Mandated Quality of Care Metrics for Medicare Patients: Examining New or Worsened Pressure Ulcers and Rehabilitation Outcomes in United States Inpatient Rehabilitation Facilities.

OBJECTIVE: To examine the association between the Medicare pressure ulcer quality indicator (the development of new or worsened pressure ulcers) and rehabilitation outcomes among Medicare patients seen in an inpatient rehabilitation facility (IRF). DESIGN: Retrospective descriptive study. SETTING: IRFs subscribed to the Uniform Data System for Medical Rehabilitation. PARTICIPANTS: Nearly 500,000 IRF Medicare patients who were discharged between January 2013 and September 2014 were examined. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Functional independence, functional change (gain), and discharge destination. RESULTS: The pressure ulcer quality indicator was associated with poorer rehabilitation outcomes; patients were less likely to achieve functional independence (odds ratio [OR], .47; 95% confidence interval [CI], .44-.51), were less likely to be discharged to a community setting (OR, .88; 95% CI, .82-.95), and made less functional gain during their IRF stay (a difference of 6 FIM points). CONCLUSIONS: These results support that the pressure ulcer quality indicator is associated with lower quality of rehabilitation outcomes; however, given that those patients with a new or worsened pressure injury still made functional gains and most were discharged to the community, the risk of pressure injury development should not preclude the admission of these cases to an IRF.

Trajectories of Functional Change After Inpatient Rehabilitation for Traumatic Brain Injury.

OBJECTIVE: To examine trajectories of functional recovery after rehabilitation for traumatic brain injury (TBI). DESIGN: Prospective study. SETTING: Inpatient rehabilitation hospitals in the Uniform Data System for Medical Rehabilitation. PARTICIPANTS: A subset of individuals receiving inpatient rehabilitation services for TBI from 2002 to 2010 who also had postdischarge measurement of functional independence (N=16,583). INTERVENTIONS: Inpatient rehabilitation. MAIN OUTCOMES MEASURES: Admission, discharge, and follow-up data were obtained from the Uniform Data System for Medical Rehabilitation. We used latent class mixture models to examine recovery trajectories for both cognitive and motor functioning as measured by the FIM instrument. RESULTS: Latent class models identified 3 trajectories (low, medium, high) for both cognitive and motor FIM subscales. Factors associated with membership in the low cognition trajectory group included younger age, male sex, racial/ethnic minority, Medicare or Medicaid (vs commercial or other insurance), comorbid conditions, and greater duration from injury date to rehabilitation admission date. Factors associated with membership in the low motor trajectory group included older age, racial/ethnic minority, Medicare or Medicaid coverage, comorbid conditions, open head injury, and greater duration to admission. CONCLUSIONS: Standard approaches to assessing recovery patterns after TBI obscure differences between subgroups with trajectories that differ from the overall mean. Select demographic and clinical characteristics can help classify patients with TBI into distinct functional recovery trajectories, which can enhance both patient-centered care and quality improvement efforts.

Characterization of Cancer Patients in Inpatient Rehabilitation Facilities: A Retrospective Cohort Study.

