Are We Selecting the Right Patients for Stroke Rehabilitation in Nursing Homes?
Abstract
Murray PK, Dawson NV, Thomas CL, Cebul RD. Are we selecting the right patients for stroke rehabilitation in nursing homes?
Objective
To examine the effect of stroke rehabilitation in the nursing home on community discharge rates and functional status among patients stratified by propensity to receive rehabilitation.
Design
Retrospective cohort.
Setting
Medicaid-certified nursing homes (N=945) in Ohio.
Participants
Patients with stroke (N=2013) admitted to an Ohio nursing home.
Intervention
Rehabilitation therapy services.
Main outcome measures
The propensity to receive rehabilitation, used to adjust for selection bias, was calculated for each patient by using a logistic regression model. Community discharge and change in functional status, measured by using a crosswalk to the FIM instrument, were determined 3 months after admission.
Results
By 3 months after admission, 36.9% of the patients were discharged to the community, 16.6% had died, and 46.5% remained in the nursing home. The overall effect of rehabilitation on community discharge (relative risk [RR]=1.58; 95% confidence interval [CI], 1.33–1.85) was not homogeneous across subgroups stratified by propensity to receive rehabilitation. Patients less likely to receive rehabilitation, as measured by a lower propensity score, had a significant benefit in terms of community discharge (RR=1.65; 95% CI, 1.35–1.97), but those more likely to receive services did not (RR=1.21; 95% CI, 0.87–1.56). Among long-term nursing home residents, rehabilitation services were not associated with improved functional status.
Conclusions
With respect to community discharge, patients who were less likely to receive rehabilitation therapy appear to receive greater benefit from rehabilitation services than those who were more likely to receive rehabilitation. This finding raises concerns about current selection practices for rehabilitation services. Research is needed to identify the patients most likely to benefit, especially in the present fiscally constrained reimbursement environment.
aCenter for Health Care Research and Policy, Case Western Reserve University, MetroHealth Medical Center, Cleveland, OH
bDepartment of Physical Medicine and Rehabilitation, Case Western Reserve University, MetroHealth Medical Center, Cleveland, OH
cDepartment of Medicine, Case Western Reserve University, MetroHealth Medical Center, Cleveland, OH
dDepartment of Epidemiology and Biostatistics, Case Western Reserve University, Cleveland, OH.
Correspondence to Patrick K. Murray, MD, MS, Center for Health Care Research and Policy, MetroHealth Medical Center, 2500 MetroHealth Dr, Cleveland, OH 44109-1998, Reprints are not available from the author.
Supported by the Ohio Board of Regents and the Agency for Health Care Policy and Research (grant no. 5 T32 HS00059-04).
No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the author(s) or on any organization with which the author(s) is/are associated.
ABSTRACT