Assessment of Differences in Inpatient Rehabilitation Services for Length of Stay and Health Outcomes Between US Medicare Advantage and Traditional Medicare Beneficiaries

Healthy Days at Home Among Older Medicare Beneficiaries With Traumatic Brain Injury Requiring Inpatient Rehabilitation

OBJECTIVE

The objectives of this study were to characterize and identify correlates of healthy days at home (HDaH) before and after TBI requiring inpatient rehabilitation.

SETTING

Inpatient hospital, nursing home, and home health services.

PARTICIPANTS

Average of n = 631 community-dwelling fee-for-service age 66+ Medicare beneficiaries across 30 replicate samples who were hospitalized for traumatic brain injury (TBI) between 2012 and 2014 and admitted to an inpatient rehabilitation facility (IRF) within 72 hours of hospital discharge.

DESIGN

Retrospective study using data from Medicare claims supplemented with data from the National Trauma Databank.

MAIN MEASURES

The primary outcome, HDaH, was calculated as time alive not using inpatient hospital, nursing home, and home health services in the year before TBI hospitalization and after IRF discharge.

RESULTS

We found HDaH declined from 93.2% in the year before TBI hospitalization to 65.3% in the year after IRF discharge (73.6% among survivors only). Most variability in HDaH was: (1) in the first 3 months after discharge and (2) by discharge disposition, with persons discharged from IRF to another acute hospital having the worst prognosis for utilization and death. In negative binomial regression models, the strongest predictors of HDaH in the year after discharge were rehabilitation Functional Independence Measure mobility score ( β  = 0.03; 95% CI, 0.002-0.06) and inpatient Charlson Comorbidity Index score ( β  = - 0.06; 95% CI, -0.13 to 0.001). Dual Medicaid eligible was associated with less HDaH among survivors ( β  = - 0.37; 95% CI, -0.66 to -0.07).

CONCLUSION

In this study, among community-dwelling older adults with TBI, we found a notable decrease in the proportion of time spent alive at home without higher-level care after IRF discharge compared to before TBI. The finding that physical disability and comorbidities were the biggest drivers of healthy days alive in this population suggests that a chronic disease management model is required for older adults with TBI to manage their complex health care needs.

Applying a Motivational Instructional Design Model to Stroke Rehabilitation: A Feasibility Study on Occupational and Swallowing Therapies

Objective

To investigate the feasibility of poststroke interventions using a motivational instructional design model with occupational therapy (OT) and swallowing therapy (ST) and the model's potential physical and mental health effects.

Design

An open-label, single-arm, feasibility study on the Attention, Relevance, Confidence, and Satisfaction model.

Setting

Two convalescent rehabilitation wards.

Participants

Twenty-five patients with stroke (N=25) (19 men; mean age, 62.4±11.9y; 61.9±36.8d from the first stroke) were recruited.

Interventions

Twelve participants received a motivational approach based on the Attention, Relevance, Confidence, and Satisfaction model during OT (OT group), and 13 received it during ST (ST group). The intervention lasted 40-60 minutes daily, 5 days weekly, for 4 weeks.

Main Outcome Measures

The primary outcomes included the dropout rate, an adverse event, and the participants' acceptability of the intervention. Paretic arm function was assessed in the OT group; swallowing ability was assessed in the ST group; and activities of daily living, depressive symptoms, and apathy were assessed in both groups.

Results

No participants dropped out of the intervention or experienced an adverse event. Twenty-one participants (84%) were satisfied with the intervention, and 19 (76%) hoped to continue receiving it. The OT group showed statistically significant improvements in paretic arm function and activities of daily living (Cohen's r=0.68-0.77), whereas the ST group improved in swallowing ability, activities of daily living, and depressive symptoms (Cohen's r=0.62-0.85).

Conclusions

The interventions using the motivational instructional model with OT and ST were feasible and could improve poststroke paretic arm function, swallowing ability, and activities of daily living after stroke.

Physical and Cognitive Function Trends in Post-acute Care after Total Joint Arthroplasty in Medicare Beneficiaries: 2013-2018

OBJECTIVES

Physical and cognitive conditions of patients discharged to skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), and home with home health agencies (HHAs) following total joint arthroplasty (TJA) have not been evaluated. The purpose of this study is to examine the physical and cognitive function trends of Medicare beneficiaries discharged to SNFs, HHAs, and IRFs following TJA from 2013 to 2018.

DESIGN

Observational study using Medicare enrollment, claims, and assessment data from 2013-2018.

