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Morrow C, Woodbury M, Simpson AN, Almallouhi E, Simpson KN. Differences in rehabilitation evaluation access for rural and socially disadvantaged stroke survivors. Top Stroke Rehabil 2024; 31:625-631. [PMID: 38369788 PMCID: PMC11269038 DOI: 10.1080/10749357.2024.2312638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 01/27/2024] [Indexed: 02/20/2024]
Abstract
BACKGROUND Most stroke survivors have ongoing deficits and report unmet needs. Despite evidence that rehabilitation improves stroke survivors' function, access to occupational and physical therapy is limited. Describing access to care for disadvantaged communities for different levels of stroke severity will provide proportions used to create Markov economic models to demonstrate the value of rehabilitation. OBJECTIVES The objective of this study was to explore differences in the frequency of rehabilitation evaluations via outpatient therapy and home health for Medicare Part B ischemic stroke survivors in rural and socially disadvantaged locations. METHODS We completed a retrospective, descriptive cohort analysis using the 2018 and 2019 5% Medicare Limited Data Sets (LDS) from the Centers for Medicare and Medicaid Services using STROBE guidelines for observational studies. We extracted rehabilitation Current Procedural Terminology (CPT) codes for those who received occupational or physical therapy to examine differences in therapy evaluations for rural and socially disadvantaged populations. RESULTS Of the 9,076 stroke survivors in this cohort, 44.2% did not receive any home health or outpatient therapy. Of these, 64.7% had a moderate or severe stroke, indicating an unmet need for therapy. Only 2.0% of stroke survivors received outpatient occupational therapy within the first year Rural and socially disadvantaged communities accessed rehabilitation evaluations at lower rates than general stroke survivors. CONCLUSIONS These findings describe the poor access to home health and outpatient rehabilitation for stroke survivors, particularly in traditionally underserved populations. These results will influence future economic evaluations of interventions aimed at improving access to care.
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Affiliation(s)
- Corey Morrow
- College of Health Professions, Medical University of South Carolina
| | | | - Annie N Simpson
- College of Health Professions, Medical University of South Carolina
| | | | - Kit N Simpson
- College of Health Professions, Medical University of South Carolina
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Kinney AR, Penzenik ME, Forster JE, O'Donnell F, Brenner LA. Facility-Level and Racial Disparities in Access to Inpatient Psychiatric Occupational Therapy Services in the Veterans Health Administration. Am J Occup Ther 2024; 78:7804205040. [PMID: 38861552 DOI: 10.5014/ajot.2024.050583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2024] Open
Abstract
IMPORTANCE Veterans receiving inpatient psychiatric services with limitations in activities of daily living (ADLs) benefit from occupational therapy, yet disparities in access are unknown. OBJECTIVE To investigate whether ADL limitations, an indicator of occupational therapy need, was associated with inpatient psychiatric occupational therapy utilization in the Veterans Health Administration (VHA) and whether this relationship differs by facility characteristics. DESIGN Secondary analysis of VHA data. Modified Poisson regression modeled occupational therapy utilization as a function of ADL limitations, facility characteristics, and covariates. Interactions estimated whether the relationship between ADL limitations and occupational therapy utilization differed across facility characteristics. SETTING VHA inpatient psychiatric setting. PARTICIPANTS Veterans receiving VHA inpatient psychiatric care from 2015 to 2020 (N = 133,844). OUTCOMES AND MEASURES Occupational therapy utilization. RESULTS Veterans with ADL limitations were more likely to receive occupational therapy. Veterans receiving care in facilities with higher complexity and greater inpatient psychiatric care quality were more likely to receive occupational therapy. Additionally, Black veterans were less likely to receive occupational therapy relative to their White, non-Hispanic counterparts. Interactions indicated that the extent to which ADL limitations drove access to occupational therapy utilization was weaker within facilities with higher complexity and care quality. CONCLUSIONS AND RELEVANCE Veterans with ADL limitations were more likely to access inpatient psychiatric occupational therapy, suggesting that such services are generally allocated to veterans in need. However, findings indicate disparities in access across patient-level (e.g., Black race) and facility-level (e.g., facility complexity) factors, informing efforts to eliminate barriers to accessing these valuable services. Plain-Language Summary: This is the first study, to our knowledge, to examine disparities in access to inpatient psychiatric occupational therapy in the Veterans Health Administration (VHA). The study findings show that access to inpatient psychiatric occupational therapy is partly driven by the needs of the patient. However, nonclinical factors, such as a patient's race and the characteristics of the facility at which they receive care (complexity, number of psychiatric beds available, and the quality of psychiatric care), are also important drivers of access. Identifying factors influencing access to these valuable services is the first step in developing strategies that reduce barriers to access for veterans in need.
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Affiliation(s)
- Adam R Kinney
- Adam R. Kinney, PhD, OTR/L, is Research Health Science Specialist, Veterans Affairs (VA) Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC) for Suicide Prevention, Rocky Mountain Regional VA Medical Center, Aurora, CO, and Assistant Professor, Department of Physical Medicine and Rehabilitation, Anschutz Medical Campus, University of Colorado, Aurora;
| | - Molly E Penzenik
- Molly E. Penzenik, MPH, is Data Analyst, VA Rocky Mountain MIRECC for Suicide Prevention, Rocky Mountain Regional VA Medical Center, Aurora, CO, and Data Analyst, Department of Physical Medicine and Rehabilitation, Anschutz Medical Campus, University of Colorado, Aurora
| | - Jeri E Forster
- Jeri E. Forster, PhD, is Director, Data and Statistical Core, VA Rocky Mountain MIRECC for Suicide Prevention, Rocky Mountain Regional VA Medical Center, Aurora, CO, and Associate Professor, Department of Physical Medicine and Rehabilitation, Anschutz Medical Campus, University of Colorado, Aurora
| | - Frederica O'Donnell
- Frederica O'Donnell, OTD, OTR/L, is National Occupational Therapy Discipline Lead, Department of Rehabilitation and Prosthetic Services, Veterans Health Administration, Washington, DC
| | - Lisa A Brenner
- Lisa A. Brenner, PhD, is Director, VA Rocky Mountain MIRECC for Suicide Prevention, Rocky Mountain Regional VA Medical Center, Aurora, CO, and Professor, Departments of Physical Medicine and Rehabilitation, Psychiatry, and Neurology, Anschutz Medical Campus, University of Colorado, Aurora
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3
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Luo D, Ouayogodé MH, Mullahy J, Cao Y(J. Regional variation in length of stay for stroke inpatient rehabilitation in traditional Medicare and Medicare Advantage. HEALTH AFFAIRS SCHOLAR 2024; 2:qxae089. [PMID: 39071107 PMCID: PMC11282463 DOI: 10.1093/haschl/qxae089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 06/04/2024] [Accepted: 07/15/2024] [Indexed: 07/30/2024]
Abstract
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.
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Affiliation(s)
- Dian Luo
- Department of Population Health Sciences, University of Wisconsin–Madison, Madison, WI 53726, United States
| | - Mariétou H Ouayogodé
- Department of Population Health Sciences, University of Wisconsin–Madison, Madison, WI 53726, United States
- Center for Demography and Health of Aging, University of Wisconsin–Madison, Madison, WI 53726, United States
| | - John Mullahy
- Department of Population Health Sciences, University of Wisconsin–Madison, Madison, WI 53726, United States
- Center for Demography and Health of Aging, University of Wisconsin–Madison, Madison, WI 53726, United States
| | - Ying (Jessica) Cao
- Department of Population Health Sciences, University of Wisconsin–Madison, Madison, WI 53726, United States
- Center for Demography and Health of Aging, University of Wisconsin–Madison, Madison, WI 53726, United States
- Health Innovation Program, University of Wisconsin–Madison, Madison, WI 53726, United States
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Kinney AR, Penzenik ME, Forster JE, O'Donnell F, Brenner LA. Association of Inpatient Occupational Therapy Utilization With Reduced Risk for Psychiatric Readmission Among Veterans. Psychiatr Serv 2024:appips20230650. [PMID: 38807577 DOI: 10.1176/appi.ps.20230650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/30/2024]
Abstract
OBJECTIVE The authors sought to investigate whether utilization of inpatient occupational therapy (OT) was associated with reduced risk for 30-day psychiatric readmission in the Veterans Health Administration (VHA). METHODS The authors conducted a secondary analysis of VHA medical record data for veterans who received inpatient psychiatric care from 2015 to 2020 (N=176,889). Mixed-effects logistic regression was used to model psychiatric readmission within 30 days of discharge (yes or no) as a function of inpatient psychiatric OT utilization (none, one, two, three, or four or more encounters) and other care utilization (e.g., previous psychiatric hospitalization), as well as clinical (e.g., primary diagnosis), sociodemographic (e.g., race-ethnicity), and facility (e.g., complexity) characteristics. Sensitivity analyses were conducted to evaluate the robustness of findings (e.g., stratification by discharge disposition). RESULTS Relatively few veterans received inpatient psychiatric OT (26.2%), and 8.4% were readmitted within 30 days. Compared with veterans who did not receive inpatient psychiatric OT, those with one (OR=0.76), two (OR=0.64), three (OR=0.67), or four or more encounters (OR=0.64) were significantly (p<0.001) less likely to be readmitted within 30 days. These findings were consistent across all sensitivity analyses. CONCLUSIONS Veterans who received inpatient OT services were less likely to experience psychiatric readmission. A clear dose-response relationship between inpatient psychiatric OT and readmission risk was not identified. These findings suggest that OT services may facilitate high-value inpatient psychiatric care in the VHA by preventing readmissions that stymie recovery and incur high costs. Future research may establish the causality of this relationship, informing policy regarding increased access to inpatient psychiatric OT.
