matter: a longitudinal study assessing functional recovery after a stroke.Â, Hoenig  JP, Thomas The next chart provides an explanation of acute vs. sub-acute rehabilitation services. 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. Inpatient rehabilitation facilities have more stringent criteria for admission than do SNFs, including the requirement that patients be able to complete 3 hours of rehabilitation therapy daily.  AW, Black  A, Hedeman  Characteristics of Patients Admission to IRF and SNF, Table 2. Maximal assistance requires another person to physically assist the patient. We hypothesized that patients discharged to IRFs would have larger improvements in mobility and self-care function than those discharged to SNFs. When it comes to inpatient rehabilitation, the Encompass Health difference is our people, our approach and our outcomes. 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. People generally receive inpatient therapy in a skilled nursing facility (SNF) or inpatient rehab facility (IRF) following hospitalization for a health event and need to be in an environment where they can receive skilled care and oversight before transitioning to the home.  ME, Jette <<27EF291824D86C4395D1B75C06CED14C>]/Prev 95442/XRefStm 2254>> Open Access: This is an open access article distributed under the terms of the CC-BY License. Had a longer hospital LOS 0000042411 00000 n To compare functional outcomes in patients with stroke after postacute care in inpatient rehabilitation facilities (IRF) vs skilled nursing facilities (SNF). 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.  L, Sandel Brinjikji  J, Tseng  P.  Sensitivity analysis in observational research: introducing the E-Value.Â, Centers for Medicare & Medicaid Services. sign up for alerts, and more, to access your subscriptions, sign up for alerts, and more, to download free article PDFs, sign up for alerts, customize your interests, and more, to make a comment, download free article PDFs, sign up for alerts and more, Archives of Neurology & Psychiatry (1919-1959), https://www.congress.gov/bill/113th-congress/house-bill/4994, http://www.medpac.gov/docs/default-source/data-book/jun19_databook_entirereport_sec.pdf?sfvrsn=0, https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/IRFPAI.html, https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html, http://medpac.gov/docs/default-source/reports/mar19_medpac_entirereport_sec.pdf?sfvrsn=0, Sign Up for Emails Based on Your Interests, FDA Approval and Regulation of Pharmaceuticals, 1983-2018, Global Burden of Skin Diseases, 1990-2017, Health Care Spending in the US and Other High-Income Countries, Life Expectancy and Mortality Rates in the United States, 1959-2017, Medical Marketing in the United States, 1997-2016, Practices to Foster Physician Presence and Connection With Patients in the Clinical Encounter, US Burden of Cardiovascular Disease, 1990-2016, US Burden of Neurological Disease, 1990-2017, Waste in the US Health Care System: Estimated Costs and Potential for Savings, Register for email alerts with links to free full-text articles. In this study, we used all-cause mortality between 30 and 365 days after hospital discharge as a control outcome.  JP.  J, Goodwin 0000070242 00000 n Effective administrative oversight will be required to ensure patients receive the appropriate care in the right setting. There are several approaches to mitigating this problem. Study Flow Diagram for the Sample, eTable 1. 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. 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. The Inpatient Rehabilitation Facility-Patient Assessment Instrument includes 5 mobility items and 6 self-care items, with a 7-point rating scale. 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.  Comparison of discharge functional status after rehabilitation in skilled nursing, home health, and medical rehabilitation settings for patients after hip fracture repair.Â, Buntin © 2020 American Medical Association.  HS, Shim  J,  CA, Byers  RM, Coe Customize your JAMA Network experience by selecting one or more topics from the list below. 0000039660 00000 n Comparing “Apples to Oranges” is a long-standing concern in studies of functional outcomes involving IRFs and SNFs.  J.  Selection of Postacute stroke rehabilitation facilities: a survey of discharge planners from the northeast cerebrovascular consortium (NECC) region.Â, Bettger 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. 0000014349 00000 n Patients have various options to meet their rehabilitation needs. 0000023944 00000 n  Medicare spending and outcomes after postacute care for stroke and hip fracture.