Changes in the status of hospitalized stroke patients since inception of the prospective payment system in 1983

Activity-based funding of hospitals and its impact on mortality, readmission, discharge destination, severity of illness, and volume of care: a systematic review and meta-analysis

Background

Activity-based funding (ABF) of hospitals is a policy intervention intended to re-shape incentives across health systems through the use of diagnosis-related groups. Many countries are adopting or actively promoting ABF. We assessed the effect of ABF on key measures potentially affecting patients and health care systems: mortality (acute and post-acute care); readmission rates; discharge rate to post-acute care following hospitalization; severity of illness; volume of care.

Methods

We undertook a systematic review and meta-analysis of the worldwide evidence produced since 1980. We included all studies reporting original quantitative data comparing the impact of ABF versus alternative funding systems in acute care settings, regardless of language. We searched 9 electronic databases (OVID MEDLINE, EMBASE, OVID Healthstar, CINAHL, Cochrane CENTRAL, Health Technology Assessment, NHS Economic Evaluation Database, Cochrane Database of Systematic Reviews, and Business Source), hand-searched reference lists, and consulted with experts. Paired reviewers independently screened for eligibility, abstracted data, and assessed study credibility according to a pre-defined scoring system, resolving conflicts by discussion or adjudication.

Results

Of 16,565 unique citations, 50 US studies and 15 studies from 9 other countries proved eligible (i.e. Australia, Austria, England, Germany, Israel, Italy, Scotland, Sweden, Switzerland). We found consistent and robust differences between ABF and no-ABF in discharge to post-acute care, showing a 24% increase with ABF (pooled relative risk  = 1.24, 95% CI 1.18–1.31). Results also suggested a possible increase in readmission with ABF, and an apparent increase in severity of illness, perhaps reflecting differences in diagnostic coding. Although we found no consistent, systematic differences in mortality rates and volume of care, results varied widely across studies, some suggesting appreciable benefits from ABF, and others suggesting deleterious consequences.

Conclusions

Transitioning to ABF is associated with important policy- and clinically-relevant changes. Evidence suggests substantial increases in admissions to post-acute care following hospitalization, with implications for system capacity and equitable access to care. High variability in results of other outcomes leaves the impact in particular settings uncertain, and may not allow a jurisdiction to predict if ABF would be harmless. Decision-makers considering ABF should plan for likely increases in post-acute care admissions, and be aware of the large uncertainty around impacts on other critical outcomes.

The crisis of stroke: experiences of patients and their family caregivers

PURPOSE

Approximately 4.8 million stroke survivors are living in the community with some level of disability requiring the assistance of family caregivers. Stroke family caregivers are often unprepared for the demands required of them. The purpose of this grounded theory study was to explore the needs of stroke patients and their family caregivers as they transitioned through the stroke care continuum from acute care to inpatient rehabilitation to home.

METHODS

Thirty-eight participants, 19 recovering stroke patients (11 male, 8 female), 15 primary family caregivers (14 spouses, 1 mother), and 4 adult children were interviewed during their stay at a rehabilitation facility and within 6 months of discharge. Interview questions were loosely structured and focused on the stroke experience and how patients and caregivers were managing postdischarge. Data were analyzed using dimensional and comparative analysis.

RESULTS

Findings were organized in a conceptual framework illustrating the trajectory of the crisis of stroke. Stroke survivors and their caregivers faced enormous challenges as they moved through 3 phases of the trajectory: the stroke crisis, expectations for recovery, and the crisis of discharge. Findings from this study suggest that as caregivers move through the phases of the trajectory, they do not have a good understanding of the role to which they are committing, and they are often underprepared to take on even the basic tasks to meet the patients' needs on discharge.

CONCLUSION

Stroke survivors and their caregivers do not have adequate time to deal with the shock and crisis of the stroke event, let al.one the crisis of discharge and all of the new responsibilities with which they must deal.

Stroke discharges from a rehabilitation unit: 1-year and 5-year domicile outcomes. Function is important

BACKGROUND

Stroke units save lives, reduce disability and increase the chances of the person returning to their own home. Following the introduction of a stroke rehabilitation unit, we assessed the durability of stroke discharges over a 1-year period and predictors of early 'failed' home discharges. Stability of discharge domicile and survival over 5 years was also reviewed.

