Original research| Volume 99, ISSUE 6, P1077-1089.e7, June 2018

Physical and Occupational Therapy From the Acute to Community Setting After Stroke: Predictors of Use, Continuity of Care, and Timeliness of Care

Published:April 04, 2017DOI:



      To identify predictors of therapist use (any use, continuity of care, timing of care) in the acute care hospital and community (home or outpatient) for patients discharged home after stroke.


      Retrospective cohort analysis of Medicare claims (2010–2013) linked to hospital-level and county-level data.


      Acute care hospital and community.


      Patients (N=23,413) who survived the first 30 days at home after being discharged from an acute care hospital after stroke.


      Not applicable.

      Main Outcome Measures

      Physical and occupational therapist use in acute care and community settings; continuity of care across the inpatient and home or the inpatient and outpatient settings; and early therapist use in the home or outpatient setting. Multivariate logistic and multinomial logistic regression analyses were conducted to identify hospital-level, county-level, and sociodemographic characteristics associated with therapist use, continuity, and timing, controlling for clinical characteristics.


      Seventy-eight percent of patients received therapy in the acute care hospital, but only 40.8% received care in the first 30 days after discharge. Hospital nurse staffing was positively associated with inpatient and outpatient therapist use and continuity of care across settings. Primary care provider supply was associated with inpatient and outpatient therapist use, continuity of care, and early therapist care in the home and outpatient setting. Therapist supply was associated with continuity of care and early therapist use in the community. There was consistent evidence of sociodemographic disparities in therapist use.


      Therapist use after stroke varies in the community and for specific sociodemographic subgroups and may be underused. Inpatient nurse staffing levels and primary care provider supply were the most consistent predictors of therapist use, continuity of care, and early therapist use.


      List of abbreviations:

      PCP (primary care physician), PMR (physical medicine and rehabilitation), RN (registered nurse)
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        • Lawrence E.S.
        • Coshall C.
        • Dundas R.
        • et al.
        Estimates of the prevalence of acute stroke impairments and disability in a multiethnic population.
        Stroke. 2001; 32: 1279-1284
        • Pollock A.
        • Baer G.
        • Campbell P.
        • et al.
        Physical rehabilitation approaches for the recovery of function and mobility following stroke.
        Cochrane Database Syst Rev. 2014; 4: CD001920
        • Gresham G.E.
        • Fitzpatrick T.E.
        • Wolf P.A.
        • et al.
        Residual disability in survivors of stroke—the Framingham study.
        N Engl J Med. 1975; 293: 954-956
        • Kind A.J.
        • Smith M.A.
        • Liou J.I.
        • et al.
        The price of bouncing back: one-year mortality and payments for acute stroke patients with 30-day bounce-backs.
        J Am Geriatr Soc. 2008; 56: 999-1005
        • Mackintosh S.F.
        • Hill K.D.
        • Dodd K.J.
        • et al.
        Balance score and a history of falls in hospital predict recurrent falls in the 6 months following stroke rehabilitation.
        Arch Phys Med Rehabil. 2006; 87: 1583-1589
        • Simpson L.A.
        • Miller W.C.
        • Eng J.J.
        Effect of stroke on fall rate, location and predictors: a prospective comparison of older adults with and without stroke.
        PLoS One. 2011; 6: e19431
        • Verheyden G.S.
        • Weerdesteyn V.
        • Pickering R.M.
        • et al.
        Interventions for preventing falls in people after stroke.
        Cochrane Database Syst Rev. 2013; 5: CD008728
        • Billinger S.A.
        • Arena R.
        • Bernhardt J.
        • et al.
        Physical activity and exercise recommendations for stroke survivors: a statement for healthcare professionals from the American Heart Association/American Stroke Association.
        Stroke. 2014; 45: 2532-2553
        • Lang C.E.
        • Lohse K.R.
        • Birkenmeier R.L.
        Dose and timing in neurorehabilitation: prescribing motor therapy after stroke.
        Curr Opin Neurol. 2015; 28: 549-555
        • Horn S.D.
        • DeJong G.
        • Smout R.J.
        • et al.
        Stroke rehabilitation patients, practice, and outcomes: is earlier and more aggressive therapy better?.
        Arch Phys Med Rehabil. 2005; 86: S101-S114
        • Quinn T.J.
        • Paolucci S.
        • Sunnerhagen K.S.
        • et al.
        Evidence-based stroke rehabilitation: an expanded guidance document from the European Stroke Organisation (ESO) guidelines for management of ischaemic stroke and transient ischaemic attack 2008.
        J Rehabil Med. 2009; 41: 99-111
        • Van Peppen R.P.
        • Kwakkel G.
        • Wood-Dauphinee S.
        • et al.
        The impact of physical therapy on functional outcomes after stroke: what's the evidence?.
        Clin Rehabil. 2004; 18: 833-862
        • Andrews A.W.
        • Li D.
        • Freburger J.K.
        Association of rehabilitation intensity for stroke and risk of hospital readmission.
        Phys Ther. 2015; 95: 1660-1667
        • Burke J.F.
        • Skolarus L.E.
        • Adelman E.E.
        • et al.
        Influence of hospital-level practices on readmission after ischemic stroke.
        Neurology. 2014; 82: 2196-2204
        • Eng J.J.
        • Pang M.Y.
        • Ashe M.C.
        Balance, falls, and bone health: role of exercise in reducing fracture risk after stroke.
        J Rehabil Res Dev. 2008; 45: 297-313
        • European Stroke Organisation (ESO) Executive Committee
        • ESO Writing Committee
        Guidelines for management of ischaemic stroke and transient ischaemic attack 2008.
        Cerebrovasc Dis. 2008; 25: 457-507
        • Dworzynski K.
        • Ritchie G.
        • Fenu E.
        • et al.
        Rehabilitation after stroke: summary of NICE guidance.
        BMJ. 2013; 346: f3615
        • Lindsay P.
        • Bayley M.
        • McDonald A.
        • et al.
        Toward a more effective approach to stroke: Canadian Best Practice Recommendations for Stroke Care.
        CMAJ. 2008; 178: 1418-1425
        • Prvu Bettger J.
        • McCoy L.
        • Smith E.E.
        • Fonarow G.C.
        • Schwamm L.H.
        • Peterson E.D.
        Contemporary trends and predictors of postacute service use and routine discharge home after stroke.
        J Am Heart Assoc. 2015; 4: e001038
        • Freburger J.K.
        • Holmes G.M.
        • Ku L.J.
        • et al.
        Disparities in postacute rehabilitation care for stroke: an analysis of the state inpatient databases.
        Arch Phys Med Rehabil. 2011; 92: 1220-1229
        • Ayanian J.Z.
        • Weissman J.S.
        Teaching hospitals and quality of care: a review of the literature.
        Milbank Q. 2002; 80: 569-593
        • Goldman L.E.
        • Vittinghoff E.
        • Dudley R.A.
        Quality of care in hospitals with a high percent of Medicaid patients.
        Med Care. 2007; 45: 579-583
        • Kane R.L.
        • Shamliyan T.
        • Mueller C.
        • et al.
        Nurse staffing and quality of patient care.
        Evid Rep Technol Assess (Full Rep). 2007; : 1-115
        • Kane R.L.
        • Shamliyan T.A.
        • Mueller C.
        • et al.
        The association of registered nurse staffing levels and patient outcomes: systematic review and meta-analysis.
        Med Care. 2007; 45: 1195-1204
        • Carretta H.J.
        • Chukmaitov A.
        • Tang A.
        • et al.
        Examination of hospital characteristics and patient quality outcomes using four inpatient quality indicators and 30-day all-cause mortality.
        Am J Med Qual. 2013; 28: 46-55
        • Saposnik G.
        • Jeerakathil T.
        • Selchen D.
        • et al.
        Socioeconomic status, hospital volume, and stroke fatality in Canada.
        Stroke. 2008; 39: 3360-3366
        • Tirschwell D.L.
        • Longstreth Jr., W.T.
        Validating administrative data in stroke research.
        Stroke. 2002; 33: 2465-2470
        • Thigpen J.L.
        • Dillon C.
        • Forster K.B.
        • et al.
        Validity of international classification of disease codes to identify ischemic stroke and intracranial hemorrhage among individuals with associated diagnosis of atrial fibrillation.
        Circ Cardiovasc Qual Outcomes. 2015; 8: 8-14
        • Spolaore P.
        • Brocco S.
        • Fedeli U.
        • et al.
        Measuring accuracy of discharge diagnoses for a region-wide surveillance of hospitalized strokes.
        Stroke. 2005; 36: 1031-1034
        • Roumie C.L.
        • Mitchel E.
        • Gideon P.S.
        • et al.
        Validation of ICD-9 codes with a high positive predictive value for incident strokes resulting in hospitalization using Medicaid health data.
        Pharmacoepidemiol Drug Saf. 2008; 17: 20-26
        • Jones S.A.
        • Gottesman R.F.
        • Shahar E.
        • et al.
        Validity of hospital discharge diagnosis codes for stroke: the Atherosclerosis Risk in Communities Study.
        Stroke. 2014; 45: 3219-3225
        • Amico P.
        • Pope P.
        • Pardasaney P.
        • et al.
        Developing outpatient therapy payment alternatives: payment alternatives report.
        (RTI Project No. 0213520.000.004) RTI International, Research Triangle Park, NC2014
        • Faurot K.R.
        • Jonsson Funk M.
        • Pate V.
        • et al.
        Using claims data to predict dependency in activities of daily living as a proxy for frailty.
        Pharmacoepidemiol Drug Saf. 2015; 24: 59-66
        • Sasichay-Akkadechanunt T.
        • Scalzi C.C.
        • Jawad A.F.
        The relationship between nurse staffing and patient outcomes.
        J Nurs Adm. 2003; 33: 478-485
        • Howard V.J.
        Reasons underlying racial differences in stroke incidence and mortality.
        Stroke. 2013; 44: S126-S128
        • Stansbury J.P.
        • Jia H.
        • Williams L.S.
        • Vogel W.B.
        • Duncan P.W.
        Ethnic disparities in stroke: epidemiology, acute care, and postacute outcomes.
        Stroke. 2005; 36: 374-386
        • Donabedian A.
        The quality of care. How can it be assessed?.
        JAMA. 1988; 260: 1743-1748