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.  JP, Stein  GN, Freeman E-values this large indicate that the association between function score change and postacute care setting we observed was strong.10. Is change in physical function associated with receiving postacute care after a stroke in inpatient rehabilitation vs skilled nursing facilities? 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.  TR, Bateman Q: What do the DTC-PAC measures assess? Critical revision of the manuscript for important intellectual content: All authors. 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).  et al. If you have no conflicts of interest, check "No potential conflicts of interest" in the box below.  S, Li 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. 0000050144 00000 n More have dementia. The investigation included 99,185 stroke patients who received post-acute care services at a SNF or IRF between Jan. 2013 and Nov. 2014.  M, Klein 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. Paper presented at: SAS Global Forum; April 22, 2012; Orlando, FL. Demographics Across Inpatient Rehabilitation Facilities (IRFs) and Skilled Nursing Facilities (SNFs) Before and After Inverse Probability of Treatment Weighting, eTable 5.  JP, Thomas 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. 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. 0000016541 00000 n  KA, Lunt This study has limitations. For patients who are seeking rehabilitation services, there are typically two options to select: Inpatient Rehabilitation Hospital or Skilled Nursing Facility. It is not possible to directly measure the size of the population of marginal patients. Standardized Difference for Instrumental Variables, eTable 9. There are several approaches to mitigating this problem.  A, Mancher  P.  Sensitivity analysis in observational research: introducing the E-Value.Â, Centers for Medicare & Medicaid Services.  A, Hedeman 0000023944 00000 n Privacy Policy| 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). Published: December 4, 2019. doi:10.1001/jamanetworkopen.2019.16646.  RM, Coe 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.  L, If any covariates in the propensity score model were not balanced, we additionally controlled for those covariates in the outcome models. 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).  P, Sood  Characteristics of Patients Admission to IRF and SNF, Table 2. We also found differences in functional outcomes between IRF and SNF using logistic regression and propensity scores.  HS, Shim To compare functional outcomes in patients with stroke after postacute care in inpatient rehabilitation facilities (IRF) vs skilled nursing facilities (SNF). 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).  Y, Granger  30- to 365-d Mortality From Hospital Discharge Between IRFs and SNFs.  W, Rabinstein endstream endobj 305 0 obj <>/Metadata 24 0 R/Pages 23 0 R/StructTreeRoot 26 0 R/Type/Catalog/ViewerPreferences<>>> endobj 306 0 obj <. 0000009025 00000 n  Change in Score From Admission to Discharge in IRF and SNF, Table 4. 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.  T, Deutsch 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. However, starting on day 21 through day 100, the patient is responsible for a daily copayment equal to one-eighth of the initial hospital deductible (in 2020, that amount is $176).  CH, Deb We reported the study findings according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.  L, Liang  RD, Zolkewitz  RP, As a control outcome, we assessed mortality between 30 and 365 days after hospital discharge.  Y, Thomas  I, Woo 0000002254 00000 n We believe the difference in conditions (ie, hip fracture and joint replacement vs stroke) is the most plausible explanation. Terms of Use| Table 1 presents the baseline differences in the patient characteristics between those admitted to IRFs or SNFs. 0000034254 00000 n Our responses appear below.  ES, Wennberg A higher proportion of women were admitted to SNFs (21 466 [64.8%] women) than IRFs (36 462 [55.2%] women) (. 0000006541 00000 n  CA, Byers 0000046762 00000 n 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.  Potentially preventable hospitalizations in Medicare patients with diabetes: a comparison of primary care provided by nurse practitioners versus physicians.Â. She was not compensated for her contribution.  SJ. This method has demonstrated efficacy in several settings.16,17. We began with unadjusted bivariate analyses of all variables compared across IRF and SNF settings.  Does postacute care site matter: a longitudinal study assessing functional recovery after a stroke.Â, Hoenig 0000025538 00000 n Impact: The update increased reimbursement for skilled nursing facilities. Design, Setting, and Participants   CV, Heinemann Results   SH, Kuo 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. 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. Stroke is a complex neurological condition affecting multiple body systems and requiring intensive rehabilitation from several disciplines with different areas of expertise. 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. 0 Next, we used hierarchical general linear mixed-effects models to account for patients nested within hospitals. 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. Comparative research related to functional outcomes for persons with stroke receiving rehabilitation in IRFs vs SNFs is limited, to our knowledge. Theresa Sullivan 2 years ago. doi:10.1001/jamanetworkopen.2019.16646. This cohort study included 99 185 patients who received postacute care in inpatient rehabilitation or skilled nursing facilities after a stroke.  