OBJECTIVES: To identify the types of cancer patients admitted to inpatient medical rehabilitation and to describe their rehabilitation outcomes. DESIGN: Retrospective cohort study. SETTING: U.S. inpatient rehabilitation facilities (IRFs). PARTICIPANTS: Adult patients (N=27,952) with a malignant cancer diagnosis admitted to an IRF with a cancer-related impairment between October 2010 and September 2012 were identified from the Uniform Data System for Medical Rehabilitation database. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Demographic, medical, and rehabilitation characteristics for patients with various cancer tumor types were summarized using data collected from the Inpatient Rehabilitation Facility-Patient Assessment Instrument. Rehabilitation outcomes included the percentage of patients discharged to the community and acute care settings, and functional change from admission to discharge. Functional status was measured using the FIM instrument. RESULTS: Cancer patients constituted about 2.4% of the total IRF patient population. Cancer types included brain and nervous system (52.9%), digestive (12.0%), bone and joint (8.7%), blood and lymphatic (7.6%), respiratory (7.1%), and other (11.7%). Overall, 72% were discharged to a community setting, and 16.5% were discharged back to acute care. Patients with blood and lymphatic cancers had the highest frequency of discharge back to acute care (28%). On average, all cancer patient groups made significant functional gains during their IRF stay (mean FIM total change ± SD, 23.5±16.2). CONCLUSIONS: In a database representing approximately 70% of all U.S. patients in IRFs, we found that patients with a variety of cancer types are admitted to inpatient rehabilitation. Most cancer patients admitted to IRFs were discharged to a community setting and, on average, improved their function. Future research is warranted to understand the referral patterns of admission to postacute care rehabilitation and to identify factors that are associated with rehabilitation benefit in order to inform the establishment of appropriate care protocols.

Measure of functional independence dominates discharge outcome prediction after inpatient rehabilitation for stroke.

BACKGROUND AND PURPOSE: Identifying clinical data acquired at inpatient rehabilitation admission for stroke that accurately predict key outcomes at discharge could inform the development of customized plans of care to achieve favorable outcomes. The purpose of this analysis was to use a large comprehensive national data set to consider a wide range of clinical elements known at admission to identify those that predict key outcomes at rehabilitation discharge. METHODS: Sample data were obtained from the Uniform Data System for Medical Rehabilitation data set with the diagnosis of stroke for the years 2005 through 2007. This data set includes demographic, administrative, and medical variables collected at admission and discharge and uses the FIM (functional independence measure) instrument to assess functional independence. Primary outcomes of interest were functional independence measure gain, length of stay, and discharge to home. RESULTS: The sample included 148,367 people (75% white; mean age, 70.6±13.1 years; 97% with ischemic stroke) admitted to inpatient rehabilitation a mean of 8.2±12 days after symptom onset. The total functional independence measure score, the functional independence measure motor subscore, and the case-mix group were equally the strongest predictors for any of the primary outcomes. The most clinically relevant 3-variable model used the functional independence measure motor subscore, age, and walking distance at admission (r(2)=0.107). No important additional effect for any other variable was detected when added to this model. CONCLUSIONS: This analysis shows that a measure of functional independence in motor performance and age at rehabilitation hospital admission for stroke are predominant predictors of outcome at discharge in a uniquely large US national data set.

Regional variation in stroke rehabilitation outcomes.

OBJECTIVE: To examine and describe regional variation in outcomes for persons with stroke receiving inpatient medical rehabilitation. DESIGN: Retrospective cohort design. SETTING: Inpatient rehabilitation units and facilities contributing to the Uniform Data System for Medical Rehabilitation from the United States. PARTICIPANTS: Patients (N=143,036) with stroke discharged from inpatient rehabilitation during 2006 and 2007. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Community discharge, length of stay (LOS), and discharge functional status ratings (motor, cognitive) across 10 geographic service regions defined by the Centers for Medicare and Medicaid Services (CMS). RESULTS: Approximately 71% of the sample was discharged to the community. After adjusting for covariates, the percentage discharged to the community varied from 79.1% in the Southwest (CMS region 9) to 59.4% in the Northeast (CMS region 2). Adjusted LOS varied by 2.1 days, with CMS region 1 having the longest LOS at 18.3 days and CMS regions 5 and 9 having the shortest at 16.2 days. CONCLUSIONS: Rehabilitation outcomes for persons with stroke varied across CMS regions. Substantial variation in discharge destination and LOS remained after adjusting for demographic and clinical characteristics.

Thirty-day hospital readmission following discharge from postacute rehabilitation in fee-for-service Medicare patients.