SETTING AND PARTICIPANTS

1,278,939 Medicare beneficiaries discharged to SNFs, HHAs, or IRFs for post-acute care following TJA from 2013 to 2018.

METHODS

Medicare data were used to examine the association between the endpoints of interest [discharge destination (SNF, HHA, or IRF) and the physical (measured using activities of daily living) and cognitive (measured using a range of setting-specific metrics) status of patients in each setting] and the year of TJA (2013-2018) by estimating multivariable models that controlled for patient- and hospital-level covariates.

RESULTS

Multivariable analysis of 1,278,939 TJAs revealed that SNF discharge decreased [44.15% (2013)-21.57% (2018), P < .001], HHA increased (46.72%-72.47%, P < .001), and IRF decreased (9.13%-5.69%, P < .001). For SNF, the mean physical function scores [14.61 (2013)-14.23 (2018), P < .001] and cognitive impairment (13.25%-12.33%, P = .01) decreased, indicating less dependence. Physical function scores (3.09-3.94, P < .001) and cognitive impairment (13.95%-16.52%, P < .001) increased for HHA patients, indicating greater dependence. For IRF, motor functional independence measure decreased (38.81-37.78, P < .001) and cognitive dependence increased (39.08%-46.36%, P < .001), indicating greater dependence.

CONCLUSIONS AND IMPLICATIONS

From 2013 to 2018, patients were increasingly discharged to HHA. Although SNF patients were less dependent over time, HHA and IRF patients were physically and cognitively more dependent. Each setting is likely to benefit from policy and fiscal supports that help them manage changes in the volume and clinical intensity of patients requiring their services.

Regional variation in length of stay for stroke inpatient rehabilitation in traditional Medicare and Medicare Advantage

Regional variation in health care use threatens efficient and equitable resource allocation. Within the Medicare program, variation in care delivery may differ between centrally administered traditional Medicare (TM) and privately managed Medicare Advantage (MA) plans, which rely on different strategies to control care utilization. As MA enrollment grows, it is particularly important for program design and long-term health care equity to understand regional variation between TM and MA plans. This study examined regional variation in length of stay (LOS) for stroke inpatient rehabilitation between TM and MA plans in 2019 and how that changed in 2020, the first year of the COVID-19 pandemic. Results showed that MA plans had larger across-region variations than TM (SD = 0.26 vs 0.24 days; 11% relative difference). In 2020, across-region variation for MA further increased, but the trend for TM stayed relatively stable. Market competition among all inpatient rehabilitation facilities (IRFs) within a region was associated with a moderate increase in within-region variation of LOS (elasticity = 0.46). Policies reducing administrative variation across MA plans or increasing regional market competition among IRFs can mitigate regional variation in health care use.

Long-term outcomes after rehabilitation in Medicare Advantage and fee-for-service beneficiaries

BACKGROUND

Financial incentives in capitated Medicare Advantage (MA) plans may lead to inadequate rehabilitation. We therefore investigated if MA enrollees had worse long-term physical performance and functional outcomes after rehabilitation.

METHODS

We conducted a retrospective cohort study of Medicare beneficiaries in the nationally representative National Health and Aging Trends Study. We compared MA and fee-for-service (FFS) beneficiaries reporting rehabilitation between 2014 and 2017 by change in (1) Short Physical Performance Battery (SPPB) and (2) NHATS-derived Functional Independence Measure (FIM) from the previous year, using t-tests incorporating inverse-probability weighting and complex survey design. Secondary outcomes were self-reported: (1) improved function during rehabilitation, (2) worse function since rehabilitation ended, (3) meeting rehabilitation goals, and (4) meeting insurance limits.

RESULTS

Among 738 MA and 1488 FFS participants, weighted mean age was 76 years (SD 7.0), 59% were female, and 9% had probable dementia. MA beneficiaries were more likely to be Black (9% vs. 6%) or Hispanic/other race (15% vs. 10%), be on Medicaid (14% vs. 10%), have lower income (median $35,000 vs. $48,000), and receive <1 month of rehabilitation (30% vs. 23%). MA beneficiaries had a similar decline in SPPB (-0.46 [SD 1.8] vs. -0.21 [SD 2.7], p-value 0.069) and adapted FIM (-1.05 [SD 3.7] vs. -1.13 [SD 5.45], p-value 0.764) compared to FFS. MA beneficiaries were less likely to report improved function during rehabilitation (61% [95% CI 56-67] vs. 70% [95% CI 67-74], p-value 0.006). Other outcomes and analyses restricted to inpatient rehabilitation participants were non-significant.