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Affiliation(s)
- Adam R Kinney
- Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, Rocky Mountain Regional Veterans Affairs (VA) Medical Center, Aurora, Colorado (Kinney, Penzenik, Forster, Brenner); Department of Physical Medicine and Rehabilitation, Anschutz Medical Campus, University of Colorado, Aurora (Kinney, Penzenik, Forster); Department of Rehabilitation and Prosthetic Services, Veterans Health Administration, Washington, D.C. (O'Donnell); Departments of Physical Medicine and Rehabilitation, Psychiatry, and Neurology, Anschutz Medical Campus, University of Colorado, Aurora (Brenner)
| | - Molly E Penzenik
- Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, Rocky Mountain Regional Veterans Affairs (VA) Medical Center, Aurora, Colorado (Kinney, Penzenik, Forster, Brenner); Department of Physical Medicine and Rehabilitation, Anschutz Medical Campus, University of Colorado, Aurora (Kinney, Penzenik, Forster); Department of Rehabilitation and Prosthetic Services, Veterans Health Administration, Washington, D.C. (O'Donnell); Departments of Physical Medicine and Rehabilitation, Psychiatry, and Neurology, Anschutz Medical Campus, University of Colorado, Aurora (Brenner)
| | - Jeri E Forster
- Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, Rocky Mountain Regional Veterans Affairs (VA) Medical Center, Aurora, Colorado (Kinney, Penzenik, Forster, Brenner); Department of Physical Medicine and Rehabilitation, Anschutz Medical Campus, University of Colorado, Aurora (Kinney, Penzenik, Forster); Department of Rehabilitation and Prosthetic Services, Veterans Health Administration, Washington, D.C. (O'Donnell); Departments of Physical Medicine and Rehabilitation, Psychiatry, and Neurology, Anschutz Medical Campus, University of Colorado, Aurora (Brenner)
| | - Frederica O'Donnell
- Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, Rocky Mountain Regional Veterans Affairs (VA) Medical Center, Aurora, Colorado (Kinney, Penzenik, Forster, Brenner); Department of Physical Medicine and Rehabilitation, Anschutz Medical Campus, University of Colorado, Aurora (Kinney, Penzenik, Forster); Department of Rehabilitation and Prosthetic Services, Veterans Health Administration, Washington, D.C. (O'Donnell); Departments of Physical Medicine and Rehabilitation, Psychiatry, and Neurology, Anschutz Medical Campus, University of Colorado, Aurora (Brenner)
| | - Lisa A Brenner
- Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, Rocky Mountain Regional Veterans Affairs (VA) Medical Center, Aurora, Colorado (Kinney, Penzenik, Forster, Brenner); Department of Physical Medicine and Rehabilitation, Anschutz Medical Campus, University of Colorado, Aurora (Kinney, Penzenik, Forster); Department of Rehabilitation and Prosthetic Services, Veterans Health Administration, Washington, D.C. (O'Donnell); Departments of Physical Medicine and Rehabilitation, Psychiatry, and Neurology, Anschutz Medical Campus, University of Colorado, Aurora (Brenner)
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Jain S, Murphy TE, Falvey JR, Leo-Summers L, O’Leary JR, Zang E, Gill TM, Krumholz HM, Ferrante LE. Social Determinants of Health and Delivery of Rehabilitation to Older Adults During ICU Hospitalization. JAMA Netw Open 2024; 7:e2410713. [PMID: 38728030 PMCID: PMC11087837 DOI: 10.1001/jamanetworkopen.2024.10713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 03/09/2024] [Indexed: 05/13/2024] Open
Abstract
Importance Older adults with socioeconomic disadvantage develop a greater burden of disability after critical illness than those without socioeconomic disadvantage. The delivery of in-hospital rehabilitation that can mitigate functional decline may be influenced by social determinants of health (SDOH). Whether rehabilitation delivery differs by SDOH during critical illness hospitalization is not known. Objective To evaluate whether SDOH are associated with the delivery of skilled rehabilitation during critical illness hospitalization among older adults. Design, Setting, and Participants This cohort study used data from the National Health and Aging Trends Study linked with Medicare claims (2011-2018). Participants included older adults hospitalized with a stay in the intensive care unit (ICU). Data were analyzed from August 2022 to September 2023. Exposures Dual eligibility for Medicare and Medicaid, education, income, limited English proficiency (LEP), and rural residence. Main Outcome and Measures The primary outcome was delivery of physical therapy (PT) and/or occupational therapy (OT) during ICU hospitalization, characterized as any in-hospital PT or OT and rate of in-hospital PT or OT, calculated as total number of units divided by length of stay. Results In the sample of 1618 ICU hospitalizations (median [IQR] patient age, 81.0 [75.0-86.0] years; 842 [52.0%] female), 371 hospitalizations (22.9%) were among patients with dual Medicare and Medicaid eligibility, 523 hospitalizations (32.6%) were among patients with less than high school education, 320 hospitalizations (19.8%) were for patients with rural residence, and 56 hospitalizations (3.5%) were among patients with LEP. A total of 1076 hospitalized patients (68.5%) received any PT or OT, with a mean rate of 0.94 (95% CI, 0.86-1.02) units/d. After adjustment for age, sex, prehospitalization disability, mechanical ventilation, and organ dysfunction, factors associated with lower odds of receipt of PT or OT included dual Medicare and Medicaid eligibility (adjusted odds ratio, 0.70 [95% CI, 0.50-0.97]) and rural residence (adjusted odds ratio, 0.65 [95% CI, 0.48-0.87]). LEP was associated with a lower rate of PT or OT (adjusted rate ratio, 0.55 [95% CI, 0.32-0.94]). Conclusions and Relevance These findings highlight the need to consider SDOH in efforts to promote rehabilitation delivery during ICU hospitalization and to investigate factors underlying inequities in this practice.
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Affiliation(s)
- Snigdha Jain
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Terrence E. Murphy
- Department of Public Health Sciences, Pennsylvania State University, State College
| | - Jason R. Falvey
- Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore
| | | | - John R. O’Leary
- Program on Aging, Yale School of Medicine, New Haven, Connecticut
| | - Emma Zang
- Department of Sociology, Yale University, New Haven, Connecticut
| | - Thomas M. Gill
- Program on Aging, Yale School of Medicine, New Haven, Connecticut
| | - Harlan M. Krumholz
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
| | - Lauren E. Ferrante
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
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Abstract
Stroke remains a major cause of disability. Intensive rehabilitation therapy can improve outcomes, but most patients receive limited doses. Telehealth methods can overcome obstacles to delivering intensive therapy and thereby address this unmet need. A specific example is reviewed in detail, focused on a telerehabilitation system that targets upper extremity motor deficits after stroke. Strengths of this system include provision of daily therapy associated with very high patient compliance, safety and feasibility in the inpatient or home setting, comparable efficacy to dose-matched therapy provided in-clinic, and a holistic approach that includes assessment, education, prevention, and activity-based therapy.
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Affiliation(s)
- Steven C Cramer
- Department of Neurology, UCLA, Los Angeles, CA, USA; California Rehabilitation Institute, 2070 Century Park East, Los Angeles, CA 90067-1907, USA.
| | - Brittany M Young
- Department of Neurology, UCLA, Los Angeles, CA, USA; California Rehabilitation Institute, 2070 Century Park East, Los Angeles, CA 90067-1907, USA
| | - Anne Schwarz
- Department of Neurology, UCLA, Los Angeles, CA, USA; California Rehabilitation Institute, 2070 Century Park East, Los Angeles, CA 90067-1907, USA
| | - Tracy Y Chang
- Department of Neurology, UCLA, Los Angeles, CA, USA; California Rehabilitation Institute, 2070 Century Park East, Los Angeles, CA 90067-1907, USA
| | - Michael Su
- Department of Neurology, UCLA, Los Angeles, CA, USA; California Rehabilitation Institute, 2070 Century Park East, Los Angeles, CA 90067-1907, USA
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French MA, Hayes H, Johnson JK, Young DL, Roemmich RT, Raghavan P. The effect of post-acute rehabilitation setting on 90-day mobility after stroke: A difference-in-difference analysis. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.01.08.24301026. [PMID: 38260437 PMCID: PMC10802638 DOI: 10.1101/2024.01.08.24301026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Background After discharged from the hospital for acute stroke, individuals typically receive rehabilitation in one of three settings: inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), or home with community services (i.e., home health or outpatient clinics). The initial setting of post-acute care (i.e., discharge location) is related to mortality and hospital readmission; however, the impact of this setting on the change in functional mobility at 90-days after discharge is still poorly understood. The purpose of this work was to examine the impact of discharge location on the change in functional mobility between hospital discharge and 90-days post-discharge. Methods In this retrospective cohort study, we used the electronic health record to identify individuals admitted to Johns Hopkins Medicine with an acute stroke and who had measurements of mobility [Activity Measure for Post Acute Care Basic Mobility (AM-PAC BM)] at discharge from the acute hospital and 90-days post-discharge. Individuals were grouped by discharge location (IRF=190 [40%], SNF=103 [22%], Home with community services=182 [(38%]). We compared the change in mobility from time of discharge to 90-days post-discharge in each group using a difference-in-differences analysis and controlling for demographics, clinical characteristics, and social determinants of health. Results We included 475 individuals (age 64.4 [14.8] years; female: 248 [52.2%]). After adjusting for covariates, individuals who were discharged to an IRF had a significantly greater improvement in AM-PAC BM from time of discharge to 90-days post-discharge compared to individuals discharged to a SNF or home with community services (β=-3.5 (1.4), p=0.01 and β=-8.2 (1.3), p=<0.001, respectively). Conclusions These findings suggest that the initial post-acute rehabilitation setting impacts the magnitude of functional recovery at 90-days after discharge from the acute hospital. These findings support the need for high-intensity rehabilitation and for policies that facilitate the delivery of high-intensity rehabilitation after stroke.