IMPORTANCE: The Centers for Medicare & Medicaid Services recently identified 30-day readmission after discharge from inpatient rehabilitation facilities as a national quality indicator. Research is needed to determine the rates and factors related to readmission in this patient population. OBJECTIVE: To determine 30-day readmission rates and factors related to readmission for patients receiving postacute inpatient rehabilitation. DESIGN, SETTING, AND PATIENTS: Retrospective cohort study of records for 736,536 Medicare fee-for-service beneficiaries (mean age, 78.0 [SD, 7.3] years) discharged from 1365 inpatient rehabilitation facilities to the community in 2006 through 2011. Sixty-three percent of patients were women, and 85.1% were non-Hispanic white. MAIN OUTCOMES AND MEASURES: Thirty-day readmission rates for the 6 largest diagnostic impairment categories receiving inpatient rehabilitation. These included stroke, lower extremity fracture, lower extremity joint replacement, debility, neurologic disorders, and brain dysfunction. RESULTS: Mean rehabilitation length of stay was 12.4 (SD, 5.3) days. The overall 30-day readmission rate was 11.8% (95% CI, 11.7%-11.8%). Rates ranged from 5.8% (95% CI, 5.8%-5.9%) for patients with lower extremity joint replacement to 18.8% (95% CI, 18.8%-18.9%). for patients with debility. Rates were highest in men (13.0% [ 95% CI, 12.8%-13.1%], vs 11.0% [95% CI, 11.0%-11.1%] in women), non-Hispanic blacks (13.8% [95% CI, 13.5%-14.1%], vs 11.5% [95% CI, 11.5%-11.6%] in whites, 12.5% [95% CI, 12.1%-12.8%] in Hispanics, and 11.9% [95% CI, 11.4%-12.4%] in other races/ethnicities), beneficiaries with dual eligibility (15.1% [95% CI, 14.9%-15.4%], vs 11.1% [95% CI, 11.0%-11.2%] for no dual eligibility), and in patients with tier 1 comorbidities (25.6% [95% CI, 24.9%-26.3%], vs 18.9% [95% CI, 18.5%-19.3%] for tier 2, 15.1% [95% CI, 14.9%-15.3%] for tier 3, and 9.9% [95% CI, 9.9%-10.0%] for no tier comorbidities). Higher motor and cognitive functional status were associated with lower hospital readmission rates across the 6 impairment categories. Adjusted readmission rates by state ranged from 9.2% to 13.6%. Approximately 50% of patients rehospitalized within the 30-day period were readmitted within 11 days of discharge. Medicare Severity Diagnosis-Related Group codes for heart failure, urinary tract infection, pneumonia, septicemia, nutritional and metabolic disorders, esophagitis, gastroenteritis, and digestive disorders were common reasons for readmission. CONCLUSIONS AND RELEVANCE: Among postacute rehabilitation facilities providing services to Medicare fee-for-service beneficiaries, 30-day readmission rates ranged from 5.8% to 18.8% for selected impairment groups. Further research is needed to understand the causes of readmission.

Inpatient rehabilitation volume and functional outcomes in stroke, lower extremity fracture, and lower extremity joint replacement.

BACKGROUND: It is unclear if volume-outcome relationships exist in inpatient rehabilitation. OBJECTIVES: Assess associations between facility volumes and 2 patient-centered outcomes in the 3 most common diagnostic groups in inpatient rehabilitation. RESEARCH DESIGN: We used hierarchical linear and generalized linear models to analyze administrative assessment data from patients receiving inpatient rehabilitation services for stroke (n=202,423), lower extremity fracture (n=132,194), or lower extremity joint replacement (n=148,068) between 2006 and 2008 in 717 rehabilitation facilities across the United States. Facilities were assigned to quintiles based on average annual diagnosis-specific patient volumes. MEASURES: Discharge functional status (FIM instrument) and probability of home discharge. RESULTS: Facility-level factors accounted for 6%-15% of the variance in discharge FIM total scores and 3%-5% of the variance in home discharge probability across the 3 diagnostic groups. We used the middle volume quintile (Q3) as the reference group for all analyses and detected small, but statistically significant (P<0.01) associations with discharge functional status in all 3 diagnosis groups. Only the highest volume quintile (Q5) reached statistical significance, displaying higher functional status ratings than Q3 each time. The largest effect was observed in FIM total scores among fracture patients, with only a 3.6-point difference in Q5 and Q3 group means. Volume was not independently related to home discharge. CONCLUSIONS: Outcome-specific volume effects ranged from small (functional status) to none (home discharge) in all 3 diagnostic groups. Patients with these conditions can be treated locally rather than at higher volume regional centers. Further regionalization of inpatient rehabilitation services is not needed for these conditions.