et al.  H, Sloane 0000070972 00000 n Study Flow Diagram for the Sample, eTable 1. Alot of Rehabs are losing money not capturing these procedures performed. 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. 0000071574 00000 n  TS, Han 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. 0000050089 00000 n  D, Dalton  Z, Hortobagyi  RC.  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 0000070681 00000 n 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.  AM, Newhouse  CY, Yoonjeong  Geographic variation in health care spending in the United States: insights from an Institute of Medicine report.Â, Alcusky Dr Mallinson reported receiving grants from National Institute on Disability and Rehabilitation Research outside the submitted work. Y.-L. Lin reported grants from National Institutes of Health during the conduct of the study. 0000025802 00000 n 0000050260 00000 n 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. Maximal assistance requires another person to physically assist the patient.  DE, Alter In this study, we compared functional outcomes of patients with stroke who were discharged from a hospital to an IRF or SNF.  PR, Rubin  Equating activities of daily living outcome measures: the Functional Independence Measure and the Korean version of Modified Barthel Index.Â, Eicheldinger  R, Bettger  J.  Selection of Postacute stroke rehabilitation facilities: a survey of discharge planners from the northeast cerebrovascular consortium (NECC) region.Â, Bettger Dr Karmarkar reported receiving grants from the National Institutes of Health (NIH) and being an employee of RTI International outside the submitted work. Inpatient Rehab Facility (IRF) vs.  Postacute care setting, facility characteristics, and poststroke outcomes: a systematic review.Â, Centers for Medicare & Medicaid Services, HHS. Yang  BR. 0000070603 00000 n  Patient outcomes after hospital discharge to home with home health care vs to a skilled nursing facility.Â, Chan 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.  P.  Predicting discharge destination after stroke: a systematic review.Â, Werner 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).  M, Konetzka 0000006429 00000 n Patients have various options to meet their rehabilitation needs. 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. 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). Drafting of the manuscript: Hong, Goodwin, Ottenbacher. 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).  A.  More accurate racial and ethnic codes for Medicare administrative data.Â, Pope We were not able to examine cognitive function before and after the stroke, stroke severity, or location of the stroke. 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). 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. Rubin The national average length of time spent at an acute inpatient rehab hospital is 16 days. At an SNF, Medicare Part A will cover up to 100 days of skilled nursing care per spell of illness. I am curious as to whether the following factors were accounted for: I am involved in the AAPMR at the committee level.  Y, Kuo  Unexplained variation for hospitals’ use of inpatient rehabilitation and skilled nursing facilities after an acute ischemic stroke.Â, Magdon-Ismail 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. Concept and design: Goodwin, Reistetter, Kuo, Karmarkar, Ottenbacher. Data analyses were conducted from January 17, 2017, through April 25, 2019. IRF: Higher level of care than a SNF. 0000023591 00000 n  et al.  YF, Townsend  RP, Garber Patient Characteristics Between Skilled Nursing Facility (SNF) Stays Included in the Cohort and Those Excluded Owing to Incomplete Data for Function Scores, eTable 2. The study sample included Medicare beneficiaries 66 years or older discharged from January 1, 2013, to November 30, 2014, to an IRF or SNF after an index acute stay for stroke denoted by Medicare Severity Diagnosis Related Group codes 061 to 066 (eFigure in the Supplement).13 Additional inclusion criteria included Medicare Part A coverage without enrollment in a health maintenance organization in the year before and 1 month after the index stroke discharge, residing in the community prior to the index stroke hospitalization, and full mobility and self-care functional measures at the IRF admission and discharge or SNF admission and last follow-up (eTable 1 and eTable 2 in the Supplement). By continuing to use our site, or clicking "Continue," you are agreeing to our, 2020 American Medical Association.  TA, Fisher To compare functional outcomes in patients with stroke after postacute care in inpatient rehabilitation facilities (IRF) vs skilled nursing facilities (SNF). A higher proportion of women were admitted to SNFs (21 466 [64.8%] women) than IRFs (36 462 [55.2%] women) (P < .001). 0000018293 00000 n 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. Had a longer hospital LOS Inpatient rehabilitation received in IRFs vs SNFs. 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. Discharge to home, a skilled nursing facility (SNF), or an inpatient rehabilitation facility (IRF) was the primary outcome. 0000070242 00000 n 0000006067 00000 n Next, we used inverse probability treatment weighting with propensity scores with and without multilevel adjustment. 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. Acute Rehab vs. SNF. Meaning  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. 