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Affiliation(s)
- Margaret A. French
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, UT
- Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, MD
| | - Heather Hayes
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, UT
| | - Joshua K. Johnson
- Department of Physical Medicine & Rehabilitation, Cleveland Clinic, Cleveland, OH
| | - Daniel L. Young
- Department of Physical Therapy, University of Nevada, Las Vegas, Las Vegas, NV
| | - Ryan T. Roemmich
- Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, MD
- Center for Movement Studies, Kennedy Krieger Institute, Baltimore, MD
| | - Preeti Raghavan
- Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, MD
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Capo-Lugo CE, McLaughlin KH, Ye B, Daley K, Young D, Lavezza A, Friedman M, Hoyer EH. Using Nursing Assessments of Mobility and Activity to Prioritize Patients Most Likely to Need Rehabilitation Services. Arch Phys Med Rehabil 2023; 104:1402-1408. [PMID: 37028697 DOI: 10.1016/j.apmr.2023.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 02/03/2023] [Accepted: 03/19/2023] [Indexed: 04/08/2023]
Abstract
OBJECTIVE To identify nursing assessments of mobility and activity associated with lower-value rehabilitation services. DESIGN Retrospective cohort analysis of admissions from December 2016 to September 2019 SETTING: Medicine, neurology, and surgery units (n=47) at a tertiary hospital. PARTICIPANTS We included patients with a length of stay ≥7 days on units that routinely assessed patient function (n=18,065 patients). INTERVENTIONS Not applicable. MAIN OUTCOME We examined the utility of nursing assessments of function to identify patients who received lower-value rehabilitation consults, defined as those who received ≤1 therapy visit. MEASURES Patient function was assessed using 2 Activity Measure for Post-Acute Care (AM-PAC or "6 clicks") inpatient short forms: (1) basic mobility (eg, bed mobility, walking) and (2) daily activity (eg, grooming, toileting). RESULTS Using an AM-PAC cutoff value of ≥23 correctly identified 92.5% and 98.7% of lower-value physical therapy and occupational therapy visits, respectively. In our cohort, using a cutoff value of ≥23 on the AM-PAC would have eliminated 3482 (36%) of lower-value physical therapy consults and 4076 (34%) of lower-value occupational therapy consults. CONCLUSIONS Nursing assessment, using AM-PAC scores, can be used to help identify lower-value rehabilitation consults, which can then be reallocated to patients with greater rehabilitation needs. Based on our results, an AM-PAC cutoff value of ≥23 can be used as a guide to help prioritize patients with greater rehabilitation needs.
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Affiliation(s)
- Carmen E Capo-Lugo
- Department of Physical Therapy, School of Health Professions, University of Alabama at Birmingham, Birmingham, Alabama; Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, Maryland.
| | - Kevin H McLaughlin
- Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Bingqing Ye
- Department of Physical Medicine and Rehabilitation, Johns Hopkins Hospital, Baltimore, Maryland
| | - Kelly Daley
- Department of Physical Medicine and Rehabilitation, Johns Hopkins Hospital, Baltimore, Maryland
| | - Daniel Young
- Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, Maryland; Department of Physical Therapy, University of Nevada, Las Vegas, Las Vegas, Nevada, United States
| | - Annette Lavezza
- Department of Physical Medicine and Rehabilitation, Johns Hopkins Hospital, Baltimore, Maryland
| | - Michael Friedman
- Department of Physical Medicine and Rehabilitation, Johns Hopkins Hospital, Baltimore, Maryland
| | - Erik H Hoyer
- Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, Maryland; Department of Physical Medicine and Rehabilitation, Johns Hopkins Hospital, Baltimore, Maryland
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Cao YJ, Luo D. Post-Acute Care in Inpatient Rehabilitation Facilities Between Traditional Medicare and Medicare Advantage Plans Before and During the COVID-19 Pandemic. J Am Med Dir Assoc 2023; 24:868-875.e5. [PMID: 37148906 PMCID: PMC10073583 DOI: 10.1016/j.jamda.2023.03.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 03/17/2023] [Accepted: 03/20/2023] [Indexed: 04/08/2023]
Abstract
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.
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Affiliation(s)
- Ying Jessica Cao
- Department of Population Health Sciences, University of Wisconsin-Madison, Madison, WI, USA.
| | - Dian Luo
- Department of Population Health Sciences, University of Wisconsin-Madison, Madison, WI, USA
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10
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Li S, Lu Y, Fang S, Wang L, Peng B. Inpatient rehabilitation therapy in stroke patients with reperfusion therapy: a national prospective registry study. BMC Neurol 2023; 23:146. [PMID: 37020194 PMCID: PMC10073784 DOI: 10.1186/s12883-023-03144-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 02/27/2023] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND Little is known about the rate of real-world inpatient rehabilitation therapy (IRT) after stroke. We aimed to determine the rate of inpatient rehabilitation therapy and its associated factors in patients who undergo reperfusion therapy in China. METHODS This national prospective registry study included hospitalized ischemic stroke patients aged 14-99 years with reperfusion therapy between January 1, 2019, and June 30, 2020, collecting hospital-level and patient-level demographic and clinical data. IRT included acupuncture or massage, physical therapy, occupational therapy, speech therapy, and others. The primary outcome was the rate of patients receiving IRT. RESULTS We included 209,189 eligible patients from 2191 hospitals. The median age was 66 years, and 64.2% were men. Four in five patients received only thrombolysis, and the rest 19.2% underwent endovascular therapy. The overall rate of IRT was 58.2% (95% CI, 58.0-58.5%). Differences in demographic and clinical variables existed between patients with and without IRT. The rates of acupuncture or massage, physical therapy, occupational therapy, speech therapy, and other rehabilitation interventions were 38.0%, 28.8%, 11.8%, 14.4%, and 22.9%, respectively. The rates of single and multimodal interventions were 28.3% and 30.0%, respectively. A lower likelihood of receiving IRT was associated with being 14-50 or 76-99 years old, female, from Northeast China, from Class-C hospitals, receiving only thrombolysis, having severe stroke or severe deterioration, a short length of stay, Covid-19 pandemic and having intracranial or gastrointestinal hemorrhage. CONCLUSION Among our patient population, the IRT rate was low with limited use of physical therapy, multimodal interventions, and rehabilitation centers and varied by demographic and clinical features. The implementation of IRT remains a challenge for stroke care, warranting urgent and effective national programs to enhance post-stroke rehabilitation and the adherence to guidelines.
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Affiliation(s)
- Shengde Li
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Shuaifuyuan1, Dong Cheng District, Beijing, 100730, China
| | - Yixiu Lu
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Shuaifuyuan1, Dong Cheng District, Beijing, 100730, China
| | - Shiyuan Fang
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Shuaifuyuan1, Dong Cheng District, Beijing, 100730, China
| | - Longde Wang
- The General Office of Stroke Prevention Project Committee, National Health Commission of the People's Republic of China, No. 118, Guang'anmen Inner Street, Beijing, 100053, China.
| | - Bin Peng
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Shuaifuyuan1, Dong Cheng District, Beijing, 100730, China.
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11
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Kumar A, Roy I, Falvey J, Rudolph JL, Rivera-Hernandez M, Shaibi S, Sood P, Childers C, Karmarkar A. Effect of Variation in Early Rehabilitation on Hospital Readmission After Hip Fracture. Phys Ther 2023; 103:pzac170. [PMID: 37172126 PMCID: PMC10071584 DOI: 10.1093/ptj/pzac170] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 08/18/2022] [Accepted: 10/16/2022] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Provision of early rehabilitation services during acute hospitalization after a hip fracture is vital for improving patient outcomes. The purpose of this study was to examine the association between the amount of rehabilitation services received during the acute care stay and hospital readmission in older patients after a hip fracture. METHODS Medicare claims data (2016-2017) for older adults admitted to acute hospitals for a hip fracture (n = 131,127) were used. Hospital-based rehabilitation (physical therapy, occupational therapy, or both) was categorized into tertiles by minutes per day as low (median = 17.5), middle (median = 30.0), and high (median = 48.8). The study outcome was risk-adjusted 7-day and 30-day all-cause hospital readmission. RESULTS The median hospital stay was 5 days (interquartile range [IQR] = 4-6 days). The median rehabilitation minutes per day was 30 (IQR = 21-42.5 minutes), with 17 (IQR = 12.6-20.6 minutes) in the low tertile, 30 (IQR = 12.6-20.6 minutes) in the middle tertile, and 48.8 (IQR = 42.8-60.0 minutes) in the high tertile. Compared with high therapy minutes groups, those in the low and middle tertiles had higher odds of a 30-day readmission (low tertile: odds ratio [OR] = 1.11, 95% CI = 1.06-1.17; middle tertile: OR = 1.07, 95% CI = 1.02-1.12). In addition, patients who received low rehabilitation volume had higher odds of a 7-day readmission (OR = 1.20; 95% CI = 1.10-1.30) compared with high volume. CONCLUSION Elderly patients with hip fractures who received less rehabilitation were at higher risk of readmission within 7 and 30 days. IMPACT These findings confirm the need to update clinical guidelines in the provision of early rehabilitation services to improve patient outcomes during acute hospital stays for individuals with hip fracture. LAY SUMMARY There is significant individual- and hospital-level variation in the amount of hospital-based rehabilitation delivered to older adults during hip fracture hospitalization. Higher intensity of hospital-based rehabilitation care was associated with a lower risk of hospital readmission within 7 and 30 days.