CONCLUSIONS AND RELEVANCE

MA enrollment was associated with lower likelihood of self-reported functional improvement during rehabilitation but no clinically or statistically significant differences in annual changes of physical performance or function. As MA expands, future studies must monitor implications on rehabilitation coverage and older adults' independence.

Inpatient Rehabilitation Facility Ownership Type Yields Mixed Performances on Quality Measures

OBJECTIVE

To evaluate the effects of inpatient rehabilitation facility (IRF) ownership type on IRF-Quality Reporting Program (IRF-QRP) measures.

DESIGN

Cross-sectional, observational design.

SETTING

We used 2 Centers for Medicare and Medicare publicly-available, facility-level data sources: (1) IRF compare files and (2) IRF rate setting files - final rule. Data from 2021 were included.

PARTICIPANTS

The study sample included 1092 IRFs (N=1092).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

We estimated the effects of IRF ownership type, defined as for-profit and nonprofit, on 15 IRF-QRP measures using general linear models. Models were adjusted for the following facility-level characteristics: (1) Centers for Medicare and Medicaid census divisions; (2) number of discharges; (3) teaching status; (4) freestanding vs hospital unit; and (5) estimated average weight per discharge.

RESULTS

Ownership type was significantly associated with 9 out of the fifteen IRF-QRP measures. Nonprofit IRFs performed better with having lower readmissions rates within stay and 30-day post discharge. For-profit IRFs performed better for all the functional measures and with higher rates of returning to home and the community. Lastly, for-profit IRFs spent more per Medicare beneficiary.

CONCLUSIONS

Ideally, IRF performance would not vary based on ownership type. However, we found that ownership type is associated with IRF-QRP performance scores. We suggest that future studies investigate how ownership type affects patient-level outcomes and the longitudinal effect of ownership type on IRF-QRP measures.

Machine learning prediction of hospital discharge disposition for inpatients with acute ischemic stroke following mechanical thrombectomy in the United States

BACKGROUND AND PURPOSE

Predicting patient recovery and discharge disposition following mechanical thrombectomy remains a challenge in patients with ischemic stroke. Machine learning offers a promising prognostication approach assisting in personalized post-thrombectomy care plans and resource allocation. As a large national database, National Inpatient Sample (NIS), contain valuable insights amenable to data-mining. The study aimed to develop and evaluate ML models predicting hospital discharge disposition with a focus on demographic, socioeconomic and hospital characteristics.

MATERIALS AND METHODS

The NIS dataset (2006-2019) was used, including 4956 patients diagnosed with ischemic stroke who underwent thrombectomy. Demographics, hospital characteristics, and Elixhauser comorbidity indices were recorded. Feature extraction, processing, and selection were performed using Python, with Maximum Relevance - Minimum Redundancy (MRMR) applied for dimensionality reduction. ML models were developed and benchmarked prior to interpretation of the best model using Shapley Additive exPlanations (SHAP).

RESULTS

The multilayer perceptron model outperformed others and achieved an AUROC of 0.81, accuracy of 77 %, F1-score of 0.48, precision of 0.64, and recall of 0.54. SHAP analysis identified the most important features for predicting discharge disposition as dysphagia and dysarthria, NIHSS, age, primary payer (Medicare), cerebral edema, fluid and electrolyte disorders, complicated hypertension, primary payer (private insurance), intracranial hemorrhage, and thrombectomy alone.

CONCLUSION

Machine learning modeling of NIS database shows potential in predicting hospital discharge disposition for inpatients with acute ischemic stroke following mechanical thrombectomy in the NIS database. Insights gained from SHAP interpretation can inform targeted interventions and care plans, ultimately enhancing patient outcomes and resource allocation.

Post-Acute Care in Inpatient Rehabilitation Facilities Between Traditional Medicare and Medicare Advantage Plans Before and During the COVID-19 Pandemic

OBJECTIVES

Compare post-acute care (PAC) utilization and outcomes in inpatient rehabilitation facilities (IRF) between beneficiaries covered by Traditional Medicare (TM) and Medicare Advantage (MA) plans during the COVID-19 pandemic relative to the previous year.

DESIGN

This multiyear cross-sectional study used Inpatient Rehabilitation Facility-Patient Assessment Instrument (IRF-PAI) data to assess PAC delivery from January 2019 to December 2020.

SETTING AND PARTICIPANTS

Inpatient rehabilitation for stroke, hip fracture, joint replacement, and cardiac and pulmonary conditions among Medicare beneficiaries 65 years or older.