METHODS

A 6-month cohort of all discharges was followed for 5 years. Changes in domicile, including entry into institutional care, were recorded out to 5 years or until death. Predictors of early (3 months) and later (1 year) discharge stability were assessed.

RESULTS

There were 142 discharges. Fifty-eight (76%) of those who returned home were still at home 12 months later. In contrast, there was a high mortality of dependent patients who were discharged to high dependency care (9 (29%) and 13 (42%) at 3 and 12 months, respectively). The chance of an early failed discharge was associated with lower functional ability on discharge (P= 0.012). Lower function on discharge was also independently associated with death in the next 12 months (P < 0.0001). At 5 years the mortality for the whole sample was 55% (78 of 141) and 38 (61%) of the survivors still lived in the community whereas 24 (39%) resided in institutional care.

CONCLUSION

Functional ability on discharge is a key predictor of ability to remain at home as well as survival and therefore every effort should be made to maximize function.

The effects of a prospective case payment system on hospital charges for total hip arthroplasty in Taiwan

We evaluate the effects of instituting prospective case payment system (PPS) system on total hip arthroplasty (THA) charges and compare our university hospital THA cost structure with comparable health care institutions in the United States. The study consisted of 5009 patients who received a primary THA in 24 hospitals between 1995 and 2001. After adjusting for inflation, the average total charge of THA for pre-PPS was 4762 US dollars and 4054 US dollars for post-PPS. The average cost for prostheses accounted for 61% of total costs at our hospital, as compared with the US studies ranging from 27% to 34%. As United States, PPS achieved the purpose of cost containment and changed practice patterns of orthopedic surgeons and hospital resource use in Taiwan.

A Follow-Up Study of Older Adults With Traumatic Brain Injury: Taking Into Account Decreasing Length of Stay

OBJECTIVE

To examine age-related differences in rehabilitation outcomes following traumatic brain injury (TBI).

DESIGN

Retrospective collaborative study.

SETTING

Patients received acute neurotrauma and inpatient rehabilitation services at 1 of the 17 National Institute on Disability and Rehabilitation Research-designated Traumatic Brain Injury Model Systems (TBIMS) centers.

PARTICIPANTS

A sample of 273 older patients (> or =55y) admitted for TBI were taken from the TBIMS National Database. Older patients were matched with subjects 44 years of age or younger, based on severity of injury (Glasgow Coma Scale score, length of coma, intracranial pressure elevations). Due to decreasing length of stay (LOS), only patients admitted from 1996 through 2002 were included.

INTERVENTION

Inpatient interdisciplinary brain injury rehabilitation.

MAIN OUTCOME MEASURES

Acute care LOS, inpatient rehabilitation LOS, admission and discharge FIM instrument and Disability Rating Scale (DRS) scores, FIM and DRS efficiency, acute and rehabilitative charges, and discharge disposition.

RESULTS

One-way analyses of variance demonstrated a statistically significant difference between older and younger patients with respect to LOS in rehabilitation but not for acute care. Total rehabilitative charges, and admission and discharge DRS and FIM scores also showed statistically significant differences between groups. Older patients progressed with significantly less efficiency on both the DRS and FIM scales. Significantly more charges were generated per unit for older patients to improve on the DRS scale, but not the FIM scale. Using chi-square analysis, a statistically significant difference in rate of discharge to home was identified between older (80.5%) and younger (94.4%) patients.

CONCLUSIONS

Results in this study are similar to those in earlier studies with smaller sample sizes. Major differences observed include significantly slower and more costly progress in inpatient rehabilitation for older patients with TBI, as well as a significantly lower rate of discharge to community for older patients. However, even with decreasing LOS in both settings, community discharge rate is still encouraging for older patients with TBI.

Toward a New Payment System for Inpatient Rehabilitation

BACKGROUND

The major fault with existing reimbursement systems lies in their failure to discriminate for the effectiveness of stay, both when paying per day and when paying per episode of treatment.

OBJECTIVES

We sought to define an average length of effective stay and recovery trends by impairment category, to design a prospective payment system that takes into account costs and expected recovery trends, and to compare the calculated reimbursement with the predicted costs estimated in a previous study (Saitto C, Marino C, Fusco D, et al. A new prospective payment system for inpatient rehabilitation. Part I: predicting resource consumption. Med Care. 2005;43:844-855).