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Affiliation(s)
- Amit Kumar
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, Utah, USA
- Center for Health Equity Research, Northern Arizona University, Flagstaff, Arizona, USA
| | - Indrakshi Roy
- Center for Health Equity Research, Northern Arizona University, Flagstaff, Arizona, USA
- Department of Health Sciences, Northern Arizona University, Flagstaff, Arizona, USA
| | - Jason Falvey
- University of Maryland School of Medicine, Department of Physical Therapy and Rehabilitation Science Baltimore, Maryland, USA
- University of Maryland School of Medicine, Department of Epidemiology and Public Health Baltimore, Maryland, USA
| | - James L Rudolph
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
| | - Maricruz Rivera-Hernandez
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Stefany Shaibi
- Creighton University Health Sciences Campus, Phoenix, Arizona, USA
| | - Pallavi Sood
- Center for Optimal Aging, Marymount University, Arlington, Virginia, USA
| | - Christine Childers
- Physical Therapy Program, University of Arizona Health Sciences, Tucson, Arizona, USA
| | - Amol Karmarkar
- Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
- Sheltering Arms Institute, Richmond, Virginia, USA
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12
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Young BM, Holman EA, Cramer SC. Rehabilitation Therapy Doses Are Low After Stroke and Predicted by Clinical Factors. Stroke 2023; 54:831-839. [PMID: 36734234 PMCID: PMC9992003 DOI: 10.1161/strokeaha.122.041098] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 12/16/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Stroke is a leading cause of long-term disability. Greater rehabilitation therapy after stroke is known to improve functional outcomes. This study examined therapy doses during the first year of stroke recovery and identified factors that predict rehabilitation therapy dose. METHODS Adults with new radiologically confirmed stroke were enrolled 2 to 10 days after stroke onset at 28 acute care hospitals across the United States. Following an initial assessment during acute hospitalization, the number of physical therapy, occupational therapy, and speech therapy sessions were determined at visits occurring 3, 6, and 12 months following stroke. Negative binomial regression examined whether clinical and demographic factors were associated with therapy counts. False discovery rate was used to correct for multiple comparisons. RESULTS Of 763 patients enrolled during acute stroke admission, 510 were available for follow-up. Therapy counts were low overall, with most therapy delivered within the first 3 months; 35.0% of patients received no physical therapy; 48.8%, no occupational therapy, and 61.7%, no speech therapy. Discharge destination was significantly related to cumulative therapy; the percentage of patients discharged to an inpatient rehabilitation facility varied across sites, from 0% to 71%. Most demographic factors did not predict therapy dose, although Hispanic patients received a lower cumulative amount of physical therapy and occupational therapy. Acutely, the severity of clinical factors (grip strength and National Institutes of Health Stroke Scale score, as well as National Institutes of Health Stroke Scale subscores for aphasia and neglect) predicted higher subsequent therapy doses. Measures of impairment and function (Fugl-Meyer, modified Rankin Scale, and Stroke Impact Scale Activities of Daily Living) assessed 3 months after stroke also predicted subsequent cumulative therapy doses. CONCLUSIONS Rehabilitative therapy doses during the first year poststroke are low in the United States. This is the first US-wide study to demonstrate that behavioral deficits predict therapy dose, with patients having more severe deficits receiving higher doses. Findings suggest directions for identifying groups at risk of receiving disproportionately low rehabilitation doses.
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Affiliation(s)
- Brittany M. Young
- Department of Neurology, University of California, Los Angeles; and California Rehabilitation Institute
| | - E. Alison Holman
- Sue and Bill Gross School of Nursing, University of California, Irvine
| | - Steven C. Cramer
- Department of Neurology, University of California, Los Angeles; and California Rehabilitation Institute
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13
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Yamakawa S, Nagayama H, Tomori K, Ikeda K, Niimi A. Effectiveness of active occupational therapy in patients with acute stroke: A propensity score-weighted retrospective study. FRONTIERS IN REHABILITATION SCIENCES 2023; 3:1045231. [PMID: 36684684 PMCID: PMC9849931 DOI: 10.3389/fresc.2022.1045231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 12/09/2022] [Indexed: 01/07/2023]
Abstract
Background and purpose The effects of therapy and patient characteristics on rehabilitation outcomes in patients with acute stroke are unclear. We investigated the effects of intensive occupational therapy (OT) on patients with acute stroke. Methods We performed a retrospective cohort study using the 2005-2016 Japan Rehabilitation Database, from which we identified patients with stroke (n = 10,270) who were admitted to acute care hospitals (n = 37). We defined active OT (AOT) and non-AOT as OT intervention times (total intervention time/length of hospital stay) longer or shorter than the daily physical therapy intervention time, respectively. The outcomes assessed were the Functional Independence Measure (FIM) and National Institutes of Health Stroke Scale (NIHSS) scores, duration of hospitalization, and rate of discharge. Propensity scores and inverse probability of treatment weighting analyses adjusted for patient characteristics were performed to investigate the effects of AOT on patient outcomes. Results We enrolled 3,501 patients (1,938 and 1,563 patients in the AOT and non-AOT groups, respectively) in the study. After inverse probability of treatment weighting, the AOT group had a shorter length of hospitalization (95% confidence interval: -3.7, -1.3, p < 0.001), and the FIM (95% confidence interval: 2.0, 5.7, p < 0.001) and NIHSS (95% confidence interval; 0.3, 1.1, p < 0.001) scores improved significantly. Subgroup analysis showed that lower NHISS scores for aphasia, gaze, and neglect and lower overall NIHSS and FIM scores on admission led to a greater increase in FIM scores in the AOT group. Conclusions AOT improved the limitations in performing activities of daily living (ADL) and physical function in patients with acute stroke and reduced the length of hospitalization. Additionally, subgroup analysis suggested that the increase in FIM score was greater in patients with severe limitations in performing ADLs and worse cognitive impairment, such as neglect, on admission.
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Affiliation(s)
- Shiori Yamakawa
- Department of Occupational Therapy, Kinugasa Hospital, Yokosuka, Japan
| | - Hirofumi Nagayama
- Department of Occupational Therapy, Kanagawa University of Human Services, Yokosuka, Japan,Correspondence: Hirofumi Nagayama
| | - Kounosuke Tomori
- Department of Occupational Therapy, Tokyo University of Technology, Tokyo, Japan
| | - Kohei Ikeda
- Department of Occupational Therapy, Kinugasa Hospital, Yokosuka, Japan
| | - Ayaka Niimi
- Department of Occupational Therapy, Yokohama Brain and Spine Center, Yokohama, Japan
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A Novel Mobilization Criteria Checklist 12 to 24 Hours After Intravenous Thrombolysis in Acute Ischemic Stroke. JOURNAL OF ACUTE CARE PHYSICAL THERAPY 2022. [DOI: 10.1097/jat.0000000000000194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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15
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Li S, Fang S, Zhang D, Lu Y, Wang L, Peng B. Association between rehabilitation after reperfusion treatment and in-hospital mortality: Results from a national registry study. Front Neurol 2022; 13:949669. [PMID: 36188393 PMCID: PMC9515317 DOI: 10.3389/fneur.2022.949669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 08/09/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundThere is no effective regimen to reduce the mortality of patients treated with intravenous thrombolysis or endovascular therapy (EVT). Therefore, we aimed to examine whether sequential therapy by rehabilitation could effectively reduce the in-hospital mortality of patients treated with reperfusion therapy.MethodsThis prospective registry study included patients with ischemic stroke who were treated by intravenous thrombolysis or endovascular therapy at Stroke Center Work Plan in China between 1 October 2018 and 31 July 2020. The patients were divided into 2 groups: those with (IRT+) or without (IRT–) inpatient rehabilitation therapy (IRT). The primary outcome was all-cause in-hospital mortality. We used Cox proportional hazards models and conducted a propensity score matching analysis to calculate hazard ratios (HRs) for mortality in the thrombolysis-only and EVT groups.ResultsOf the 189,519 patients in the thrombolysis-only group, 35.7% were women, and the median (interquartile range, IQR) age, onset-to-needle time, and follow-up time were 66 (57–74) years, 165 (119–220) min, and 9 (5–12) days, respectively. Among the 45,211 patients in the EVT group, 35.9% were women, and the median (interquartile range, IQR) age, onset-to-puncture time, and follow-up time were 66 (56–74) years, 297 (205–420) min, and 11 (6–16) days, respectively. In the thrombolysis-only group with a median (IQR) initial National Institutes of Health Stroke Scale (NIHSS) score of 6 (3–11), 105,244 patients (55.5%) treated with IRT had significantly lower all-cause in-hospital mortality [0.6 vs. 2.3%; adjusted HR 0.18 (95% confidence interval (CI) 0.16–0.2)] than those without IRT. In the EVT group with a median (IQR) initial NIHSS score of 15 (10–20), 31,098 patients (68.8%) treated with IRT also had significantly lower all-cause in-hospital mortality [2 vs. 12.1%; adjusted HR, 0.13 (95% CI 0.12–0.15)]. IRT remained significantly associated with reduced in-hospital mortality in sensitivity, subgroup, and propensity score matching analyses among both the thrombolysis-only and EVT groups.ConclusionAmong the patients with ischemic stroke treated with intravenous thrombolysis or endovascular therapy, sequential therapy by rehabilitation was associated with lower all-cause in-hospital mortality. These findings suggest the necessity of promoting inpatient rehabilitation therapy after reperfusion in patients with ischemic stroke.
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Affiliation(s)
- Shengde Li
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Shiyuan Fang
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Dingding Zhang
- Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yixiu Lu
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Longde Wang
- The General Office of Stroke Prevention Project Committee, National Health Commission of the People's Republic of China, Beijing, China
- *Correspondence: Longde Wang
| | - Bin Peng
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
- Bin Peng
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Dür M, Wenzel C, Simon P, Tucek G. Patients' and professionals' perspectives on the consideration of patients' convenient therapy periods as part of personalised rehabilitation: a focus group study with patients and therapists from inpatient neurological rehabilitation. BMC Health Serv Res 2022; 22:372. [PMID: 35313879 PMCID: PMC8939130 DOI: 10.1186/s12913-022-07755-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 03/07/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Research on the optimal period for administering health services, especially rehabilitation interventions, is scarce. The aims of this study were to explore the construct of patients' convenient therapy periods and to identify indicators based on the perspectives of patients and different health professionals from inpatient neurological rehabilitation clinics. METHODS This study was part of a larger project on patients' convenient therapy periods following a mixed methods approach. In the current study a grounded theory approach was employed based on the use of focus group interviews. Focus group interviews were conducted in three different inpatient neurological rehabilitation clinics. Patients and therapists from inpatient neurological rehabilitation clinics who were able to speak and to participate in conversations were included. RESULTS A total of 41 persons, including 23 patients and 18 therapists, such as music and occupational therapists, participated in a total of six focus group interviews. The analysis of the focus group interviews resulted in the identification of a total of 1261 codes, which could be summarised in fifteen categories. However, these categories could be divided into five indicators and ten impact factors of convenient therapy periods. Identified indicators were verbal and non-verbal communication, mental functions, physiological needs, recreational needs, and therapy initiation. CONCLUSIONS The results provide initial evidence that convenient therapy periods are clinically relevant for patients and therapists. Different states of patients' ability to effectively participate in a rehabilitation intervention exist. A systematic consideration of patients' convenient therapy periods could contribute to a personalised and more efficient delivery of intervention in neurological rehabilitation. To our knowledge, this study is one of the first attempts to research convenient therapy periods.
