Abstract TMP47: Impact of Medicare Reform on Inpatient Rehabilitation Facility Access for Hemorrhagic Stroke Patients

Introduction: There is growing evidence that ICH patients make larger & faster recovery gains compared to ischemic stroke patients. Inpatient rehabilitation facility (IRF) care can significantly facilitate improvement. In 2010, changes to IRF admission criteria potentially restricted access. We hypothesize the Centers for Medicare and Medicaid Services (CMS) 2010 IRF Prospective Payment System Rule decreased IRF access & increased skilled nursing facility (SNF) utilization in ICH patients.

Methods: The proportion of ICH survivors discharged to IRF, SNF or home was estimated using GWTG-Stroke data between 1/1/2008 & 12/31/2015 (n=265,444). Two binary hierarchical models determined the association between the 1/1/2010 CMS admission criteria change for IRFs and discharge setting, adjusting for patient & hospital characteristics. Subgroup analyses evaluated the effects of age, region & hospital type. Sensitivity analyses used complete NIHSS data (≈49%).

Results: The prevalence of the 3 discharge destinations changed significantly over time (CMH row-mean-score P<0.0001; Figure 1). IRF rehab odds decreased and SNF rehab odds increased for ICH patients compared to home after the CMS 2010 IRF PPS Rule (Figure 2a & 2b). Decreased IRF rehab odds were found in patients age<65, Western US location or at non-teaching hospitals (Figure 2a). Increased SNF rehab odds were found in patients age≥65, Midwest location or at teaching hospitals (Figure 2b).

Conclusions: IRF Rehab odds decreased and SNF rehab odds increased during the time period after CMS 2010 IRF PPS Rule implementation in ICH patients. The impact of such legislative changes on patient outcomes warrants further study.

Abstract WP180: Association Between Medicare Reform and Access to Rehabilitation in Ischemic Stroke Patients

Introduction: In 2010, the Centers for Medicare and Medicaid Services (CMS) implemented the Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) Rule, requiring IRF patients to tolerate 3 hours of daily therapy (PT &OT/SLP). If unable, rehab at a skilled nursing facility (SNF) is recommended, contrasting the 2016 AHA Stroke Rehabilitation Guidelines for optimal recovery.

Hypothesis: Stroke patients are more likely to receive rehab at a SNF compared to an IRF after implementation of the CMS 2010 IRF PPS Rule.

Methods: We calculated the proportion of stroke patients discharged to IRF vs home and SNF vs home using prospectively collected registry data from Get with the Guidelines - Stroke, for a cohort of ischemic (85.7%) and hemorrhagic (14.3%) stroke patients between 2008 and 2015 (n=1,962,933). Univariate analyses compared stroke severity by NIHSS, sociodemographic/clinical characteristics and in hospital rehabilitation assessments. Multivariable regression modeling assessed the association between CMS 2010 IRF PPS Rule and age, teaching versus non-teaching hospital and US geographic region.

Results: Post CMS 2010 IRF PPS Rule, 1 out of 15 ischemic stroke patients had lower IRF rehab odds (OR 0.94; 95%CI 0.92-0.95; P<0.0001); 1 out of 9 ischemic stroke patients had higher SNF rehab odds (OR 1.12, 95% CI 1.10-1.14; P<0.0001). Multivariable regression - ischemic stroke: Across all ages, in the South, Northeast and at teaching hospitals, the odds of IRF rehab decreased and the odds of SNF rehab increased after implementation of CMS 2010 IRF PPS Rule (Fig 1 & 2).

Conclusions: Ischemic stroke patients, with similar clinical histories & stroke severity, had decreased odds of inpatient rehabilitation facility rehab and increased odds of skilled nursing facility rehab after implementation of the CMS 2010 IRF PPS Rule. Additional studies analyzing the effects of low intensity SNF rehab versus IRF rehab on return home and long-term disability are needed.