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Are We Selecting the Right Patients for Stroke Rehabilitation in Nursing Homes?

  • Patrick K. Murray
    Correspondence
    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.
    Affiliations
    Center for Health Care Research and Policy, Case Western Reserve University, MetroHealth Medical Center, Cleveland, OH

    Department of Physical Medicine and Rehabilitation, Case Western Reserve University, MetroHealth Medical Center, Cleveland, OH

    Department of Epidemiology and Biostatistics, Case Western Reserve University, Cleveland, OH.
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  • Neal V. Dawson
    Affiliations
    Center for Health Care Research and Policy, Case Western Reserve University, MetroHealth Medical Center, Cleveland, OH

    Department of Medicine, Case Western Reserve University, MetroHealth Medical Center, Cleveland, OH

    Department of Epidemiology and Biostatistics, Case Western Reserve University, Cleveland, OH.
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  • Charles L. Thomas
    Affiliations
    Center for Health Care Research and Policy, Case Western Reserve University, MetroHealth Medical Center, Cleveland, OH
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  • Randall D. Cebul
    Affiliations
    Center for Health Care Research and Policy, Case Western Reserve University, MetroHealth Medical Center, Cleveland, OH

    Department of Medicine, Case Western Reserve University, MetroHealth Medical Center, Cleveland, OH

    Department of Epidemiology and Biostatistics, Case Western Reserve University, Cleveland, OH.
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      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.

      Key words

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