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Affiliation(s)
- Mona Dür
- Department of Health Sciences, IMC University of Applied Sciences, Applied Health Sciences Master Degree Programme, Piaristengasse 1, 3500, Krems, Austria. .,IMC University of Applied Sciences, Josef Ressel Centre for Horizons of personalised music therapy, University of Applied Sciences Krems, Piaristengasse 1, 3500, Krems, Austria. .,Duervation, Spitalgasse 6/1, 3500, Krems, Austria.
| | - Claudia Wenzel
- IMC University of Applied Sciences, Josef Ressel Centre for Horizons of personalised music therapy, University of Applied Sciences Krems, Piaristengasse 1, 3500, Krems, Austria.,Department of Health Sciences, IMC University of Applied Sciences, Music Therapy Bachelor and Master Degree Programme, Piaristengasse 1, 3500, Krems, Austria
| | - Patrick Simon
- IMC University of Applied Sciences, Josef Ressel Centre for Horizons of personalised music therapy, University of Applied Sciences Krems, Piaristengasse 1, 3500, Krems, Austria.,Department of Health Sciences, IMC University of Applied Sciences, Music Therapy Bachelor and Master Degree Programme, Piaristengasse 1, 3500, Krems, Austria
| | - Gerhard Tucek
- IMC University of Applied Sciences, Josef Ressel Centre for Horizons of personalised music therapy, University of Applied Sciences Krems, Piaristengasse 1, 3500, Krems, Austria.,Department of Health Sciences, IMC University of Applied Sciences, Music Therapy Bachelor and Master Degree Programme, Piaristengasse 1, 3500, Krems, Austria
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17
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Bosch PR, Karmarkar AM, Roy I, Fehnel CR, Burke RE, Kumar A. Association of Medicare-Medicaid Dual Eligibility and Race and Ethnicity With Ischemic Stroke Severity. JAMA Netw Open 2022; 5:e224596. [PMID: 35357456 PMCID: PMC8972034 DOI: 10.1001/jamanetworkopen.2022.4596] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 02/03/2022] [Indexed: 12/13/2022] Open
Abstract
Importance Black and Hispanic US residents are disproportionately affected by stroke incidence, and patients with dual eligibility for Medicare and Medicaid may be predisposed to more severe strokes. Little is known about differences in stroke severity for individuals with dual eligibility, Black individuals, and Hispanic individuals, but understanding hospital admission stroke severity is the first important step for focusing strategies to reduce disparities in stroke care and outcomes. Objective To examine whether dual eligibility and race and ethnicity are associated with stroke severity in Medicare beneficiaries admitted to acute hospitals with ischemic stroke. Design, Setting, and Participants This retrospective cross-sectional study was conducted using Medicare claims data for patients with ischemic stroke admitted to acute hospitals in the United States from October 1, 2016, to November 30, 2017. Data were analyzed from July 2021 and January 2022. Exposures Dual enrollment for Medicare and Medicaid; race and ethnicity categorized as White, Black, Hispanic, and other. Main Outcomes and Measures Claim-based National Institutes of Health Stroke Scale (NIHSS) categorized into minor (0-7), moderate (8-13), moderate to severe (14-21), and severe (22-42) stroke. Results Our sample included 45 459 Medicare fee-for-service patients aged 66 and older (mean [SD] age, 80.2 [8.4]; 25 303 [55.7%] female; 7738 [17.0%] dual eligible; 4107 [9.0%] Black; 1719 [3.8%] Hispanic; 37 715 [83.0%] White). In the fully adjusted models, compared with White patients, Black patients (odds ratio [OR], 1.21; 95% CI, 1.06-1.39) and Hispanic patients (OR, 1.54; 95% CI, 1.29-1.85) were more likely to have a severe stroke. Using White patients without dual eligibility as a reference group, White patients with dual eligibility were more likely to have a severe stroke (OR, 1.75; 95% CI, 1.56-1.95). Similarly, Black patients with dual eligibility (OR, 2.15; 95% CI, 1.78-2.60) and Hispanic patients with dual eligibility (OR, 2.50; 95% CI, 1.98-3.16) were more likely to have a severe stroke. Conclusions and Relevance In this cross-sectional study, Medicare fee-for-service patients with ischemic stroke admitted to acute hospitals who were Black or Hispanic had a higher likelihood of worse stroke severity. Additionally, dual eligibility status had a compounding association with stroke severity regardless of race and ethnicity. An urgent effort is needed to decrease disparities in access to preventive and poststroke care for dual eligible and minority patients.
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Affiliation(s)
- Pamela R. Bosch
- College of Health and Human Services, Northern Arizona University, Phoenix Biomedical Campus, Phoenix
| | - Amol M. Karmarkar
- Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University, Richmond
- Sheltering Arms Institute, Richmond, Virginia
| | - Indrakshi Roy
- Center for Health Equity Research, Northern Arizona University, Flagstaff
| | - Corey R. Fehnel
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Marcus Institute for Aging Research, Boston, Massachusetts
| | - Robert E. Burke
- Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Amit Kumar
- College of Health and Human Services, Northern Arizona University, Phoenix Biomedical Campus, Phoenix
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18
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Kumar A, Roy I, Warren M, Shaibi SD, Fabricant M, Falvey JR, Vashist A, Karmarkar AM. Impact of Hospital-Based Rehabilitation Services on Discharge to the Community by Value-Based Payment Programs After Joint Replacement Surgery. Phys Ther 2022; 102:6506306. [PMID: 35079829 PMCID: PMC9190306 DOI: 10.1093/ptj/pzab313] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 10/13/2021] [Accepted: 12/15/2021] [Indexed: 01/16/2023]
Abstract
OBJECTIVE The purpose of this study was to examine the impact of hospital-based rehabilitation services on community discharge rates after hip and knee replacement surgery according to hospital participation in value-based care models: bundled payments for care improvement (BPCI) and comprehensive care for joint replacement (CJR). The secondary objective was to determine whether community discharge rates after hip and knee replacement surgery differed by participation in these models. METHODS A secondary analysis of Medicare fee-for-service claims was conducted for beneficiaries 65 years of age or older who underwent hip and knee replacement surgery from 2016 to 2017. Independent variables were hospital participation in value-based programs categorized as: (1) BPCI, (2) CJR, and (3) non-BPCI/CJR; and total minutes per day of hospital-based rehabilitation services categorized into tertiles. The primary outcome variable was discharged to the community versus discharged to institutional post-acute care settings. The association between rehabilitation amount and community discharge among BPCI, CJR, and non-BPCI/CJR hospitals was adjusted for patient-level clinical and hospital characteristics. RESULTS Participation in BPCI or CJR was not associated with community discharge. This analysis found a dose-response relationship between the amount of rehabilitation services and odds of community discharge. Among those who received a hip replacement, this relationship was most pronounced in the BPCI group; compared with the low rehabilitation category, the medium category had odds ratio (OR) = 1.28 (95% CI = 1.17 to 1.41), and the high category had OR = 1.90 (95% CI = 1.71 to 2.11). For those who received a knee replacement, there was a dose-response relationship in the CJR group only; compared with the low rehabilitation category, the medium category had OR = 1.21 (95% CI = 1.15 to 1.28), and the high category had OR = 1.56 (95% CI = 1.46 to 1.66). CONCLUSION Regardless of hospital participation in BPCI or CJR models, higher amounts of rehabilitation services delivered during acute hospitalization is associated with a higher likelihood of discharge to community following hip and knee replacement surgery. IMPACT In the era of value-based care, frontloading of rehabilitation care is vital for improving patient-centered health outcomes in acute phases of lower extremity joint replacement.
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Affiliation(s)
- Amit Kumar
- Department of Physical Therapy, Phoenix Biomedical Campus, College of Health and Human Services, Northern Arizona University, Phoenix, Arizona, USA
| | - Indrakshi Roy
- Center for Health Equity Research, Northern Arizona University, Flagstaff, Arizona, USA
| | - Meghan Warren
- Department of Physical Therapy, Phoenix Biomedical Campus, College of Health and Human Services, Northern Arizona University, Phoenix, Arizona, USA
| | - Stefany D Shaibi
- Department of Physical Therapy, Phoenix Biomedical Campus, College of Health and Human Services, Northern Arizona University, Phoenix, Arizona, USA
| | - Maximilian Fabricant
- Department of Physical Therapy, Phoenix Biomedical Campus, College of Health and Human Services, Northern Arizona University, Phoenix, Arizona, USA
| | - Jason R Falvey
- Department of Physical Therapy and Rehabilitation Sciences, School of Medicine, University of Maryland, Baltimore, Maryland, USA,Department of Epidemiology and Public Health, School of Medicine, University of Maryland, Baltimore, Maryland, USA
| | | | - Amol M Karmarkar
- Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA,Sheltering Arms Institute, Richmond, Virginia, USA,Address all correspondence to Dr Karmarkarat at:
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Kinney AR, Graham JE, Middleton A, Edelstein J, Wyrwa J, Malcolm MP. Mobility status and acute care physical therapy utilization: The Moderating roles of age, significant others, and insurance type. Arch Phys Med Rehabil 2022; 103:1600-1606.e1. [PMID: 35007549 DOI: 10.1016/j.apmr.2021.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 11/03/2021] [Accepted: 12/16/2021] [Indexed: 11/02/2022]
Abstract
OBJECTIVE To investigate whether a direct measure of need for PT, mobility status, was associated with acute care PT utilization and whether this relationship differs across sociodemographic factors and insurance type. DESIGN In a secondary analysis of electronic health records data, we estimated logistic regression models to determine whether mobility status was associated with acute care PT utilization. Interactions between mobility and both sociodemographic factors (sex; age; significant other; minority status) and insurance type were included to investigate whether the relationship between mobility and PT utilization varied across patient characteristics. SETTING Five regional hospitals from one health system. PARTICIPANTS 60,459 adults admitted between 2014 and 2018 who received a PT evaluation. INTERVENTIONS None. MAIN OUTCOME MEASURE(S) Received acute care PT; Activity Measure for Post-Acute Care (AM-PAC) "6-Clicks" measure of mobility. RESULTS Half of patients who received a PT evaluation received subsequent treatment. Patients with mobility limitations were more likely to receive PT. Interaction terms indicated that among patients with mobility limitations, those who 1) were younger; 2) had significant others; and 3) had private insurance (vs. public) were more likely to receive PT. Among patients with greater mobility status, older patients and those without a significant other were more likely to receive PT. CONCLUSIONS The relationship between acute care PT need and utilization differed across sociodemographic factors and insurance type. We offer potential explanations for these findings to guide studies targeting equitable distribution of beneficial PT services.