Looking back and thinking forward: 20 years of disability and rehabilitation research.

The National Center for Medical Rehabilitation Research recently celebrated its 20th Anniversary. The celebration included a symposium highlighting advances in rehabilitation science over the past 2 decades. The anniversary also reminds us of the challenges that remain in order to strengthen the foundation of disability and rehabilitation research. These challenges have been described in 3 reports published by the Institute of Medicine (IOM) in 1991, 1997, and 2007. Three areas of concern appear across the IOM reports. These include (1) the lack of a comprehensive disability monitoring program, (2) the need for better integration and coordination of federally supported disability research, and (3) funding levels that are inconsistent with the current and projected impacts of disability on individuals, families, and communities. In this commentary we examine the lack of progress in addressing the recommendations contained in the IOM reports. We conclude that renewed efforts by consumers, clinicians, educators, researchers, administrators, and policy makers are needed to achieve the promise of rehabilitation and disability science identified 20 years ago.

Utility of functional status for classifying community versus institutional discharges after inpatient rehabilitation for stroke.

OBJECTIVE: To evaluate the ability of patient functional status to differentiate between community and institutional discharges after rehabilitation for stroke. DESIGN: Retrospective cross-sectional design. SETTING: Inpatient rehabilitation facilities contributing to the Uniform Data System for Medical Rehabilitation. PARTICIPANTS: Patients (N=157,066) receiving inpatient rehabilitation for stroke from 2006 and 2007. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Discharge FIM rating and discharge setting (community vs institutional). RESULTS: Approximately 71% of the sample was discharged to the community. Receiver operating characteristic curve analyses revealed that FIM total performed as well as or better than FIM motor and FIM cognition subscales in differentiating discharge settings. Area under the curve for FIM total was .85, indicating very good ability to identify persons discharged to the community. A FIM total rating of 78 was identified as the optimal cut point for distinguishing between positive (community) and negative (institution) tests. This cut point yielded balanced sensitivity and specificity (both=.77). CONCLUSIONS: Discharge planning is complex, involving many factors. Identifying a functional threshold for classifying discharge settings can provide important information to assist in this process. Additional research is needed to determine if the risks and benefits of classification errors justify shifting the cut point to weight either sensitivity or specificity of FIM ratings.

Influence of sex and age on inpatient rehabilitation outcomes among older adults with traumatic brain injury.

UNLABELLED: Graham JE, Radice-Neumann DM, Reistetter TA, Hammond FM, Dijkers M, Granger CV. Influence of sex and age on inpatient rehabilitation outcomes among older adults with traumatic brain injury. OBJECTIVE: To assess the influence of sex and age on inpatient rehabilitation outcomes in a large national sample of older adults with traumatic brain injury (TBI). DESIGN: Prospective case series. SETTING: Eight hundred forty-eight inpatient rehabilitation facilities that subscribe to the Uniform Data System for Medical Rehabilitation. PARTICIPANTS: Patients (n=18,413) age 65 years and older admitted for inpatient rehabilitation after TBI from 2005 through 2007. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Rehabilitation length of stay, discharge FIM motor and cognitive ratings, discharge setting, and scheduled home health services at discharge. RESULTS: Mean age +/- SD of the sample was 79+/-7 years, and 47% were women. In multivariable models, higher age was associated with shorter lengths of stay (P<.001), lower discharge FIM motor and cognitive ratings (P<.001), and greater odds of home health services at discharge (P<.001). Women demonstrated shorter lengths of stay (P=.006) and greater odds of being scheduled for home health services at discharge (P<.001) than men. The sex-by-age interaction term was not significant in any outcome model. Sex differences and trends were consistent across the entire age range of the sample. CONCLUSIONS: Sex and age patterns in rehabilitation outcomes among older adults with TBI varied by outcome. The current findings related to rehabilitation length of stay may be helpful for facility-level resource planning. Additional studies are warranted to identify the factors associated with returning to home and to assess the long-term benefits of combined inpatient rehabilitation and home health services for older adults with TBI.

