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Functional Impairment and Postacute Care Discharge Setting May Be Useful for Stroke Survival Prognostication.

ABSTRACT: Background The aim of this study was to discussions about post-stroke outcomes related to post-stroke function and post-acute care discharge setting.inform patient-provider. Methods and Results We conducted a retrospective cohort study of Medicare beneficiaries with acute ischemic stroke or intracerebral hemorrhage in 2013. Our primary outcome was mortality within at least 1-year post discharge. We performed multivariate logistic regression to estimate 90-day odds ratios (ORs) and Cox proportional hazards regression to estimate post 90-day hazard ratios on mortality, adjusting for demographics, procedures, comorbidities, discharge setting (inpatient rehabilitation facility, skilled nursing facility, or home health care agency), post-stroke function (measured by the Functional/Pseudo-Functional Independence Measure) and setting-function interactions. There were 167 000 patients with a mean follow-up of 441 days. Mortality within 90 days was associated with post-stroke function (OR, 0.23; 95% CI, 0.19-0.27 comparing highest to lowest quintile of post-stroke function) and discharge setting (OR, 4.05; 95% CI, 3.78-4.33 for skilled nursing facility versus inpatient rehabilitation facility). Among the highest functioning patients, those discharged to inpatient rehabilitation facility had a 1-year mortality of 9% and those discharged with home health had 11% mortality at 1 year. The lowest functioning survivors of stroke discharged to a skilled nursing facility had 64% mortality at 1 year and those discharged to an inpatient rehabilitation facility had 29.6% mortality at 1 year. Conclusions Nearly two thirds of the lowest functioning survivors of stroke discharged to a skilled nursing facility die within a year. This finding should inform discussions between providers and patients/caregivers in aligning goals of care with the care survivors of stroke receive.

SUBMITTER: Springer MV

PROVIDER: S-EPMC9075325 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:OBJECTIVES:To synthesize research comparing poststroke health outcomes between patients rehabilitated in skilled nursing facilities (SNFs) and those in inpatient rehabilitation facilities (IRFs) as well as to evaluate relations between facility characteristics and outcomes. DATA SOURCES:PubMed and CINAHL searches spanned January 1, 1998, to October 6, 2016, and encompassed MeSH and free-text keywords for stroke, IRF/SNF, and study outcomes. Searches were restricted to peer-reviewed research in humans published in English. STUDY SELECTION:Observational and experimental studies examining outcomes of adult patients with stroke rehabilitated in an IRF or SNF were eligible. Studies had to provide site of care comparisons and/or analyses incorporating facility-level characteristics and had to report ?1 primary outcome (discharge setting, functional status, readmission, quality of life, all-cause mortality). Unpublished, single-center, descriptive, and non-US studies were excluded. Articles were reviewed by 1 author, and when uncertain, discussion with study coauthors achieved consensus. Fourteen titles (0.3%) were included. DATA EXTRACTION:The types of data, time period, size, design, and primary outcomes were extracted. We also extracted 2 secondary outcomes (length of IRF/SNF stay, cost) when reported by included studies. Effect measures, modeling approaches, methods for confounding adjustment, and potential confounders were extracted. Data were abstracted by 1 author, and the accuracy was verified by a second reviewer. DATA SYNTHESIS:Two studies evaluating community discharge, 1 study evaluating the predicted probability of readmission, and 3 studies evaluating all-cause mortality favored IRFs over SNFs. Functional status comparisons were inconsistent. No studies evaluated quality of life. Two studies confirmed increased costs in the IRF versus SNF setting. Although substantial facility variation was described, few studies characterized sources of variation. CONCLUSIONS:The few studies comparing poststroke outcomes indicated better outcomes (with higher costs) for patients in IRFs versus those in SNFs. Contemporary research on the role of the postacute care setting and its attributes in determining health outcomes should be prioritized to inform reimbursement system reform.

