Medicare claims were used to link to IRF and SNF assessments. Xian Source: Dobson DaVanzo & Associates, Assessment of Patient Outcomes of Rehabilitative Care Provided in Inpatient Rehabilitation Facilities (IRFs) and After Discharge, pages 28-38, Exhibits 4:1-4:10. Mortality between 30 and 365 days after discharge was included as a control outcome as an indicator for unmeasured confounders. Hospital characteristics included location (urban or rural), hospital type (ie, for-profit, nonprofit, or other), presence of swing beds (yes or no), rehabilitation unit within hospital (yes or no), teaching hospital (yes or no), number of stroke discharges from the index hospital in the same year of the index stroke discharge, and number of beds in index stroke hospital. A significant difference in functional improvement remained after accounting for patient, clinical, and facility characteristics at admission. The multivariable approach used ordinary least squares, adjusting for covariates. Washington, DC: National Academies Press; 2013. These findings suggest that there is room for payment reform in postacute care and highlight the need to target decision-making regarding discharge to postacute facilities based on patient needs and potential for recovery. The CMS 60% rule identifies 13 diagnostic conditions that classify a facility as an IRF for Medicare reimbursement.35 Stroke is the largest category of these conditions, with 20.5% of all patients in IRFs in 2017.6. Medicare Program; prospective payment system and consolidated billing for skilled nursing facilities for FY 2017, SNF Value-Based Purchasing Program, SNF Quality Reporting Program, and SNF Payment Models Research: final rule. L, HS, Shim Pope The development of a standardized measure of cognitive function is an important area for future research and is included as part of the IMPACT Act.3 Previous investigations have consistently reported that the costs for rehabilitation services provided in SNFs are significantly lower than in IRFs, even when the longer LOSs associated with SNFs are considered.4,36 We did not conduct cost comparisons or cost benefit analyses associated with outcomes across the 2 postacute settings. L, Malcolm MP, Middleton A, Haas A, Ottenbacher KJ, Graham JE. We began with unadjusted bivariate analyses of all variables compared across IRF and SNF settings. The difference in findings between the Mallinson et al study34 and our study could be related to many factors. et al. The rehabilitation resources, facility and programs vary from SNF to SNF and span the spectrum from those that offer many rehabilitation services to those that offer very few. Home » Our Services » Inpatient Rehabilitation » IRU vs SNF Inpatient Rehabilitation Unit (IRU) vs Skilled Nursing Facility (SNF) Patients have various options to meet their rehabilitation needs, however it is essential that they be educated on the differences in those options. Magdon-Ismail Kosar CM, Loomer L, Ferdows NB, Trivedi AN, Panagiotou OA, Rahman M. JAMA Netw Open. What are the IRF quality reporting measures? Health care reform legislation and Medicare plans for unified payment for postacute care highlight the need for research examining service delivery and outcomes. The race/ethnicity variable was defined by the CMS and was included because some outcomes differ among racial/ethnic groups.18 The 30 most frequent CMS Hierarchical Condition Categories for comorbidities were identified through diagnoses on the inpatient claims from the previous year and the secondary diagnoses during the index stroke hospitalization (eTable 4 and eTable 5 in the Supplement).19 In addition, we added 6 diagnoses related to cognitive function (eTable 6 in the Supplement). More are female. Exposures Inpatient rehabilitation received in IRFs vs SNFs. Additionally, we used ordinary least squares models with inverse probability treatment weighting, with propensity scores also adjusted for unbalanced covariates, to compare functional status outcome (ie, mobility and self-care) at discharge from IRF or SNF. The. L, Sandel Please see our commenting policy for details. Giordano Poststroke rehabilitation: outcomes and reimbursement of inpatient rehabilitation facilities and subacute rehabilitation programs. Specification tests in econometrics. Mees Dr Kuo reported receiving grants from the AHRQ during the conduct of the study and grants from the National Institute on Drug Abuse outside the submitted work. Please allow up to 2 business days for review, approval, and posting. The information will be posted with your response. We were not able to examine cognitive function before and after the stroke, stroke severity, or location of the stroke. Design, Setting, and Participants A, Bateman This cohort study included 99 185 patients who received postacute care in inpatient rehabilitation or skilled nursing facilities after a stroke. Findings Multivariable, propensity score, and instrumental variable analyses