Rasch-derived latent trait measurement of outcomes: insightful use leads to precision case management and evidence-based practices in functional healthcare.

The use of Rasch-derived latent trait measurement of outcomes for persons with chronic disease and disablement evolved from other fields, particularly education. Person-metrics is the measurement of how much chronic disease and disablement affects an individual's daily activities physically, cognitively, and through vocational and social role participation. The ability of the Rasch model to assume that the probability of a given person/item interaction is governed by the difficulty of the item and the ability of the person is invaluable to disability measurement. The difference between raw scores and true measures is illustrated by an example of a patient whose physical difficulty is rated on rising from a wheelchair and walking 100m (known to be more difficult), and then walking an additional 200m. Though number ratings of 0-1-2 are assigned to these tasks, they are not equidistant, and only a true measure shows the actual levels of physical difficulty.

Measuring function in young children with impairments.

PURPOSE: To determine the psychometric properties of a new functional assessment tool, the WeeFIM 0-3 instrument, intended to measure function in young children with physical, cognitive, or developmental impairments from birth to 3 years of age. Specific aims were to determine whether differences exist in WeeFIM 0-3 ratings in children with impairments as compared with those without, controlling for age and gender, and to determine the internal consistency, validity, and hierarchical properties of the instrument. METHODS: Cross-sectional study of 173 children with impairments and 354 without impairments. RESULTS: Controlling for age, children without impairments had significantly higher mean WeeFIM 0-3 ratings than children with impairments. There were no differences in mean ratings by gender. The instrument displayed high internal consistency, construct, and predictive validity; maintained a hierarchy of item difficulty; and discriminant properties. CONCLUSION: Further reliability studies are needed to determine the instrument sensitivity and ability to detect change over time.

A comparative evaluation of inpatient rehabilitation for older adults with debility, hip fracture, and myopathy.

OBJECTIVE: To compare the functional outcomes and discharge location of older adults admitted to inpatient rehabilitation for debility, hip fracture, and myopathy. DESIGN: Retrospective cohort study from 2002 to 2003 with information from the Uniform Data System for Medical Rehabilitation (UDSMR). SETTING: United States inpatient rehabilitation facilities subscribing to the UDSMR. PARTICIPANTS: Patients 65 years or older (N=84.701) with primary diagnoses of debility (n=14,835), hip fracture (n=68,915), and myopathy (n=951). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Change in functional status, including efficiency (change in functional status divided by length of stay in days) and discharge setting. RESULTS: The efficiency of the patients with debility (1.7+/-2.1) was significantly lower than that of the patients with hip fracture (1.9+/-1.6; P<.001), but not different from the patients with myopathy (1.6+/-1.4; P=.3). Significantly more patients with debility (68%) were discharged home than the hip fracture and myopathy groups (66% and 65%, respectively; P<.001). CONCLUSIONS: Although statistical differences exist, the functional recovery and rate of discharge home of older adult patients admitted to inpatient rehabilitation with a primary debility diagnosis are essentially the same clinically as those of patients with a diagnosis of either hip fracture or myopathy. Given these findings, and given that hip fracture and myopathy are approved medical conditions according to the Centers for Medicare and Medicaid Services 75% rule, the medical condition debility warrants consideration for inclusion as a qualifying medical diagnosis under this rule. However, further research is needed to develop relatively objective criteria for the debility diagnosis, and to identify those patients with debility who are most likely to benefit from inpatient rehabilitation.