Â, Ottenbacher 0000070281 00000 n In a skilled nursing facility, Medicare pays for 100 days per stretch, with the first 20 days fully paid for under certain conditions. Our methods are described in more detail in the eAppendix in the Supplement. 304 0 obj <> endobj Mortality between 30 and 365 days after discharge was included as a control outcome as an indicator for unmeasured confounders.  J, Raji A federal government website managed by the Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, MD 21244 We were not able to examine cognitive function before and after the stroke, stroke severity, or location of the stroke. 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, … 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. These resources will help determine what is best for you or your loved one. 0000006541 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. Multivariable, propensity score, and instrumental variable analyses showed a similar magnitude of better improvements in patients admitted to IRF vs those admitted to SNF. 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). At SNFs, therapy services vary widely and are generally less than IRFs, Dr. Arbabi says. 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). 0  M, McCoy Standardized Difference for Instrumental Variables, eTable 9.  CA. Corresponding Author: Kenneth J. Ottenbacher, PhD, OTR, University of Texas Medical Branch, School of Health Professions, Division of Rehabilitation Sciences, 301 University Blvd, Galveston, TX 77555-1137 (kottenba@utmb.edu). 0000003831 00000 n Please see our commenting policy for details.  KL, Wang 0000010004 00000 n If you have no conflicts of interest, check "No potential conflicts of interest" in the box below.  PR, Rubin  DB.  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 All Rights Reserved. 0000003667 00000 n 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.  30- to 365-d Mortality From Hospital Discharge Between IRFs and SNFs. 0000016541 00000 n Dr Mallinson reported receiving grants from National Institute on Disability and Rehabilitation Research outside the submitted work. 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. 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. More have dementia. We reported the study findings according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline. This is an important topic for future research. Researchers …  A, Granger An IRF is designed to provide intensive rehabilitation to complex patients who need specialized care. 0000049018 00000 n 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). I am curious as to whether the following factors were accounted for: I am involved in the AAPMR at the committee level. Comparative research related to functional outcomes for persons with stroke receiving rehabilitation in IRFs vs SNFs is limited, to our knowledge. A higher proportion of women were admitted to SNFs (21 466 [64.8%] women) than IRFs (36 462 [55.2%] women) (P < .001). © 2020 American Medical Association. 0000046431 00000 n  CV, Heinemann 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. 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. 0000000016 00000 n Terms of Use| The lower confidence limit of the E-value was 4.0 for the change in mobility and 4.2 for self-care scores. JAMA Network Open. 0000070603 00000 n By contrast, Medicare patients in some subacute rehab SNF may not see a doctor more than once a week or in some instances even longer. 2019;2(12):e1916646. 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.  Factors influencing selection for rehabilitation after stroke: a questionnaire using case scenarios to investigate physician perspectives and level of agreement.Â, Xian h�b``d`��������� �� @1v�'/S�1�G�$L$>aT��Д�tjZ�R)�4���^W�U����Wt A������l!F ��>`i>� ���}�́��L%��� �  et al.  A, Mancher  NB, Qi 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). Find Medicare-certified inpatient rehabilitation facilities and compare them based on the quality of care they provide to patients.  YF, Duan Yang  et al. 0000009025 00000 n  M, Klein 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. Additional Contributions: Sarah Toombs Smith, PhD, ELS (University of Texas Medical Branch), provided assistance in proofreading and editing the manuscript. Inpatient rehabilitation received in IRFs vs SNFs. Newhouse 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. 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. 0000070457 00000 n Hospital characteristics included location (urban or rural), hospital type (ie, for-profit, nonprofit, or other), presence of swing beds (yes or no), rehabilitation unit within hospital (yes or no), teaching hospital (yes or no), number of stroke discharges from the index hospital in the same year of the index stroke discharge, and number of beds in index stroke hospital.  