RESEARCH DESIGN

We considered all rehabilitation admissions from 5 Italian inpatient facilities during a 12-month period for which total cost of care had already been estimated and daily cost predicted through regression model. We ascertained recovery trends by impairment category through repeated MDS-PAC schedules and factorial analysis of functional status. We defined effective stay and daily resource consumption by impairment category and used these parameters to calculate reimbursement for the admission. We compared our reimbursement with predicted cost through regression analysis and evaluated the goodness of fit through residual analysis.

RESULTS

We calculated reimbursement for 2079 admissions. The r(2) values for the reimbursement to cost correlation ranged from 0.54 in the whole population to 0.56 for "multiple trauma" to 0.85 for "other medical disorders." The best fit was found in the central quintiles of the cost and severity distributions.

CONCLUSION

For each impairment category, we determined the number of days of effective hospital stay and the trends of functional gain. We demonstrated, at least within the Italian health care system, the feasibility of a reimbursement system that matches costs with functional recovery. By linking reimbursement to effective stay adjusted for trends of functional gain, we suggest it is possible to avoid both needless cuts and extensions of hospital admissions.

Influence of the Prospective Payment System on Speech-Language Pathology Services

OBJECTIVE

The present study was performed to determine the clinical effects of the Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) on speech and language intervention services and to examine the feasibility of using the federally mandated FIM instrument to establish resource allocation to patients with cognitive, communication, and swallowing disorders.

DESIGN

A pre-IRF PPS and post-IRF PPS comparative study was conducted over a 1-yr time interval using data from the American Speech-Language-Hearing Association's National Outcomes Measurement System. Toward this end, the National Outcomes Measurement System's Functional Communication Measures were used to obtain data from 2,631 patients residing in 96 freestanding rehabilitation hospitals or hospitals with rehabilitation units implementing the prospective payment system on or after January 1, 2002. To ensure reliable retrospective and prospective data comparisons, all sites were active participants within the National Outcomes Measurement System program before the introduction of IRF PPS within their facilities.

RESULTS

Findings revealed changes in both the utilization of speech-language pathologists and patient outcomes. Under the IRF PPS, there was a clear decline in speech- and language-related lengths of stay. However, clinicians attempted to compensate for these decrements in lengths of stay by increasing the intensity and frequency of their speech and language services. Despite these compensatory efforts, further analyses of the data revealed that under the IRF PPS, fewer patients achieved multiple levels of functional progress in speech and language abilities than before this payment system was implemented. This trend was most noteworthy in the treatment areas of swallowing, motor speech, and memory. In addition, this study revealed that, compared with the National Outcomes Measurement System's Functional Communication Measures, the FIM instrument significantly under-represented and undervalued the extent of a patient's overall progress in recovering from their cognitive, communication, or swallowing disabilities.

CONCLUSION

These findings support the notion that the introduction of the IRF PPS has, perhaps unintentionally, caused more patients with cognitive, communication, and swallowing disorders to be discharged from inpatient rehabilitative care with less than adequate functional skill levels. The discouraging results in speech-language pathology utilization and patient outcomes will be useful for clinicians in the future when facing the ongoing challenges of maintaining quality care while streamlining services under the prospective payment system.

The effect of prospective payment on rehabilitative care

OBJECTIVES

To estimate the difference between cost and prospective payment system (PPS) reimbursements for rehabilitation care and to simulate potential consequences of cost-reducing strategies.

DESIGN

A retrospective study to estimate costs and functional status at discharge from care.

SETTING

An academic, urban, rehabilitation hospital.

PARTICIPANTS

Stroke patients on their first admission to a rehabilitation hospital between 1994 and 1998.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Cost was estimated from billing databases. Function was measured using the motor and cognitive components of the FIM instrument.

RESULTS

PPS reimbursements were 10,825 dollars (37%) lower than costs. No matter how much therapy was reduced, the costs were still greater than the mean PPS reimbursement. A reduction in length of stay by 9.6 days was required to bring costs in line with the PPS reimbursement, reducing discharge cognitive function by 1.1 points (P <.01). Use of group therapy brought costs close to PPS reimbursement amount and improved discharge cognitive function by 0.5 points (P <.10).

CONCLUSIONS

Our study shows the large difference between costs and expected PPS reimbursements that would have been observed before the PPS. Institutions have many options that reduce costs, with little effect on function at discharge. Future studies should determine the impact of evolving reimbursement rules on facilities financial status, and on patient outcomes.