Association Between 2010 Medicare Reforms and Utilization of Postacute Inpatient Rehabilitation in Ischemic Stroke

An examination of geographic access to outpatient stroke rehabilitation services in Tennessee, a stroke belt state

BACKGROUND

While over half of US stroke patients were discharged to home, estimates of geographic access to outpatient stroke rehab facilities are unavailable. The objective of our study was to assess distance and travel time to the nearest outpatient stroke rehab facility in Tennessee, a high stroke prevalence state.

METHODS

We systematically scraped Google Maps with the terms "stroke", "rehabilitation", and "outpatient" to identify Tennessee stroke rehab facilities. We then averaged/aggregated Census block-level travel distance and travel time to determine the mean travel distance/time to a facility for each of the 95 Tennessee counties and the overall state. Comparisons of mean travel time/distance were made between rural and urban counties and between low, medium, and high stroke prevalence counties.

RESULTS

We found that 79% of facilities were in urban areas. Significantly higher median of mean travel times and distances (p values both <0.001) were observed in rural (22.0 miles, 31.6 min) versus urban counties (10.5 miles, 18.4 min). High (21.5 miles, 32.5 min) and medium (18.7 miles, 28.3 minutes) stroke prevalence counties, which often overlap with rural counties, had significantly higher median of mean travel times and distance than low stroke prevalence counties (7.3 miles, 14.5 min).

CONCLUSIONS

Rural Tennessee counties were faced with high stroke prevalence, inadequate facilities, and significantly greater travel distance and time to access care. Additional efforts to address transportation barriers and accelerate telerehabilitation implementation are crucial for improving equal access to stroke aftercare in these areas.

Variations in Discharge Destination Following Severe TBI across the United States

BACKGROUND

Discharge destination after traumatic brain injury (TBI) may be influenced by non-patient factors such as regional or institutional practice patterns. We hypothesized that non-patient factors would be associated with discharge destination in severe TBI patients.

METHODS

All patients in the ACS Trauma Quality Improvement Program 2016 data set with severe TBI, defined as head Abbreviated Injury Scale ≥3, were categorized by discharge destination. Logistic regression was used to assess factors associated with each destination; odds ratios and 95% confidence level are reported. Regressions were adjusted for age, gender, race, insurance, GCS, ISS, polytrauma, mechanism, neurosurgical procedure, geographic region, teaching status, trauma center level, hospital size, and neurosurgeon group size.

RESULTS

75,690 patients met inclusion criteria. 51% were discharged to home, 16% to rehab, 14% to SNF, and 11% deceased. Mortality was similar across geographic region, teaching status, and hospital size. Southern patients were more likely to be discharged to home while Northeastern patients were more likely to be discharged to rehab. Treatment by groups of 3 or more neurosurgeons was associated with SNF discharge as was treatment at community or non-teaching hospitals. Patients treated at larger hospitals were less likely to be discharged to rehab and more likely to go to SNF.

CONCLUSIONS

Geographic region, neurosurgeon group size, teaching status, and hospital size are significantly associated with variation in discharge destination following severe TBI. Regional and institutional variation in practice patterns may play important roles in recovery for some patients with severe TBI.

Association Between 2010 Medicare Reform and Inpatient Rehabilitation Access in People With Intracerebral Hemorrhage

Background

Evidence suggests intracerebral hemorrhage survivors have earlier recovery compared with ischemic stroke survivors. The Centers for Medicare and Medicaid Services prospective payment system instituted documentation rules for inpatient rehabilitation facilities (IRFs) in 2010, with the goal of optimizing patient selection. We investigated whether these requirements limited IRF and increased skilled nursing facility (SNF) use compared with home discharge.

Methods and Results

Intracerebral hemorrhage discharges to IRF, SNF, or home were estimated using GWTG (Get With The Guidelines) Stroke registry data between January 1, 2008, and December 31, 2015 (n=265 444). Binary hierarchical models determined associations between the 2010 Rule and discharge setting; subgroup analyses evaluated age, geographic region, and hospital type. From January 1, 2008, to December 31, 2009, 45.5% of patients with intracerebral hemorrhage had home discharge, 22.2% went to SNF, and 32.3% went to IRF. After January 1, 2010, there was a 1.06% absolute increase in home discharge, a 0.46% increase in SNF, and a 1.52% decline in IRF. The adjusted odds of IRF versus home discharge decreased 3% after 2010 (adjusted odds ratio [aOR], 0.97; 95% CI, 0.95–1.00). Lower odds of IRF versus home discharge were observed in people aged <65 years (aOR, 0.92; 95% CI, 0.89–0.96), Western states (aOR, 0.89; 95% CI, 0.84–0.95), and nonteaching hospitals (aOR, 0.90; 95% CI, 0.86–0.95). Adjusted odds of SNF versus home discharge increased 14% after 2010 (aOR, 1.14; 95% CI, 1.11–1.18); there were significant associations in all age groups, the Northeast, the South, the Midwest, and teaching hospitals.

Conclusions

The Centers for Medicare and Medicaid Services 2010 IRF prospective payment system Rule resulted in fewer discharges to IRF and more discharges to SNF in patients with intracerebral hemorrhage. Health policy changes potentially affect access to intensive postacute rehabilitation.