Relationship between diabetes codes that affect Medicare reimbursement (tier comorbidities) and outcomes in stroke rehabilitation.

OBJECTIVES: To examine the extent to which diabetes codes that increase reimbursement (tier comorbidities) under the prospective payment system are related to length of stay and functional outcomes in stroke rehabilitation. DESIGN: Secondary data analysis. SETTING: Inpatient rehabilitation facilities (N=864) across the United States. PARTICIPANTS: Patients (N=135,097) who received medical rehabilitation for stroke in 2002-2003. INTERVENTION: None. MAIN OUTCOME MEASURES: Length of stay, FIM instrument, and discharge setting. Diabetes status was assigned to 1 of 3 categories: tier (increases reimbursement), nontier (no reimbursement effect), and no diabetes. RESULTS: Mean +/- standard deviation age of the sample was 70.4+/-13.4 years, and 31% had diabetes (6% tier, 25% nontier). Diabetes status by age demonstrated significant (P<.05) interaction effects, which lead to the following age-specific findings. In younger stroke patients (60y), tier diabetes was associated with shorter lengths of stay compared with both groups, lower FIM discharge scores compared with both groups, and lower odds of discharge home relative to the no-diabetes group. In older stroke patients (80y), tier diabetes was associated with longer lengths of stay compared with both groups and with higher FIM discharge scores compared with the nontier group. CONCLUSIONS: The diabetes-related conditions identified as tier comorbidities under the prospective payment system are significant predictors of stroke rehabilitation outcomes, but these relationships are moderated by patient age.

Racial and ethnic differences in postacute rehabilitation outcomes after stroke in the United States.

BACKGROUND AND PURPOSE: Incidence, prevalence, and mortality for stroke vary by race and ethnicity with higher rates for blacks compared with non-Hispanic whites. Little information is available regarding differences in postacute care outcomes for racial and ethnic groups after a stroke. METHODS: A retrospective analysis was conducted of 161,692 patients from the Uniform Data System for Medical Rehabilitation who received inpatient medical rehabilitation after a first stroke in 2002 and 2003. Multivariable models examined the effects of race and ethnicity on length of stay, functional status, rehabilitation efficiency, and discharge setting. RESULTS: The mean age was 70.97 years (SD=12.87), 53% were female, and 76% were non-Hispanic white. Mean length of stay was similar for all groups ranging from 17.39 days (SD=10.86) to 17.93 (SD=10.59). Non-Hispanic white patients had higher admission and discharge functional status ratings compared with patients in the minority groups (P<0.01). Differences in functional status across racial/ethnic groups were related to age (F=20.49, P<0.001); the older the comparison group, the greater the difference in functional status. Non-Hispanic whites were discharged home less often than blacks (OR=0.64, 95% CI=0.62 to 0.66), Hispanics (OR=0.58, 95% CI=0.55 to 0.62), or other minority groups (OR=0.67, 95% CI=0.57 to 0.67). CONCLUSIONS: The findings suggest racial and ethnic disparities exist in postacute care outcomes for persons with stroke.

Race/ethnicity and outcomes following inpatient rehabilitation for hip fracture.