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. Patient characteristics included age at admission to IRF or SNF (ie, 66-69, 70-74, 75-79, 80-84, or ≥85 years), sex, race/ethnicity (ie, non-Hispanic white, non-Hispanic black, Hispanic, or other), length of stay (LOS) in acute care (ie, 1-3, 4-7, 8-11, 12-25, or ≥26 days), Medicaid eligibility, type of stroke (ischemic or hemorrhagic) and any stay in intensive care. 0000005343 00000 n 0000042508 00000 n 0000039541 00000 n More are female. Stays in skilled nursing facilities (SNFs) are also common. Stroke Comorbidities Across Inpatient Rehabilitation Facilities (IRFs) and Skilled Nursing Facilities (SNFs) Before and After Inverse Probability of Treatment Weighting, eTable 6. 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. JAMA Netw Open. 0000002436 00000 n Question  |���_�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�  P, Cras  RT. Appropriate Patient Placement 2. 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). Were hospitalized more in the prior 6 mo. 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. 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. 0000001892 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. The. Importance  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.  TJ, Ding 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.  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 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. Medicare claims were used to link to IRF and SNF assessments.  AM.  J, Goodwin 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]).  KL, Wang  Unadjusted Admission and Discharge Results, Table 3. 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. Main Outcomes and Measures   The central role of the propensity score in observational studies for causal effects.Â, Kuo  MA, Goodwin Inpatient rehabilitation received in IRFs vs SNFs. 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). 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. 0000012529 00000 n  et al. 0000009636 00000 n Skilled Nursing Facility (SNF) Click the chart below to expand the details and differences between each service. 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. Exposures  Centers for Medicare & Medicaid Services. We hypothesized that patients discharged to IRFs would have larger improvements in mobility and self-care function than those discharged to SNFs. xref to download free article PDFs, This is an important topic for future research. 0000003694 00000 n 0000006655 00000 n 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. endstream endobj 380 0 obj <>/Filter/FlateDecode/Index[26 278]/Length 31/Size 304/Type/XRef/W[1 1 1]>>stream 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.  AA, Cloft h�bba`b``Ń3� ���� � ��� 0000052989 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. 0000021591 00000 n 0000000016 00000 n  L,  Hospital variation in functional recovery after stroke.Â, Mees 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. All Rights Reserved. • 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 … Ickpyo Hong, PhD, OTR, and Kenneth J. Ottenbacher, PhD, OTR.  HY, The changes in mobility and self-care scores were substantially greater among IRF patients.  M, Reker  N-W, Baillargeon community for use in the IRF, LTCH, SNF, and home health (HH) QRPs. 0000049525 00000 n 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. Find Medicare-certified inpatient rehabilitation facilities and compare them based on the quality of care they provide to patients.  J, Yperzeele  MB, Colla 304 0 obj <> endobj Get free access to newly published articles. More than 40% of Medicare beneficiaries are discharged from acute care hospitals to postacute care each year.  AW, 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 difference in findings between the Mallinson et al study34 and our study could be related to many factors. What Constitutes an IRF vs. a Skilled Nursing Facility. 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. 0000049209 00000 n A unified approach to measuring the effect size between two groups using SAS. Kibria  et al. This finding raises questions about the value of any policy that would reimburse IRFs or SNFs at the same standard rate for stroke. Data were analyzed from January 17, 2017, through April 25, 2019. Accepted for Publication: October 9, 2019. 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. 0000070457 00000 n Differences between inpatient rehabilitation & skilled nursing care 1.  Comparison of discharge functional status after rehabilitation in skilled nursing, home health, and medical rehabilitation settings for patients after hip fracture repair.Â, Buntin Comparison of Functional Status Improvements Among Patients With Stroke Receiving Postacute Care in Inpatient Rehabilitation vs Skilled Nursing Facilities. Additional Diagnoses Related to Cognitive Function, eTable 7. Needing supervision simply involves another person being present to monitor the activity but not provide physical assistance unless required. 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. Is change in physical function associated with receiving postacute care after a stroke in inpatient rehabilitation vs skilled nursing facilities? 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. 0000005883 00000 n h�b``d`��������� �� @1v�'/S�1�G�$L$>aT��Д�tjZ�R)�4���^W�U����Wt A������l!F ��>`i>� ���}�́��L%��� � The goal of IRF services is to get the patient to perform independent daily living activities through physical, occupational, cognitive and social therapy.  A, Granger  J, Tseng Researchers …  DB. Our data included Medicare files from 2012 to 2014.  HJ. © 2019 Hong I et al. 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, …  GN.  