P, Cras |���_�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�  et al. 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. 0000021088 00000 n Patient Comorbidities Between Skilled Nursing Facility (SNF) Stays Included in the Cohort and Those Excluded Due to Incomplete Data for Function Scores, eTable 3. This cohort study included 99 185 patients who received postacute care in inpatient rehabilitation or skilled nursing facilities after a stroke. Published: December 4, 2019. doi:10.1001/jamanetworkopen.2019.16646. 0000004856 00000 n 0000053395 00000 n 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. An SNF requires a 3-day pre-qualifying hospital stay for Medicare coverage. 0000057261 00000 n IRF: Higher level of care than a SNF. 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.  AM, Paper presented at: SAS Global Forum; April 22, 2012; Orlando, FL.  AA, Cloft If any covariates in the propensity score model were not balanced, we additionally controlled for those covariates in the outcome models. Drafting of the manuscript: Hong, Goodwin, Ottenbacher.  AM, Newhouse These differences were no longer statistically significant in the instrumental variable analyses.  Jr, Goodwin  Unexplained variation for hospitals’ use of inpatient rehabilitation and skilled nursing facilities after an acute ischemic stroke.Â, Magdon-Ismail  JS. All Rights Reserved.  The reliability of the functional independence measure: a quantitative review.Â. 0000006655 00000 n  JE. Table 3 presents stroke outcomes by mobility and self-care discharge scores for patients in IRF or SNF. The Medicare Payment Advisory Commission reports6,37 consistently demonstrate that IRF costs are higher than those of SNF and home health.  Patient outcomes after hospital discharge to home with home health care vs to a skilled nursing facility.Â, Chan What Constitutes an IRF vs. a Skilled Nursing Facility. Our website uses cookies to enhance your experience. 0000050144 00000 n  RC. IRF versus SNF. 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.  AW, %PDF-1.4 %���� Our findings also have implications regarding the IMPACT Act.3 Studies that compare functional outcomes for all patients discharged to postacute care may be missing treatment effects that appear only in some impairment groups requiring the intense or specialized rehabilitation available in IRFs.30 For many hospital discharges, the postacute care setting may not matter, but our results suggest that, for at least one-third of patients with a stroke, discharge to an IRF vs SNF was associated with a significant difference in self-care and mobility at discharge. 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. Alot of Rehabs are losing money not capturing these procedures performed.  Association between cholecystectomy with vs without intraoperative cholangiography and risk of common duct injury.Â, Stukel 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. 0000049131 00000 n By continuing to use our site, or clicking "Continue," you are agreeing to our, 2020 American Medical Association. 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. Administrative, technical, or material support: Mallinson. Data analyses were conducted from January 17, 2017, through April 25, 2019.  JA.  L, Velozo 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). Acquisition, analysis, or interpretation of data: All authors. doi:10.1001/jamanetworkopen.2019.16646.  GN, Freeman Inpatient rehabilitation received in IRFs vs SNFs. 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). Q: What do the DTC-PAC measures assess? Is change in physical function associated with receiving postacute care after a stroke in inpatient rehabilitation vs skilled nursing facilities? 0000025802 00000 n We began with unadjusted bivariate analyses of all variables compared across IRF and SNF settings. 0000071050 00000 n 0000049209 00000 n 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.  RP,  S, Li 0000023767 00000 n At an SNF, Medicare Part A will cover up to 100 days of skilled nursing care per spell of illness. 0000050260 00000 n  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 The researchers found that IRF patients had better clinical outcomes than patients treated in SNFs on five of six measures. Conflict of Interest Disclosures: Dr Reistetter reported receiving grants from the Agency for Healthcare Research and Quality (AHRQ) during the conduct of the study. 381 0 obj <>stream Accessibility Statement, Table 1. Data were analyzed from January 17, 2017, through April 25, 2019. Skilled Nursing Facility (SNF) Click the chart below to expand the details and differences between each service.