METHODS

Patient-level multivariate regression models with difference-in-differences approach were used to compare TM and MA plans in length of stay (LOS), payment per episode, functional improvements, and discharge locations.

RESULTS

A total of 271,188 patients were analyzed [women (57.1%), mean (SD) age 77.8 (0.06) years], among whom 138,277 were admitted for stroke, 68,488 hip fracture, 19,020 joint replacement, and 35,334 cardiac and 10,069 pulmonary conditions. Before the pandemic, MA beneficiaries had longer LOS (+0.22 days; 95% CI: 0.15-0.29), lower payment per episode (-$361.05; 95% CI: -573.38 to -148.72), more discharges to home with a home health agency (HHA) (48.9% vs 46.6%), and less to a skilled nursing facility (SNF) (15.7% vs 20.2%) than TM beneficiaries. During the pandemic, both plan types had shorter LOS (-0.68 day; 95% CI: 0.54-0.84), higher payment (+$798; 95% CI: 558-1036), increased discharges to home with an HHA (52.8% vs 46.6%), and decreased discharges to an SNF (14.5% vs 20.2%) than before. Differences between TM and MA beneficiaries in these outcomes became smaller and less significant. All results were adjusted for beneficiary and facility characteristics.

CONCLUSIONS AND IMPLICATIONS

Although the COVID-19 pandemic affected PAC delivery in IRF in the same directions for both TM and MA plans, the timing, time duration, and magnitude of the impacts were different across measures and admission conditions. Differences between the 2 plan types shrank and performance across all dimensions became more comparable over time.

Effects of dynamic body weight support on functional independence measures in acute ischemic stroke: a retrospective cohort study

BACKGROUND

Stroke remains a major public health concern in the United States and a leading cause of long-term disability in adults. Dynamic body weight support (DBWS) systems are popular technology available for use in clinical settings such inpatient rehabilitation. However, there remains limited studies in such inpatient settings that compare DBWS to standard of care (SOC) using real world outcome measures. For survivors of acute ischemic stroke, we determine if incorporating a dynamic body weight support (DBWS) system into inpatient therapy offers greater improvement than standard of care (SOC).

METHODS

A retrospective chart review included 52 individuals with an acute ischemic stroke admitted to an inpatient rehabilitation facility. Functional Independence Measure (FIM) data, specifically changes in FIM at discharge, served as the primary outcome measure. Patient cohorts received either therapies per SOC or therapies incorporating DBWS. Regardless of cohort group, all patients underwent therapies for 3 h per day for 5 days a week.

RESULTS

For both groups, a statistically and clinically significant increase in total FIM (P < 0.0001) was observed at discharge compared to at admission. Improvements for the DBWS group were significantly greater than the SOC group as evidenced by higher gains in total FIM (p = 0.04) and this corresponded to a medium effect size (Cohen's d = 0.58). Among FIM subscores, the DBWS group achieved a significant increase in sphincter control while all other subscore changes remained non-significant.

CONCLUSIONS

This preliminary evidence supports the benefit of using DBWS during inpatient rehabilitation in individuals who have experienced an acute ischemic stroke. This may be due to the greater intensity and repetitions of tasks allowed by DBWS. These preliminary findings warrant further investigations on the use of DBWS in inpatient settings.

Effect of Race/ethnicity, Insurance Status, and Area Deprivation on Hip Fracture Outcomes Among Older Adults in the United States

This retrospective cohort study used electronic health records to explore the effect of race/ethnicity, insurance status, and area deprivation on post-discharge outcomes in older patients undergoing hip fracture surgery between 2015 and 2018 (N = 1,150). Inverse probability of treatment weight-adjusted regression analysis was used to identify the effects of the predictors on outcomes. White patients had higher 90- and 365-day readmission risks than Black patients and higher all-period readmissions than the Other racial/ethnic (Hispanic, Asian, American Indian, and Multicultural) group (p < .000). Black patients had a higher risk of 30- and 90-day readmission than the Other racial/ethnic group (p < .000). Readmission risk across 1-year follow-up was generally higher among patients from less deprived areas than more deprived areas (p < .05). The 90- and 365-day mortality risk was lower for patients from less deprived areas (vs. more deprived areas) and patients with Medicare Advantage (vs. Medicare), respectively (p < .05). Our findings can guide efforts to identify patients for additional post-discharge support. Nevertheless, the findings regarding readmission risks contrast with previous knowledge and thus require more validation studies.