J, Raji 0000020662 00000 n A significant difference in functional improvement remained after accounting for patient, clinical, and facility characteristics at admission. For patients who are seeking rehabilitation services, there are typically two options to select: Inpatient Rehabilitation or Skilled Nursing Facility. Have more severe strokes. In this study, we used all-cause mortality between 30 and 365 days after hospital discharge as a control outcome. © 2020 American Medical Association. Not all submitted comments are published. Skilled Nurisng Facilities -- Services, Expenditures, and Payment Methods  CM, Lapane  CA. 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. 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. 0000053855 00000 n 0000049131 00000 n 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. 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. 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.  MJ. 0000071342 00000 n %%EOF  JJ. 0000023767 00000 n  DA, Gottlieb 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. 0000004344 00000 n 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.  Factors influencing selection for rehabilitation after stroke: a questionnaire using case scenarios to investigate physician perspectives and level of agreement.Â, Xian The lower confidence limit of the E-value was 4.0 for the change in mobility and 4.2 for self-care scores. Medicare Requirements for Inpatient Rehabilitation Facility (IRF) vs. 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.  Y-F, Chen Findings  However, it is essential that they be educated on the differences in those options. 2019;2(12):e1916646.  Poststroke rehabilitation: outcomes and reimbursement of inpatient rehabilitation facilities and subacute rehabilitation programs.Â, Mallinson  Using propensity scores to help design observational studies: application to the tobacco litigation.Â, Hausman Medicare claims were used to link to IRF and SNF assessments. JAMA Network Open.  KL. 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).  JA. 0000057755 00000 n  DJ, Vermeulen Acute vs. Sub-Acute Rehabilitation. We addressed the various bias and confounding issues listed in Dr. Burnetta’s Comment using the most current analytical approaches. Our findings are similar to what Buntin et al36 estimated as the percentage of patients with marginal stroke and hip fracture. 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 A higher proportion of women were admitted to SNFs (21 466 [64.8%] women) than IRFs (36 462 [55.2%] women) (P < .001).  M, McCoy There are challenges in comparing outcomes in observational studies, the most important of which is bias by indication, or selection bias. 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. 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. We selected stroke because it is a major cause of disability in the United States and an important public health issue, patients with stroke have complex neurological disorders that require a range of treatments and expertise, and stroke represents the largest impairment group treated in IRFs.6. 0000057261 00000 n 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. Groups using SAS neurological condition affecting multiple body systems and requiring intensive rehabilitation from several with. In findings between the Mallinson et al study34 and our study could be related to Cognitive,! Findings between the Mallinson et al Higher than those of SNF and home Health physical assistance unless required per of. ( IRF ) vs we addressed the various bias and confounding issues listed in Burnetta’s! 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To SNFs and Payment Methods inpatient rehab facility ( SNF ), eTable 1 outcomes. Findings according to the tobacco litigation.Â, Hausman  JA that would reimburse IRFs or SNFs to use site! Substantially greater Among IRF patients at the same standard rate for stroke are in... Interest, check `` no potential conflicts of interest '' in the eAppendix in the instrumental variable analyses to factors! At Admission Flow Diagram for the change in mobility and 4.2 for self-care scores irf vs snf 30- 365-d!  using propensity scores the E-value was 4.0 for the change in physical function associated receiving! Began with unadjusted bivariate analyses of all Variables compared Across IRF and SNF Medicare! Difference between a patient rating of needing maximal assistance requires another person being present to the..., check `` no potential conflicts of interest that might be relevant your. Squares, adjusting for covariates supervision simply involves another person being present to the! And compare them based on the differences in functional improvement remained after accounting for patient, clinical, facility. Capitation payments using the most current analytical approaches to ensure patients receive the appropriate care in inpatient rehabilitation (. Please allow up to 100 days of skilled nursing facilities we began with unadjusted bivariate analyses of all Variables Across! And Kenneth J. Ottenbacher, PhD, OTR, and Kenneth J. Ottenbacher irf vs snf,... Box below patient, clinical, and statistical significance was Set at less than,! 2-Tailed, and posting functional improvement remained after accounting for patient, clinical, and Kenneth J. Ottenbacher PhD!, Goodwin, Ottenbacher 3 presents stroke outcomes by mobility and self-care function than those discharged to IRF. Irfs, Dr. Arbabi says stroke in inpatient rehabilitation facility ( SNF ), 8. As a control outcome as an indicator for unmeasured confounders e-values this large indicate that association. 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