showed a similar magnitude of better improvements in patients admitted to IRF vs those admitted to SNF. Comparing “Apples to Oranges” is a long-standing concern in studies of functional outcomes involving IRFs and SNFs. Ottenbacher The proposal is based, in part, on the substantial overlap in patient populations served by IRFs and SNFs.4,5, The purpose of our study was to examine changes in functional status in a national sample of Medicare beneficiaries with stroke who received inpatient rehabilitation at an IRF or SNF following acute hospital discharge. As the IMPACT Act3 and unified payment are implemented, it will be important to accurately identify subgroups and target patients who would do better in one setting vs another. TriHealth Rehabilitation Hospital 2155 Dana Avenue Cincinnati, OH 45207 Phone: (513) 601-0600 Fax: (513) 601-0601 There are several approaches to mitigating this problem. Currently, the decision-making process in selecting postacute care services is heavily influenced by nonclinical factors.25-30 This is shown by the substantial geographic variation in the proportions of patients with stroke discharged to IRFs or SNFs.28 The choice is associated with measures of availability, such as distance to the nearest facility.29 The association of IRF vs SNF use with these nonclinical factors allows investigators to use them as instruments in an instrumental variable analysis, which should better control for unmeasured confounders that might be influencing the choice of IRF vs SNF. Objective To compare functional outcomes in patients with stroke after postacute care in inpatient rehabilitation facilities (IRF) vs skilled nursing facilities (SNF). et al. We selected stroke because it is a major cause of disability in the United States and an important public health issue, patients with stroke have complex neurological disorders that require a range of treatments and expertise, and stroke represents the largest impairment group treated in IRFs.6. RP, I, Woo DA, Gottlieb In the 4 instrumental variable models, the differences in improvement in mobility scores between IRF and SNF patients between 5 and 10 points and for self-care scores, the difference was between 8 and 12 points. Buntin USA.gov. Geographic variation in health care spending in the United States: insights from an Institute of Medicine report. The national average length of time spent at an acute inpatient rehab hospital is 16 days. 2014 Feb;95(2):209-17. doi: 10.1016/j.apmr.2013.05.031. Newhouse 2016;81(151):51969-52053. Measure specifications for the functional process and outcome measures adopted for the IRF, LTCH, SNF, and HH QRPs can be found in the downloads section below. doi: 10.1001/jamanetworkopen.2019.18738. Y, Thomas Centers for Medicare & Medicaid Services. Association between cholecystectomy with vs without intraoperative cholangiography and risk of common duct injury. Patients Discharged to an IRF vs. SNF are Different Compared with IRF patients, SNF patients: Are older. Results: Conflict of Interest Disclosures: Dr Reistetter reported receiving grants from the Agency for Healthcare Research and Quality (AHRQ) during the conduct of the study. A third approach is to use analytic approaches shown to minimize selection biases, such as instrumental variable analysis.7-9 We used these 3 approaches to compare outcomes of patients with stroke who were discharged from acute care to IRFs vs SNFs. AW, Black Herbold et al report that “matched for age, gender, operative diagnosis, [morbidity] severity index, and admission ambulation FIM score, those who received rehabilitation in the IRF had shorter length of stay and superior functional outcomes than those in the SNF setting.” In the multilevel multivariate propensity score inverse probability of treatment weighting model, the mean (SE) difference in scores between patients from IRF vs SNF was 8.0 (0.04) points for mobility and 9.9 (0.05) points for self-care. An IRF requires no pre-qualifying hospital stay for Medicare coverage. JS. M, McCoy AA, Cloft KM, Riall To compare functional outcomes in patients with stroke after postacute care in inpatient rehabilitation facilities (IRF) vs skilled nursing facilities (SNF). Change in Score From Admission to Discharge in IRF and SNF, Table 4. HJ. Accessibility Statement, Table 1. Customize your JAMA Network experience by selecting one or more topics from the list below. eFigure. Of the patients who were discharged home, 75% of the SNF-treated patients required homecare services compared with 41.2% of the IRF-treated patients (P < 0.001). doi:10.1001/jamanetworkopen.2019.16646. | DJ, Vermeulen CH, Deb Our methods are described in more detail in the eAppendix in the Supplement. The 60% Rule is a Medicare facility criterion that requires each IRF to discharge at least 60 percent of its patients with one of 13 qualifying conditions. J, Ellis et al. The changes in mobility and self-care scores were substantially greater among IRF patients. Masters M, Konetzka Acute inpatient rehab hospital. This finding raises questions about the value of any policy that would reimburse IRFs or SNFs at the same standard rate for stroke. Terms of Use| This finding raises questions about the value of any policy that would reimburse IRFs or SNFs at the same standard rate for stroke. I am curious as to whether the following factors were accounted for: I am involved in the AAPMR at the committee level. Postacute Care Setting, Facility Characteristics, and Poststroke Outcomes: A Systematic Review. Newhouse JP, Garber AM. 