Choosing the right level of postacute care for stroke patients
Randie M. Black-Schaffer, M.D., M.A.
Division of Stroke and Neurology, Department of Physical Medicine
and Rehabilitation, Harvard Medical School, Boston MA
Two questions
• What characteristics distinguish patients who
go to Inpatient Rehabilitation Hospitals (IRFs)
from those who go to Skilled Nursing Facilities
(SNFs) for post-acute stroke care?
• Does IRF care lead to better outcomes than
SNF care?
Hakkennes, SJ, et al. Selection for Inpatient
Rehabilitation after Acute Stroke: A Systematic
Review of the Literature. Arch Phys Med Rehabil 2011
FACTORS that predict acute discharge disposition
•
•
•
•
•
Age
Severity of impairment
Functional level after stroke
Cognition
Urinary continence
FACTORs not considered in the literature
• Motivation
• Patient goals
Impact of Levels of Service: How Much is Postacute
Care Use Affected by Its Availability?
Buntin, MB, et al, Health Services Research, 2005
• All Medicare pts in hospital 1999 for stroke,
hip fx, Jt replacement
• Results:
– IRF vs SNF related to distance
– Number of facilities in the patient’s area
– SNF or IRF related to acute facility
State Variation in Stroke Discharge Destination (2002-2004)
Top 10 IRF users (FFS Medicare)
State
Nevada
Arkansas
Louisiana
Oklahoma
Arizona
Pennsylvania
North Dakota
Kansas
Texas
New Hampshire
Discharge Rank
to IRF
30%
28%
27%
26%
24%
23%
23%
23%
22%
22%
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
Discharge Rank
to SNF
15%
20%
14%
19%
21%
30%
27%
21%
21%
27%
(50)
(47)
(51)
(48)
(44)
(21)
(34)
(43)
(46)
(33)
Any
IRF as a Rank
Inpatient % of
Inpatient
50%
49%
52%
49%
46%
54%
50%
45%
49%
50%
59%
57%
53%
53%
53%
43%
45%
50%
46%
45%
(1)
(2)
(5)
(3)
(4)
(14)
(10)
(6)
(8)
(11)
Kramer A, Holthaus D., et al. Study of Stroke Post-Acute Care and Outcomes: Final Report. Aurora, CO. Division of Health Care
Policy and Research, University of Colorado at Denver and Health Sciences Center, 2006.
http://aspe.hhs.gov/daltcp/reports/2006/strokePAC.htm
State Variation in Stroke Discharge Destination (2002-2004)
Bottom 10 IRF users (FFS Medicare)
State
Virginia
Minnesota
Florida
Alabama
Nebraska
Vermont
Iowa
Connecticut
Oregon
Maryland
Discharge
to IRF
Rank
15%
14%
14%
14%
13%
13%
13%
12%
11%
4%
(42)
(43)
(44)
(45)
(46)
(47)
(48)
(49)
(50)
(51)
Discharge Rank
to SNF
30%
35%
33%
28%
29%
30%
29%
40%
33%
35%
(20)
(4)
(10)
(30)
(23)
(19)
(22)
(1)
(8)
(3)
Any
Inpatient
45%
50%
48%
43%
47%
43%
42%
56%
45%
39%
IRF as a
% of
Inpatient
33%
28%
30%
32%
28%
30%
30%
22%
25%
10%
Rank
(38)
(47)
(46)
(41)
(48)
(45)
(44)
(50)
(49)
(51)
Kramer A, Holthaus D., et al. Study of Stroke Post-Acute Care and Outcomes: Final Report. Aurora, CO. Division of Health Care
Policy and Research, University of Colorado at Denver and Health Sciences Center, 2006.
http://aspe.hhs.gov/daltcp/reports/2006/strokePAC.htm
Stein J, et al. Predicting Rehab Care
after Acute Stroke
• 736 pts at 22 acute hospitals in NECC, 2010-2011
• Ischemic and hemorrhagic stroke
• IRF disposition from acute more likely than SNF if
– Younger (P<.001)
– Pre-stroke mRS 0-1 (P=.004)
– Acute care Barthel Index 25-40 (P=.004), or 45-60 (P=.018)
• Home more likely than IRF/SNF if
–
–
–
–
Barthel Index 85-100
Lower pre-stroke mRS (P<.001)
Higher Short Portable Mental Status score (P<.001)
Lower NIHSS (P<.001)
Factors associated with IRF vs SNF
placement
•
•
•
•
•
•
Younger age
Higher functional level
Continent
Better cognitive status
IRF nearby
IRF related to acute hospital
PAL (Post Acute Levelling) Tool Domains
The Post Acute Leveling (PAL) Tool looks at
the following:
Patient Age
 Major Driver of Post Acute Care
 Physician Need
in visits per week
 Nursing Need
 in hours per day
Estimated Length of Stay
Rehabilitation Needs
in hours per day
 Program
 Specialty Needs
 Social, Payor, and Medication issues.
Are outcomes better with IRF or SNF
post-acute care for stroke?
