Joint Replacement Rehabilitation Outcomes on Discharge From Skilled Nursing Facilities and Inpatient Rehabilitation Facilities

Abstract 

DeJong G, Horn SD, Smout RJ, Tian W, Putman K, Gassaway J. Joint replacement rehabilitation outcomes on discharge from skilled nursing facilities and inpatient rehabilitation facilities.

Objective

To compare functional outcomes at discharge across postacute settings.

Design

Prospective observational cohort study.

Setting

Eleven inpatient rehabilitation facilities (IRFs), 8 freestanding skilled nursing facilities (SNFs), and 1 hospital-based SNF from across the United States.

Participants

Consecutively enrolled patients (N=2152): patients with knee replacement (n=1401) and patients with hip replacement (n=751).

Interventions

None; examination of existing practice patterns.

Main Outcome Measure

FIM discharge motor score.

Results

Freestanding SNF patients entered with higher motor FIM scores and left with higher scores than did IRF patients. IRF patients, however, achieved larger motor FIM gains and achieved them in a shorter time. In multivariate models controlling for patient differences and onset days, IRFs were associated with better discharge motor outcomes, but the overall setting effect was not large. The largest motor FIM differences were between medium-volume IRFs and low-volume freestanding SNFs: 4.6 motor FIM points for patients with knee replacement and 7.3 motor FIM points for patients with hip replacement. Other differences between settings were much smaller. Multivariate models explained between a third and a half of the variance in outcome.

Conclusions

As a group, IRFs had better motor FIM outcomes than did SNFs, but the size of the IRF advantage was not large. Other important facility and practice characteristics also were associated with discharge outcomes after joint replacement rehabilitation. Earlier and more intensive rehabilitation was associated with better outcomes. The volume of joint replacement patients seen by a facility also plays a part: medium-volume facilities among both SNFs and IRFs had better outcomes.

Key Words: Arthroplasty, replacement, hip, Arthroplasty, replacement, knee, Rehabilitation, Skilled nursing facilities

List of Abbreviations: BMI, body mass index, CMG, case-mix group, CMS, Centers for Medicare and Medicaid Services, CSI, Comprehensive Severity Index, IRF, inpatient rehabilitation facility, JOINTS I, Joint Replacement Outcomes in Inpatient Rehabilitation Facilities and Nursing Treatment Sites, JOINTS II, follow up study to Joint Replacement Outcomes in Inpatient Rehabilitation Facilities and Nursing Treatment Sites, LOS, length of stay, OLS, ordinary least squares, OT, occupational therapy, POC, point-of-care, PPS, prospective payment system, PT, physical therapy, SNF, skilled nursing facility