BACKGROUND: Hip fracture results in severe and often permanent reductions in overall health and quality of life for many older adults. As the U.S. population grows older and more diverse, there is an increasing need to assess and improve outcomes across racial/ethnic cohorts of older hip fracture patients. METHODS: We examined data from 42,479 patients receiving inpatient rehabilitation for hip fracture who were discharged in 2003 from 825 facilities across the United States. Outcomes of interest included length of stay, discharge setting, and functional status at discharge and 3- to 6-month follow-up. RESULTS: Mean age was 80.2 (standard deviation [SD] = 8.0) years. A majority of the sample was non-Hispanic white (91%), followed by non-Hispanic black (4%), Hispanic (4%), and Asian (1%). After controlling for sociodemographic factors and case severity, significant (p <.05) differences between the non-Hispanic white and minority groups were observed for predicted lengths of stay in days (Asian: 1.1; 95% confidence interval [CI], 0.5-1.7; non-Hispanic black: 0.8; 95% CI, 0.6-1.1), odds of home discharge (Asian: 2.1; 95% CI, 1.6-2.8; non-Hispanic black: 2.0; 95% CI, 1.8-2.3; Hispanic: 1.9; 95% CI, 1.6-2.2), lower discharge Functional Independence Measure (FIM) ratings (non-Hispanic black: 3.6; 95% CI, 3.0-4.2; Hispanic: 1.6; 95% CI, 0.9-2.2 points lower), and lower follow-up FIM ratings (Hispanic: 4.4; 95% CI, 2.8-5.9). CONCLUSIONS: Race/ethnicity differences in outcomes were present in a national sample of hip fracture patients following inpatient rehabilitation. Recognizing these differences is the first step toward identifying and understanding potential mechanisms underlying the relationship between race/ethnicity and outcomes. These mechanisms may then be addressed to improve hip fracture care for all patients.

Apparent changes in inpatient rehabilitation facility outcomes due to a change in the definition of program interruption.

OBJECTIVE: To describe changes in inpatient rehabilitation facility (IRF) outcomes due to the program interruption definitional change, from 30 days to 3 days, in 2002. DESIGN: Secondary data analysis of the Uniform Data System for Medical Rehabilitation (UDSMR) database. SETTING: Four hundred eleven IRFs that submitted data to the UDSMR database in each of the years 1998 through 2003. PARTICIPANTS: Patient assessment data for 772,584 Medicare fee-for-service beneficiaries. INTERVENTIONS: None. MAIN OUTCOME MEASURES: The number of IRF patient discharges, percent of IRF patients discharged to the community, percent of IRF patients discharged to acute care, percent of IRF patients with program interruptions, percent of IRF inpatient deaths, and average IRF length of stay (LOS). RESULTS: IRF outcomes appeared to change because of the program interruption redefinition, with changes varying by impairment group. The largest changes due to the redefinition occurred for patients with traumatic spinal cord injury, including the largest percentage increase in patients (5.16%), the largest decrease in program interruptions (5.14%), the largest increase in acute care discharges (5.04%), and the largest mean decrease in LOS (1.27d). Community discharge showed the largest decrease for patients with Guillain-Barré syndrome (4.03%). CONCLUSION: The change in the definition of program interruptions creates the appearance of changes in IRF performance and is important to consider when comparing the preprospective payment system (PPS) and PPS assessment data.

Ethnic differences in discharge destination among older patients with traumatic brain injury.

UNLABELLED: Ethnic differences in discharge destination among older patients with traumatic brain injury. OBJECTIVE: To estimate the association between ethnicity and discharge destination in older patients with traumatic brain injury (TBI). DESIGN: A retrospective analysis. SETTING: Nationally representative sample of older patients from the Uniform Data System for Medical Rehabilitation in 2002 and 2003. PARTICIPANTS: Patients (N=9240) aged 65 years or older who received inpatient rehabilitation services for TBI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Discharge destination (home, assisted living facility, institution) and ethnicity (white, black, Hispanic). RESULTS: Multinomial logit models showed that older Hispanics (odds ratio [OR]=2.24; 95% confidence interval [CI], 1.66-3.02) and older blacks (OR=2; 95% CI, 1.55-2.59) with TBI were significantly more likely to be discharged home than older whites with TBI, after adjusting for relevant risk factors. Older blacks were also 78% less likely (OR=.22; 95% CI, .08-.60) to be discharged to an assisted living facility than whites after adjusting for relevant risk factors. CONCLUSIONS: Our findings indicate that older minority patients with TBI were significantly more likely to be discharged home than white patients with TBI. Studies are needed to investigate underlying factors associated with this ethnic difference.