Project description:Importance:Health care reform legislation and Medicare plans for unified payment for postacute care highlight the need for research examining service delivery and outcomes. Objective:To compare functional outcomes in patients with stroke after postacute care in inpatient rehabilitation facilities (IRF) vs skilled nursing facilities (SNF). Design, Setting, and Participants:This cohort study included patients with stroke who were discharged from acute care hospitals to IRF or SNF from January 1, 2013, to November 30, 2014. Medicare claims were used to link to IRF and SNF assessments. Data analyses were conducted from January 17, 2017, through April 25, 2019. Exposures:Inpatient rehabilitation received in IRFs vs SNFs. Main Outcomes and Measures:Changes in mobility and self-care measures during an IRF or SNF stay were compared using multivariate analyses, inverse probability weighting with propensity score, and instrumental variable analyses. Mortality between 30 and 365 days after discharge was included as a control outcome as an indicator for unmeasured confounders. Results:Among 99 185 patients who experienced a stroke between January 1, 2013, and November 30, 2014, 66 082 patients (66.6%) were admitted to IRFs and 33 103 patients (33.4%) were admitted to SNFs. A higher proportion of women were admitted to SNFs (21 466 [64.8%] women) than IRFs (36 462 [55.2%] women) (P < .001). Compared with patients admitted to IRFs, patients admitted to SNFs were older (mean [SD] age, 79.4 [7.6] years vs 83.3 [7.8] years; P < .001) and had longer hospital length of stay (mean [SD], 4.6 [3.0] days vs 5.9 [4.2] days; P < .001) than those admitted to IRFs. In unadjusted analyses, patients with stroke admitted to IRF compared with those admitted to SNF had higher mean scores for mobility on admission (44.2 [95% CI, 44.1-44.3] points vs 40.8 [95% CI, 40.7-40.9] points) and at discharge (55.8 [95% CI, 55.7-55.9] points vs 44.4 [95% CI, 44.3-44.5] points), and for self-care on admission (45.0 [95% CI, 44.9-45.1] points vs 41.8 [95% CI, 41.7-41.9] points) and at discharge (58.6 [95% CI, 58.5-58.7] points vs 45.1 [95% CI, 45.0-45.2] points). Additionally, patients in IRF compared with those in SNF had larger improvements for mobility score (11.6 [95% CI, 11.5-11.7] points vs 3.5 [95% CI, 3.4-3.6] points) and for self-care score (13.6 [95% CI, 13.5-13.7] points vs 3.2 [95% CI, 3.1-3.3] points). Multivariable, propensity score, and instrumental variable analyses showed a similar magnitude of better improvements in patients admitted to IRF vs those admitted to SNF. The differences between SNF and IRF in odds of 30- to 365-day mortality (unadjusted odds ratio, 0.48 [95% CI, 0.46-0.49]) were reduced but not eliminated in multivariable analysis (adjusted odds ratio, 0.72 [95% CI, 0.69-0.74]) and propensity score analysis (adjusted odds ratio, 0.75 [95% CI, 0.72-0.77]). These differences were no longer statistically significant in the instrumental variable analyses. Conclusions and Relevance:In this cohort study of a large national sample, inpatient rehabilitation in IRFs for patients with stroke was associated with substantially improved physical mobility and self-care function compared with rehabilitation in SNFs. This finding raises questions about the value of any policy that would reimburse IRFs or SNFs at the same standard rate for stroke.

Project description:ImportanceChanges in financial incentives have led to more patients being discharged home than to institutional forms of postacute care, such as skilled nursing facilities (SNFs), after elective lower extremity total joint replacement (LEJR).ObjectiveTo evaluate the association of this change with hospital readmissions, surgical complications, and mortality.Design, setting, and participantsThis cohort study used cross-temporal propensity-matching to identify 104 828 adult patients who were discharged home following LEJR between 2016 and 2018 (after changes in financial incentives) and 84 121 adult patients discharged to institutional forms of postacute care (eg, SNFs) between 2011 and 2013 (before changes in financial incentives). A difference-in-differences design was used to compare differences in outcomes between these groups to a propensity-matched group of patients discharged to institutional postacute care in both periods. Data were collected from Pennsylvania all-payer claims database, which includes all surgical procedures and hospitalizations across payers and hospitals in Pennsylvania. Data were analyzed between August 2019 and February 2020.ExposuresType of postacute care (home, including home with home health vs institutional postacute care, including SNF, inpatient rehabilitation facilities, and long-term acute care hospitals).Main outcomes and measuresMain outcomes were 30- and 90-day hospital readmissions, LEJR complication rates, and mortality rates.ResultsOf 189 949 patients, 113 981 (60.0%) were women, and 83 444 (43.9%) were aged 40 to 64 years. The rate of discharge home increased from 63.6% (54 097 of 85 121) in 2011 to 2013 to 78.4% (82 199 of 104 828) in 2016 to 2018. In the adjusted difference-in-differences comparison, matched patients discharged home in 2016 to 2018 had significantly lower 30-day (difference, -2.9%; 95% CI, -4.2% to -1.6%) and 90-day (difference, -3.9%; 95% CI, -5.8% to -2.0%) readmission rates compared with similar patients sent to institutional postacute care in 2011 to 2013. Surgical complication and mortality rates were unchanged. Results were similar across payers and across hospital bundled payment participation status.Conclusions and relevanceIn this cohort study, increases in discharges home following LEJR surgery did not seem to be associated with increased harm during a period in which changes in financial incentives likely spurred observed changes in postacute care.

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Functional Impairment and Postacute Care Discharge Setting May Be Useful for Stroke Survival Prognostication.

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