Alternative Payment Models and Associations With Stroke Outcomes, Spending, and Service Utilization: A Systematic Review

Stroke contributes an estimated $28 billion to US health care costs annually, and alternative payment models aim to improve outcomes and lower spending over fee-for-service by aligning economic incentives with high value care. This systematic review evaluates historical and current evidence regarding the impacts of alternative payment models on stroke outcomes, spending, and utilization. Included studies evaluated alternative payment models in 4 categories: pay-for-performance (n=3), prospective payments (n=14), shared savings (n=5), and capitated payments (n=14). Pay-for-performance models were not consistently associated with improvements in clinical quality indicators of stroke prevention. Studies of prospective payments suggested that poststroke spending was shifted between care settings without consistent reductions in total spending. Shared savings programs, such as US Medicare accountable care organizations and bundled payments, were generally associated with null or decreased spending and service utilization and with no differences in clinical outcomes following stroke hospitalizations. Capitated payment models were associated with inconsistent effects on poststroke spending and utilization and some worsened clinical outcomes. Shared savings models that incentivize coordination of care across care settings show potential for lowering spending with no evidence for worsened clinical outcomes; however, few studies evaluated clinical or patient-reported outcomes, and the evidence, largely US-based, may not generalize to other settings.

A Mobility Measure for Inpatient Rehabilitation Using Multigroup, Multidimensional Methods

BACKGROUND AND PURPOSE

Inpatient rehabilitation facilities (IRFs) report patient functional status to Medicare and other payers using Quality Indicators (QI). While the QI is useful for payment purposes, its measurement properties are limited for monitoring patient progress. A mobility measure based on QI items and additional standardized assessments may enhance clinicians' ability to track patient improvement. Thus, we developed the Mobility Ability Quotient (Mobility AQ) to assess mobility during inpatient rehabilitation.

METHODS

For 10 036 IRF inpatients, we extracted assessments from electronic health records, used confirmatory factor analysis to define subdimensions of mobility, and then applied multidimensional item response theory (MIRT) methods to develop a unidimensional construct. Assessments included the QI items and standardized measures of mobility, motor performance, and wheelchair and transfer skills.

RESULTS

Confirmatory factor analysis resulted in good-fitting models (root-mean-square errors of approximation ≤0.08, comparative fit indices, and nonnormed fit indices ≥0.95) for 3 groups defined by anticipated primary mode of locomotion at discharge-walking, wheelchair propulsion, or both. Reestimation as a multigroup, MIRT model yielded scores more sensitive to change compared with QI mobility items (dlast-first = 1.08 vs 0.60 for the QI; dmax-min = 1.16 vs 1.05 for the QI). True score equating analysis demonstrated a higher ceiling and lower floor for the Mobility AQ than the QI.

DISCUSSION AND CONCLUSIONS

The Mobility AQ demonstrates improved sensitivity over the QI mobility items. This MIRT-based mobility measure describes patient function and progress for patients served by IRFs and has the potential to reduce assessment burden and improve communication regarding patient functional status.Video Abstract available for more insights from authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A341).

Inpatient rehabilitation service utilization and outcomes under US ACA Medicaid expansion

Background

To investigate the impact of the US Medicaid expansion on care utilization and health outcomes of patients treated in the inpatient rehabilitation facilities (IRF).

Methods

A retrospective observational study with a difference-in-difference design. The data was obtained from Inpatient Rehabilitation Facility – Patient Assessment Instrument (IRF-PAI). Sample included all Medicaid beneficiaries (aged 18–64 years) who received initial inpatient rehabilitation for stroke, hip fracture (acute conditions), or joint replacement (elective condition) (N = 14,917) before (2013) and after (2016) the expansion. The study estimated the differences in length of stay, functional improvement, and possibility of returning to community before and after ACA Medicaid expansion in the expansion regions relative to the non-expansion regions. The analysis was fully adjusted for patient demographics, health conditions, facility characteristics and time trends.

Results

Compared with non-expansion states, service volume in the expansion regions increased more for the two acute conditions (49 and 27% vs. 1% and − 4%) and decreased less for the selective condition (− 12% vs. -34%) after ACA Medicaid expansion. Medicaid expansion was associated with significant decreases in patient functional improvements (− 1.63 points for stroke, − 3.61 points for fracture and − 2.73 points for joint; P < 0.05). Length of stay and the possibility of returning to community after discharge were not significantly different.

Conclusions

Medicaid expansion was associated with increases in the utilization of inpatient rehabilitation services and decreases in the patient functional improvements. Cautions should be taken with the decreases in functional improvements among some subpopulation in the short-term; longer follow up periods are needed to account for gradual changes in patient needs.