Poststroke rehabilitation: outcomes and reimbursement of inpatient rehabilitation facilities and subacute rehabilitation programs.

BACKGROUND AND PURPOSE: To assess whether poststroke rehabilitation outcomes and reimbursement for Medicare beneficiaries differ across inpatient rehabilitation facilities (IRFs) and skilled nursing facility (SNF) subacute rehabilitation programs. METHODS: Clinical data were linked with Medicare claims for 58,724 Medicare beneficiaries with a recent stroke who completed treatment in 1996 or 1997 in IRFs and subacute rehabilitation SNFs that subscribed to the Uniform Data System for Medical Rehabilitation. Outcome measures were discharge destination, discharge FIM ratings and Medicare Part A reimbursement during the institutional stay. RESULTS: IRF patients that were more likely to have a community-based discharge, compared with rehabilitation SNF patients, were patients with mild motor disabilities and FIM cognitive ratings of 23 or greater (adjusted odds ratio [AOR]=2.19; 95% CI: 1.52 to 3.14), patients with moderate motor disabilities (AOR=1.98; 95% CI: 1.49 to 2.61), patients with significant motor disabilities (AOR=1.26; 95% CI: 1.01 to 1.57) and patients younger than 82 with severe motor disabilities (AOR=1.43; 95% CI: 1.25 to 1.64). IRF patients with significant and severe motor disabilities achieved greater motor function of 2 or more FIM units compared with rehabilitation SNF patients. Medicare Part A payments for IRFs were higher than rehabilitation SNF payments across all subgroups. CONCLUSIONS: For most patients, poststroke rehabilitation in the more costly and intensive IRFs resulted in higher functional outcomes compared with care in a SNF-based rehabilitation program. IRF and SNF outcomes were similar for patients with minimal motor disabilities and patients with mild motor disabilities and significant cognitive disabilities. Cost-effectiveness analyses require considering the costs of the full episode of care.

Hospital Readmission Following Discharge From Inpatient Rehabilitation for Older Adults With Debility.

BACKGROUND: Debility accounts for 10% of inpatient rehabilitation cases among Medicare beneficiaries. Debility has the highest 30-day readmission rate among 6 impairment groups most commonly admitted to inpatient rehabilitation. OBJECTIVE: The purpose of this study was to examine rates, temporal distribution, and factors associated with hospital readmission for patients with debility up to 90 days following discharge from inpatient rehabilitation. DESIGN: A retrospective cohort study was conducted using records for 45,424 Medicare fee-for-service beneficiaries with debility discharged to community from 1,199 facilities during 2006-2009. METHODS: Cox proportional hazard regression models were used to estimate hazard ratios for readmission. Schoenfeld residuals were examined to identify covariate-time interactions. Factor-time interactions were included in the full model for Functional Independence Measure (FIM) discharge motor functional status, comorbidity tier, and chronic pulmonary disease. Most prevalent reasons for readmission were summarized by Medicare severity diagnosis related groups. RESULTS: Hospital readmission rates for patients with debility were 19% for 30 days and 34% for 90 days. The highest readmission count occurred on day 3 after discharge, and 56% of readmissions occurred within 30 days. A higher FIM discharge motor rating was associated with lower hazard for readmissions prior to 60 days (30-day hazard ratio=0.987; 95% confidence interval=0.986, 0.989). Comorbidities with hazard ratios >1.0 included comorbidity tier and 11 Elixhauser conditions, 3 of which (heart failure, renal failure, and chronic pulmonary disease) were among the most prevalent reasons for readmission. LIMITATIONS: Analysis of Medicare data permitted only use of variables reported for administrative purposes. Comorbidity data were analyzed only for inpatient diagnoses. CONCLUSIONS: One-third of patients were readmitted to acute hospitals within 90 days following rehabilitation for debility. Protective effect of greater motor function was diminished by 60 days after discharge from inpatient rehabilitation.