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Affiliation(s)
- Adam R Kinney
- Rocky Mountain Mental Illness Research, Education, and Clinical Center, Department of Veterans Affairs, Aurora, Colorado; Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado.
| | - James E Graham
- Department of Occupational Therapy, Colorado State University, Fort Collins, CO
| | - Addie Middleton
- New England Geriatric Research Education and Clinical Center, VA Boston Healthcare System, Boston, MA, USA; Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA
| | - Jessica Edelstein
- Department of Occupational Therapy, Colorado State University, Fort Collins, CO
| | - Jordan Wyrwa
- UCHealth, University of Colorado Hospital, Anschutz Medical Campus, Aurora, Colorado
| | - Matt P Malcolm
- Department of Occupational Therapy, Colorado State University, Fort Collins, CO; Colorado School of Public Health, Colorado State University, Fort Collins, CO
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20
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Kinney AR, Graham JE, Bukhari R, Hoffman A, Malcolm MP. Activities of Daily Living Performance and Acute Care Occupational Therapy Utilization: Moderating Factors. Am J Occup Ther 2022; 76:23141. [PMID: 34997754 DOI: 10.5014/ajot.2022.049060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
IMPORTANCE Hospitalized patients who have difficulty performing activities of daily living (ADLs) benefit from occupational therapy services; however, disparities in access to such services are understudied. OBJECTIVE To investigate whether need (i.e., limited ADL performance) predicts acute care occupational therapy utilization and whether this relationship differs across sociodemographic factors and insurance type. DESIGN A secondary analysis of electronic health records data. Logistic regression models were specified to determine whether ADL performance predicted use of occupational therapy treatment. Interactions were included to investigate whether the relationship between ADL performance and occupational therapy utilization varied across sociodemographic factors (e.g., age) and insurance type. PARTICIPANTS A total of 56,022 adults admitted to five regional hospitals between 2014 and 2018 who received an occupational therapy evaluation. INTERVENTION None. Outcomes and Measures: Occupational therapy service utilization, Activity Measure for Post-Acute Care "6-Clicks" measure of daily activity. RESULTS Forty-four percent of the patients evaluated for occupational therapy received treatment. Patients with lower ADL performance were more likely to receive occupational therapy treatment; however, interaction terms indicated that, among patients with low ADL performance, those who were younger, were White and non-Hispanic, had significant others, and had private insurance (vs. public) were more likely to receive treatment. These differences were smaller among patients with greater ADL performance. CONCLUSIONS AND RELEVANCE Greater need was positively associated with receiving occupational therapy services, but this relationship was moderated by age, minoritized status, significant other status, and insurance type. The findings provide direction for exploring determinants of disparities in occupational therapy utilization. What This Article Adds: Acute care occupational therapy utilization is driven partly by patient need, but potential disparities in access to beneficial services may exist across sociodemographic characteristics and insurance type. Identifying potential determinants of disparities in acute care occupational therapy utilization is the first step in developing strategies to reduce barriers for those in need.
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Affiliation(s)
- Adam R Kinney
- Adam R. Kinney, PhD, OTR/L, is Research Health Science Specialist, Rocky Mountain Mental Illness Research, Education, and Clinical Center, Department of Veterans Affairs, Aurora, CO, and Assistant Professor, Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora;
| | - James E Graham
- James E. Graham, PhD, DC, FACRM, is Professor, Department of Occupational Therapy, and Director, Center for Community Partnerships, Colorado State University, Fort Collins
| | - Rayyan Bukhari
- Rayyan Bukhari, MSOT, is PhD Student, Department of Occupational Therapy, Colorado State University, Fort Collins, and Lecturer, Department of Occupational Therapy, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Amanda Hoffman
- Amanda Hoffman, MSOT, OTR/L, BCPR, is Inpatient Rehabilitation Supervisor, UCHealth, University of Colorado Hospital, Anschutz Medical Campus, Aurora
| | - Matt P Malcolm
- Matt P. Malcolm, PhD, OTR/L, is Associate Professor and PhD Program Director, Department of Occupational Therapy, Colorado State University, Fort Collins, and Colorado School of Public Health, Colorado State University, Fort Collins
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Kinney AR, Graham JE, Bukhari R, Hoffman A, Malcolm MP. Activities of Daily Living Performance and Acute Care Occupational Therapy Utilization: Moderating Factors. Am J Occup Ther 2022; 76:23139. [PMID: 34990509 DOI: 10.5014/ajot.121.049060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
IMPORTANCE Hospitalized patients who have difficulty performing activities of daily living (ADLs) benefit from occupational therapy services; however, disparities in access to such services are understudied. OBJECTIVE To investigate whether need (i.e., limited ADL performance) predicts acute care occupational therapy utilization and whether this relationship differs across sociodemographic factors and insurance type. DESIGN A secondary analysis of electronic health records data. Logistic regression models were specified to determine whether ADL performance predicted use of occupational therapy treatment. Interactions were included to investigate whether the relationship between ADL performance and occupational therapy utilization varied across sociodemographic factors (e.g., age) and insurance type. PARTICIPANTS A total of 56,022 adults admitted to five regional hospitals between 2014 and 2018 who received an occupational therapy evaluation. INTERVENTION None. Outcomes and Measures: Occupational therapy service utilization, Activity Measure for Post-Acute Care "6-Clicks" measure of daily activity. RESULTS Forty-four percent of the patients evaluated for occupational therapy received treatment. Patients with lower ADL performance were more likely to receive occupational therapy treatment; however, interaction terms indicated that, among patients with low ADL performance, those who were younger, were White and non-Hispanic, had significant others, and had private insurance (vs. public) were more likely to receive treatment. These differences were smaller among patients with greater ADL performance. CONCLUSIONS AND RELEVANCE Greater need was positively associated with receiving occupational therapy services, but this relationship was moderated by age, minoritized status, significant other status, and insurance type. The findings provide direction for exploring determinants of disparities in occupational therapy utilization. What This Article Adds: Acute care occupational therapy utilization is driven partly by patient need, but potential disparities in access to beneficial services may exist across sociodemographic characteristics and insurance type. Identifying potential determinants of disparities in acute care occupational therapy utilization is the first step in developing strategies to reduce barriers for those in need.
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Affiliation(s)
- Adam R Kinney
- Adam R. Kinney, PhD, OTR/L, is Research Health Science Specialist, Rocky Mountain Mental Illness Research, Education, and Clinical Center, Department of Veterans Affairs, Aurora, CO, and Assistant Professor, Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora;
| | - James E Graham
- James E. Graham, PhD, DC, FACRM, is Professor, Department of Occupational Therapy, and Director, Center for Community Partnerships, Colorado State University, Fort Collins
| | - Rayyan Bukhari
- Rayyan Bukhari, MSOT, is PhD Student, Department of Occupational Therapy, Colorado State University, Fort Collins, and Lecturer, Department of Occupational Therapy, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Amanda Hoffman
- Amanda Hoffman, MSOT, OTR/L, BCPR, is Inpatient Rehabilitation Supervisor, UCHealth, University of Colorado Hospital, Anschutz Medical Campus, Aurora
| | - Matt P Malcolm
- Matt P. Malcolm, PhD, OTR/L, is Associate Professor and PhD Program Director, Department of Occupational Therapy, Colorado State University, Fort Collins, and Colorado School of Public Health, Colorado State University, Fort Collins
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Malcolm MP, Kinney AR, Graham JE. Predicting Community Discharge for Occupational Therapy Recipients in the Neurological Critical Care Unit. Am J Occup Ther 2022; 76:23111. [PMID: 34935915 DOI: 10.5014/ajot.2022.045450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
IMPORTANCE Occupational therapy in the neurological critical care unit (NCCU) may enable safe community discharge by restoring functional ability. However, the influence of patient characteristics and NCCU occupational therapy on discharge disposition is largely unknown. OBJECTIVE To examine how patient factors and receipt of occupational therapy predict discharge disposition for NCCU patients. DESIGN Retrospective cross-sectional cohort study of electronic health records data from adults admitted to the NCCU between May 2013 and September 30, 2015. SETTING NCCU in a large urban academic hospital. PARTICIPANTS Adults age 18 yr or older (N = 1,134) admitted to the NCCU. Outcomes and Measures: Using logistic regression with discharge disposition as the dependent variable, we entered sex, age, length of stay (LOS), baseline Glasgow Coma Scale score, Elixhauser Comorbidity Index, and receipt of occupational therapy services as predictor variables. RESULTS Of NCCU patients, 39% received occupational therapy. Younger age, shorter LOS, lower comorbidity burden, and not receiving occupational therapy services increased the likelihood of discharge to the community. Men who received occupational therapy were less likely to be discharged to the community than men who did not receive occupational therapy. As age increased, differences in the probability of community discharge decreased between recipients and nonrecipients of occupational therapy services. CONCLUSIONS AND RELEVANCE Our results suggest that patients receiving occupational therapy services in the NCCU may have a lower likelihood of community discharge. However, these findings may result from therapist's consideration of the safest discharge location to ensure the greatest balance between independence and support. What This Article Adds: This study's findings suggest that receipt of occupational therapy in the NCCU is associated with higher likelihood for noncommunity discharge (i.e., to inpatient rehabilitation, skilled nursing, or long-term care). However, activity limitations and comorbidity burden may be greater for recipients of occupational therapy, and these NCCU patients are presumably less prepared for community discharge.