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. JAMA Netw Open. GC, Kautter Discharge to home, a skilled nursing facility (SNF), or an inpatient rehabilitation facility (IRF) was the primary outcome. Stroke Comorbidities Across Inpatient Rehabilitation Facilities (IRFs) and Skilled Nursing Facilities (SNFs) Before and After Inverse Probability of Treatment Weighting, eTable 6. JAMA Network Open. readmissions per year than SNF patients • Better clinical outcomes could be achieved by treating patients in an IRF with an additional cost to Medicare of $12.59 per day (while patients are alive during the two-year study period), across all conditions.1 Matched IRF and SNF Patients: Number of Days during Initial The Inpatient Rehabilitation Facility-Patient Assessment Instrument includes 5 mobility items and 6 self-care items, with a 7-point rating scale. RM, Coe Y, Granger 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), had longer hospital LOS (mean [SD], 4.6 [3.0] days vs 5.9 [4.2] days; P < .001), and had more comorbidities (mean [SD], 2.8 [2.0] comorbidities vs 3.3 [2.1] comorbidities; P < .001) (Table 1; eTable 4 in the Supplement). We hypothesized that patients discharged to IRFs would have larger improvements in mobility and self-care function than those discharged to SNFs. Comparative research related to functional outcomes for persons with stroke receiving rehabilitation in IRFs vs SNFs is limited, to our knowledge. JAMA Netw Open. J, Get free access to newly published articles. We reported the study findings according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline. AM, Newhouse It is not possible to directly measure the size of the population of marginal patients. Centers for Medicare & Medicaid Services. ME, Jette Background: We sought to compare outcomes 6-12 months post-injury between patients discharged to an inpatient rehabilitation facility (IRF) and a skilled nursing facility (SNF). 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). Limits of observational data in determining outcomes from cancer therapy. Published: December 4, 2019. doi:10.1001/jamanetworkopen.2019.16646. Mallinson Velozo Comparison of discharge functional status after rehabilitation in skilled nursing, home health, and medical rehabilitation settings for patients after hip fracture repair. Additional research is necessary to confirm our findings and to identify whether any of the other 13 conditions identified by CMS as priority diagnoses for receiving services in IRFs (the 60% rule) may also show differences in functional outcomes based on treatment in IRFs vs SNFs. DE, Alter Study Flow Diagram for the Sample, eTable 1. Analysis of observational studies in the presence of treatment selection bias: effects of invasive cardiac management on AMI survival using propensity score and instrumental variable methods. Mallinson SJ. DB. CY, Yoonjeong Our website uses cookies to enhance your experience. Dr Mallinson reported receiving grants from National Institute on Disability and Rehabilitation Research outside the submitted work. JS. Z, Sicklick The 2014 Improving Medicare Post-Acute Care Transformation (IMPACT) Act3 requires the Secretary of the Department of Health and Human Services to establish a unified payment system for postacute care. Inpatient rehabilitation facilities have more stringent criteria for admission than do SNFs, including the requirement that patients be able to complete 3 hours of rehabilitation therapy daily. Factors influencing selection for rehabilitation after stroke: a questionnaire using case scenarios to investigate physician perspectives and level of agreement. 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). RC. Length of stay: The national average length of time spent at a skilled nursing facility rehab is 28 days. Rubin Z, Hortobagyi Case-mix classification system used under the SNF PPS The new SNF Patient-Driven-Payment-Model (PDPM) will become effective on October 1, 2019. ): e1918738 at an acute ischemic stroke measure, links to measure specifications, measure become... Korean version of Modified Barthel Index simply involves another person being present to the. As a control outcome, we used all-cause mortality between 30 and 365 after..., Panagiotou OA, Rahman M. JAMA Netw open you will find descriptions of measure... 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