Outcomes and Costs After Hip Fracture and Stroke: A
Comparison of Rehabilitation Settings
Kramer, AM, et al. JAMA 1997
Characteristic
Rehab (N=292)
SNF (N=193)
Age
75.8
81.2
P=.001
Willing caregiver
93
53
P=.001
Institutionalized
PTA
1
11
P=.001
Hemiparesis
14
31
P=.001
Comorbidities
1.57
1.87
P=.05
Incontinence
45
59
P=.001
Acute LOS
10.7
16.1
P=.001
Function on
admission to postacute care (BI)
8.0
5.3
P=.001
MMSE
23
15
P=.001
Outcomes and Costs After Hip Fracture and Stroke: A
Comparison of Rehabilitation Settings
Kramer, AM, et al. JAMA 1997
• Stroke patients: 292 to IRF, 193 to SNF
• LOS at IRF 28 days; LOS SNF 56 days
• “Study findings are consistent with enhanced
outcomes for elderly patients with stroke treated in
rehabilitation hospitals but not for patients with hip
fracture.”
• IRF stroke patients more likely to be in community at
6 mo. than SNF patients (OR 3.3; CI 1.5-7.2)
Does Postacute Care Site Matter?
Chan L, Sandel ME, Jette AM, et al. Arch PMR 2013
• Hypothesis: Pts with stroke receiving IRF care would
have better 6 mo. Functional outcomes than those who
received postacute care in SNF, HH/OP.
• 222 stroke pts at 4 acute hospitals
• Evaluation at DC from acute care and 6 mo.
• AM-PAC Activity Measure for Post Acute Care functional status
• NIHSS - stroke severity
• mRS – pre-stroke function
• mCharlson - comorbidities
Chan L, et al. 2013
• 4 groups:
– IRF: N= 66
– SNF: N= 29
– HH/OP only: N=48
– No PAC: N=79
• Intensity of therapy per Kaiser Foundation
Health Plan:
– IRF : 3 hrs/day for 6 days per wk
– SNF: 1.3 hrs/day for 5 days per wk
Chan L, et al: Results
• Controlling for
– Age, BMI, baseline function, pre-stroke mRS,
– mCharlson Index, hx prior stroke
• Patients who went to an IRF made greater
gains in mobility, ADL, and cognition
measured at 6 mo. compared to those who
went to SNF.
Chan L, et al: interpretation
•
•
•
•
Pts in IRFs have greater access to MDs, RNs
Higher intensity of rehab therapy
Often within an acute hospital
Greater pt/fam education, care coordination,
DC planning
Dobson Davanzo & Associates. Assessment of
Patient Outcomes of Rehabilitative Care Provided in
IRF and After Discharge. 2014.
• SNF vs IRF utilization Medicare pts 2005-2009
– Changes over time for 13 conditions
• Longitudinal outcomes for 2 years after
– Mortality
– Days at home
– Acute readmissions
– ER visits
IRF Utilization 2005-2009
Dobson/Davanzo: Propensity Score matching
• Patients matched for:
– Age
– Gender
– Race
– Condition
– Procedure codes
– Diagnosis codes
– Charges by dept.
• Patients not matched
for:
– Prestroke function
– Function on
admission to rehab
– Severity of
impairment
– Severity of
comorbidities
Stroke Outcomes
Dobson/Davanzo 2014
LOS (days)
IRF
15.5
SNF
32.1
P
<.0001
Medicare payment/day
$1235
$327
Mortality next 2 years
34.2%
48.4%
<.0001
Days at home next 2 years
518
426
<.0001
ER visits/1000pts/year
785.9
823.0
<.0001
Readmissions/1000pts/year 1123
1227
.904
Comments
• “The contribution of this study is that the
propensity score matching of IRF and SNF
patients controls for observed differences in
patient characteristics, thereby isolating the
impact of the PAC setting.”
• Patients not matched re functional level or
impairment
Patients may go to multiple levels of
Post Acute Care after Stroke
Acute Care
Acute Care
IRF
SNF
SNF
IRF
Home
Home
Acute Care
Acute Care
LTAC
LTAC
IRF
SNF
Home
Home
Patient Trajectory through Post-Acute Care
Acute Care. 60 yo female s/p thalamic hemorrhage with L
hemiplegia. PEG placement led to abdominal sepsis. She
suffered DVT in all 4 limbs, HO in left hip.
Transferred to LTAC. Antibiotics completed, drains removed,
po intake resumed, PEG removed, hip pain managed.
Transferred to IRF. A&O x 3, able to participate, poor
endurance. Mobility limited by L hip pain and hemiplegia.
Transfers mod A of one at discharge. Walking 30 feet with
mod-max A at discharge. HO pain diminished.
Discharged home with home care services.
Days
Acute Care
LTAC
IRF
Home
63
69
64
Day 196
Conclusions
• IRF outcomes better than SNF for initial stroke
rehab
• Widespread selection bias to send younger,
healthier patients to IRF, therefore
• Claims of long term health benefits of IRF vs.
SNF should be viewed with caution
• Multiple PAC levels of care for a single patient
common
Thank you! rblackschaffer@partners.org
Division of Stroke and Neurology, Department of Physical
Medicine and Rehabilitation, Harvard Medical School