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Affiliation(s)
- Matt P Malcolm
- Matt P. Malcolm, PhD, OTR/L, is Associate Professor, Department of Occupational Therapy, Colorado State University, Fort Collins, and Associate Professor, Colorado School of Public Health, Aurora;
| | - Adam R Kinney
- Adam R. Kinney, PhD, OTR/L, is Research Health Science Specialist, Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, U.S. Department of Veterans Affairs, Aurora, CO, and Assistant Professor, Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora
| | - James E Graham
- James E. Graham, PhD, DC, FACRM, is Professor, Department of Occupational Therapy, Colorado State University, Fort Collins
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Stein J, Rodstein BM, Levine SR, Cheung K, Sicklick A, Silver B, Hedeman R, Egan A, Borg-Jensen P, Magdon-Ismail Z. Which Road to Recovery?: Factors Influencing Postacute Stroke Discharge Destinations: A Delphi Study. Stroke 2021; 53:947-955. [PMID: 34706561 DOI: 10.1161/strokeaha.121.034815] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The criteria for determining the level of postacute care for patients with stroke are variable and inconsistent. The purpose of this study was to identify key factors influencing the selection of postacute level of care for these patients. METHODS We used a collaborative 4-round Delphi process to achieve a refined list of factors influencing postacute level of care selection. Our Delphi panel of experts consisted of 32 panelists including physicians, physical therapists, occupational therapists, speech-language pathologists, nurses, stroke survivors, administrators, policy experts, and individuals associated with third-party insurance companies. RESULTS In round 1, 207 factors were proposed, with subsequent discussion resulting in consolidation into 15 factors for consideration. In round 2, 15 factors were ranked with consensus on 10 factors; in round 3,10 factors were ranked with consensus on 9 factors. In round 4, the final round, 9 factors were rated with Likert scores ranging from 5 (most important) to 1(not important). The percentage of panelists who provided a rating of 4 or above were as follows: likelihood to benefit from an active rehabilitation program (97%), need for clinicians with specialized rehabilitation skills (94%), need for active and ongoing medical management and monitoring (84%), ability to tolerate an active rehabilitation program (74%), need for caregiver training to return to the community (48%), family/caregiver support (39%), likelihood to return to community/home (39%), ability to return to physical home environment (32%), and premorbid dementia (16%). CONCLUSIONS This study provides an expert, consensus-based set of key factors to be considered when determining where stroke patients are discharged for postacute care. These factors may be useful in developing a decision support tool for use in clinical settings.
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Affiliation(s)
- Joel Stein
- Department of Rehabilitation and Regenerative Medicine, Columbia University Vagelos College of Physicians and Surgeons, NY (J.S.).,Department of Rehabilitation Medicine, Weill Cornell Medical College, NY (J.S.).,NewYork-Presbyterian Hospital, NY (J.S.)
| | - Barry M Rodstein
- University of Massachusetts Medical School-Baystate Health, Springfield (B.M.R.)
| | - Steven R Levine
- Departments of Neurology and Emergency Medicine, and Stroke Center, SUNY Downstate Health Sciences University, Brooklyn, NY (S.R.L.).,Department of Neurology, Kings County Hospital Center, Brooklyn, NY (S.R.L.).,Jaffe Stroke Center and Department of Neurology, Maimonides Medical Center, Brooklyn, NY (S.R.L.)
| | - Ken Cheung
- Department of Biostatistics, Columbia University Irving Medical Center, NY (K.C.)
| | | | - Brian Silver
- Department of Neurology, University of Massachusetts Medical School, Worcester (B.S.)
| | | | - Abigail Egan
- The American Heart Association/American Stroke Association, Eastern States, Albany, NY (A.E., P.B.-J., Z.M.-I.)
| | - Pamela Borg-Jensen
- The American Heart Association/American Stroke Association, Eastern States, Albany, NY (A.E., P.B.-J., Z.M.-I.)
| | - Zainab Magdon-Ismail
- The American Heart Association/American Stroke Association, Eastern States, Albany, NY (A.E., P.B.-J., Z.M.-I.).,Capital District Physician's Health Plan, Albany NY (Z.M.-I.)
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Capo-Lugo CE, Askew RL, Boebel M, DeLeo C, Deutsch A, Heinemann A. A comparative approach to quantifying provision of acute therapy services. Medicine (Baltimore) 2021; 100:e27377. [PMID: 34622841 PMCID: PMC8500582 DOI: 10.1097/md.0000000000027377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 09/13/2021] [Indexed: 01/05/2023] Open
Abstract
This study aims to compare delivery of acute rehabilitation therapy using metrics reflecting distinct aspects of rehabilitation therapy services. Seven general medical-surgical hospitals in Illinois and Indiana prospectively collected rehabilitation therapy data. De-identified data on all patients who received any type of acute rehabilitation therapy (n = 35,449) were extracted and reported as aggregate of minutes of therapy services per discipline. Metrics included therapy types, total minutes, and minutes per day (intensity), as charted by therapists. Extended hospital stay was defined as a length of stay (LOS) longer than Medicare's geometric mean LOS. Discharge destination was coded as postacute care or home discharge. Substantial variability was observed in types, number of minutes, and intensity of therapy services by condition and hospital. The odds of an extended hospital stay increased with increased number of minutes, increased number of therapy types, and decreased with increased rehabilitation intensity. This comparative approach to assessing provision of acute therapy services reflect differential effects of service provision on LOS and discharge destination. Investigators, policymakers, and hospital administrators should examine multiple metrics of rehabilitation therapy provision when evaluating the impact of health care processes on patient outcomes.
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Affiliation(s)
- Carmen E. Capo-Lugo
- Department of Physical Therapy, School of Health Professions, University of Alabama at Birmingham, AL
| | | | | | | | - Anne Deutsch
- Center for Rehabilitation Outcomes Research, Shirley Ryan AbilityLab, Chicago, IL
- Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, IL
- RTI International, Chicago, IL
| | - Allen Heinemann
- Center for Rehabilitation Outcomes Research, Shirley Ryan AbilityLab, Chicago, IL
- Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, IL
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Stein J, Katz DI, Black Schaffer RM, Cramer SC, Deutsch AF, Harvey RL, Lang CE, Ottenbacher KJ, Prvu-Bettger J, Roth EJ, Tirschwell DL, Wittenberg GF, Wolf SL, Nedungadi TP. Clinical Performance Measures for Stroke Rehabilitation: Performance Measures From the American Heart Association/American Stroke Association. Stroke 2021; 52:e675-e700. [PMID: 34348470 DOI: 10.1161/str.0000000000000388] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The American Heart Association/American Stroke Association released the adult stroke rehabilitation and recovery guidelines in 2016. A working group of stroke rehabilitation experts reviewed these guidelines and identified a subset of recommendations that were deemed suitable for creating performance measures. These 13 performance measures are reported here and contain inclusion and exclusion criteria to allow calculation of rates of compliance in a variety of settings ranging from acute hospital care to postacute care and care in the home and outpatient setting.
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Waddell KJ, Patel MS, Clark K, Harrington TO, Greysen SR. Leveraging insights from behavioral economics to improve mobility for adults with stroke: Design and rationale of the BE Mobile clinical trial. Contemp Clin Trials 2021; 107:106483. [PMID: 34129953 DOI: 10.1016/j.cct.2021.106483] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 06/06/2021] [Accepted: 06/10/2021] [Indexed: 11/29/2022]
Abstract
Physical inactivity post-stroke can negatively impact long-term health outcomes and contribute to cardiovascular deconditioning, muscle loss, and increased risk for recurrent stroke. The limited number of interventions designed to improve daily physical activity post-stroke have lacked precision in step goals, are resource intensive, and difficult to scale. The purpose of the Leveraging Insights from Behavioral Economics to Improve Mobility for Adults with Stroke (BE Mobile) trial is to examine the preliminary effectiveness of a novel gamification with social incentives intervention for improving physical activity post-stroke. This trial includes adults who have experienced an ischemic or hemorrhagic stroke ≥3 months prior to the time of recruitment who are randomized to a control or gamification arm. All participants receive a Fitbit Inspire 2 wearable device to quantify daily steps and complete a 2-week baseline run-in period followed by an 8-week intervention period. All participants select a daily step goal and the gamification arm is enrolled in a game with loss-framed points and levels to help participants achieve their daily step goal. Participants in the gamification arm also select a support partner who receives weekly updates on their progress in the game. The primary outcome is change in daily steps from baseline during the intervention period. The secondary outcome is difference in the proportion of days participants achieved their daily step goal. Results from this trial will inform future, larger studies that leverage insights from behavioral economics to help improve daily physical activity post-stroke. Trial registration: NCT #04607811.
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Affiliation(s)
- Kimberly J Waddell
- Penn Medicine Nudge Unit, University of Pennsylvania, Philadelphia, PA, USA; Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA.
| | - Mitesh S Patel
- Penn Medicine Nudge Unit, University of Pennsylvania, Philadelphia, PA, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; The Wharton School, University of Pennsylvania, Philadelphia, PA, USA; The LDI Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA; Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
| | - Kayla Clark
- Penn Medicine Nudge Unit, University of Pennsylvania, Philadelphia, PA, USA
| | - Tory O Harrington
- Penn Medicine Nudge Unit, University of Pennsylvania, Philadelphia, PA, USA
| | - S Ryan Greysen
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Keeney T, Kumar A, Erler KS, Karmarkar AM. Making the Case for Patient-Reported Outcome Measures in Big-Data Rehabilitation Research: Implications for Optimizing Patient-Centered Care. Arch Phys Med Rehabil 2021; 103:S140-S145. [PMID: 33548207 DOI: 10.1016/j.apmr.2020.12.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 12/11/2020] [Accepted: 12/15/2020] [Indexed: 11/02/2022]
Abstract
Advances in data science and timely access to health informatics provide a pathway to integrate patient-reported outcome measures (PROMs) into clinical workflows and optimize rehabilitation service delivery. With the shift toward value-based care in the United States health care system, as highlighted by the recent Centers for Medicare and Medicaid Services incentive and penalty programs, it is critical for rehabilitation providers to systematically collect and effectively use PROMs to facilitate evaluation of quality and outcomes within and across health systems. This editorial discusses the potential of PROMs to transform clinical practice, provides examples of health systems using PROMs to guide care, and identifies barriers to aggregating data from PROMs to conduct health services research. The article proposes 2 priority areas to help advance rehabilitation health services research: (1) standardization of collecting PROMs data in electronic health records to facilitate comparing health system performance and quality and (2) increased partnerships between rehabilitation providers, researchers, and payors to accelerate health system learning. As health care reform continues to emphasize value-based payment strategies, it is essential for the field of physical medicine and rehabilitation to be at the forefront of demonstrating its value in the care continuum.
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Affiliation(s)
- Tamra Keeney
- Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI; Division of Palliative Care and Geriatric Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA.
| | - Amit Kumar
- Department of Physical Therapy, Northern Arizona University, Flagstaff, AZ
| | - Kimberly S Erler
- Department of Occupation Therapy, MGH Institute of Health Professions, Boston, MA
| | - Amol M Karmarkar
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA; Sheltering Arms Institute, Richmond, VA
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The Relationship Between Fall Risk and Hospital-Based Therapy Utilization Is Moderated by Demographic Characteristics and Insurance Type. Arch Phys Med Rehabil 2020; 102:1124-1133. [PMID: 33373599 DOI: 10.1016/j.apmr.2020.12.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 12/02/2020] [Accepted: 12/03/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To investigate whether indicators of patient need (comorbidity burden, fall risk) predict acute care rehabilitation utilization, and whether this relation varies across patient characteristics (ie, demographic characteristics, insurance type). DESIGN Secondary analysis of electronic health records data. SETTING Five acute care hospitals. PARTICIPANTS Adults (N=110,209) admitted to 5 regional hospitals between 2014 and 2018. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Occupational therapy (OT) and physical therapy (PT) utilization. Logistic regression models determined whether indicators of patient need predicted OT and PT utilization. Interactions between indicators of need and both demographic factors (eg, minority status, presence of significant other) and insurance type were included to investigate whether the relation between patient need and therapy access varied across patient characteristics. RESULTS Greater comorbidity burden was associated with a higher likelihood of receiving OT and PT. Relative to those with low fall risk, those with moderate and high fall risk were more likely to receive OT and PT. The relation between fall risk and therapy utilization differed across patient characteristics. Among patients with higher levels of fall risk, those with a significant other were less likely to receive OT and PT; significant other status did not explain therapy utilization among patients with low fall risk. Among those with high fall risk, patients with VA insurance and minority patients were more likely to receive PT than those with private insurance and nonminority patients, respectively. Insurance type and minority status did not appear to explain PT utilization among those with lower fall risk. CONCLUSIONS Patients with greater comorbidity burden and fall risk were more likely to receive acute care rehabilitation. However, the relation between fall risk and utilization was moderated by insurance type, having a significant other, and race/ethnicity. Understanding the implications of these utilization patterns requires further research.
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Stein J, Borg-Jensen P, Sicklick A, Rodstein BM, Hedeman R, Bettger JP, Hemmitt R, Silver BM, Thode HC, Magdon-Ismail Z. Are Stroke Survivors Discharged to the Recommended Postacute Setting? Arch Phys Med Rehabil 2020; 101:1190-1198. [PMID: 32272107 DOI: 10.1016/j.apmr.2020.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 03/02/2020] [Accepted: 03/02/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To examine the processes and barriers involved in providing postdischarge stroke care. DESIGN Prospective study of discharge planners' (DP) and physical therapists' (PT) interpretation of factors contributing to patients' discharge destination. SETTING Twenty-three hospitals in the northeastern United States. PARTICIPANTS After exclusions, data on patients (N=427) hospitalized with a primary diagnosis of stroke between May 2015 and November 2016 were examined. Of the patients, 45% were women, and the median age was 71 years. DPs and PTs caring for these patients were queried regarding the selection of discharge destination. INTERVENTIONS None. MAIN OUTCOME MEASURES Comparison of actual discharge destination for stroke patients with the destinations recommended by their DPs and PTs. RESULTS In total, 184 patients (43.1%) were discharged home, 146 (34.2%) to an inpatient rehabilitation facility, 94 (22.0%) to a skilled nursing facility, and 3 (0.7%) to a long-term acute care hospital. DPs and PTs agreed on the recommended discharge destination in 355 (83.1%) cases. The actual discharge destination matched the DP and PT recommended discharge destination in 92.5% of these cases. In 23 cases (6.5%), the patient was discharged to a less intensive setting than recommended by both respondents. In 4 cases (1.1%), the patient was discharged to a more intensive level of care. In 2 cases (0.6%), the patient was discharged to a long-term acute care hospital rather than an inpatient rehabilitation facility as recommended. Patient or family preference was cited by at least 1 respondent for the discrepancy in discharge destination for 13 patients (3.1%); insurance barriers were cited for 9 patients (2.3%). CONCLUSIONS Most stroke survivors in the northeast United States are discharged to the recommended postacute care destination based on the consensus of DP and PT opinions. Further research is needed to guide postacute care service selection.
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Affiliation(s)
- Joel Stein
- Department of Rehabilitation and Regenerative Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York; Department of Rehabilitation Medicine, Weill Cornell Medicine, New York, New York; New York-Presbyterian Hospital, New York, New York.
| | - Pamela Borg-Jensen
- The American Heart Association/American Stroke Association, Eastern States, Albany, New York
| | | | | | | | - Janet Prvu Bettger
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Roseanne Hemmitt
- The American Heart Association/American Stroke Association, Eastern States, Albany, New York
| | - Brian M Silver
- Department of Neurology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Henry C Thode
- Department of Emergency Medicine, Renaissance School of Medicine, Stony Brook University, Stony Brook, New York
| | - Zainab Magdon-Ismail
- The American Heart Association/American Stroke Association, Eastern States, Albany, New York
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Cao Y, Nie J, Sisto SA, Niewczyk P, Noyes K. Assessment of Differences in Inpatient Rehabilitation Services for Length of Stay and Health Outcomes Between US Medicare Advantage and Traditional Medicare Beneficiaries. JAMA Netw Open 2020; 3:e201204. [PMID: 32186746 PMCID: PMC7081121 DOI: 10.1001/jamanetworkopen.2020.1204] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
IMPORTANCE Enrollment in Medicare Advantage (MA) has been increasing and has reached one-third of total Medicare enrollment. Because of data limitations, direct comparison of inpatient rehabilitation services between MA and traditional Medicare (TM) beneficiaries has been very scarce. Subgroups of elderly individuals admitted to inpatient rehabilitation facilities (IRFs) may experience different care outcomes by insurance types. OBJECTIVE To measure the differences in length of stay and health outcomes of inpatient rehabilitation services between TM and MA beneficiaries in the US. DESIGN, SETTING, AND PARTICIPANTS This multiyear cross-sectional study used the Uniform Data System for Medical Rehabilitation to assess rehabilitation services received by elderly (aged >65 years) Medicare beneficiaries in IRFs between 2007 and 2016 for stroke, hip fracture, and joint replacement. Generalized linear models were used to assess whether an association existed between Medicare insurance type and IRF care outcomes. Models were adjusted for demographic characteristics, clinical conditions, and facility characteristics. Data were analyzed from September 2018 to August 2019. EXPOSURES Medicare insurance plan type, TM or MA. MAIN OUTCOMES AND MEASURES Inpatient length of stay in IRFs, functional improvements, and possibility of returning to the community after discharge. RESULTS The sample included a total of 1 028 470 patients (634 619 women [61.7%]; mean [SD] age, 78.23 [7.26] years): 473 017 patients admitted for stroke, 323 029 patients admitted for hip fracture, and 232 424 patients admitted for joint replacement. Individuals enrolled in MA plans were younger than TM beneficiaries (mean [SD] age, 76.96 [7.02] vs 77.95 [7.26] years for stroke, 79.92 [6.93] vs 80.85 [6.87] years for hip fracture, and 74.79 [6.58] vs 75.88 [6.80] years for joint replacement) and were more likely to be black (17 086 [25.5%] vs 54 648 [17.9%] beneficiaries) or Hispanic (14 496 [28.5%] vs 24 377 [8.3%] beneficiaries). The MA beneficiaries accounted for 21.8% (103 204 of 473 017) of admissions for stroke, 11.5% (37 160 of 323 029) of admissions for hip fracture, and 11.8% (27 314 of 232 424) of admissions for joint replacement. The MA beneficiaries had shorter mean lengths of stay than did TM beneficiaries for both stroke (0.11 day; 95% CI, -0.15 to -0.07 day; 1.15% shorter) and hip fracture (0.17 day; 95% CI, -0.21 to -0.13 day; 0.85% shorter). The MA beneficiaries also had higher possibilities of returning to the community than did TM beneficiaries, by 3.0% (95% CI, 2.6%-3.4%) for stroke and 5.0% (95% CI, 4.4%-5.6%) for hip fracture. The shorter length of stay and better ultimate outcomes were achieved without substantially compromising the intermediate functional improvements. Facility type (freestanding vs within an acute care hospital) and patient alternative payment sources other than Medicare (none vs other) partially explained the differences between insurance types. CONCLUSIONS AND RELEVANCE This study suggests that MA enrollees experience shorter length of stay and better outcomes for postacute care than do TM beneficiaries in IRFs. The magnitude of the differences depends on treatment deferability, patient sociodemographic subgroups, and facility characteristics.
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Affiliation(s)
- Ying Cao
- Division of Health Services Policy and Practice, Department of Epidemiology and Environmental Health, University at Buffalo, Buffalo, New York
| | - Jing Nie
- Division of Health Services Policy and Practice, Department of Epidemiology and Environmental Health, University at Buffalo, Buffalo, New York
| | - Sue Ann Sisto
- Department of Rehabilitation Science, University at Buffalo, Buffalo, New York
| | - Paulette Niewczyk
- Uniform Data System for Medical Rehabilitation, University at Buffalo, Buffalo, New York
| | - Katia Noyes
- Division of Health Services Policy and Practice, Department of Epidemiology and Environmental Health, University at Buffalo, Buffalo, New York
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