Original research| Volume 100, ISSUE 7, P1317-1323, July 2019

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The Effect of Frailty on Discharge Location for Medicare Beneficiaries After Acute Stroke

  • Bryant A. Seamon
    Corresponding author Bryant A. Seamon, PT, DPT, NCS, CSCS, Department of Health and Research, College of Health Professions, Medical University of South Carolina, 77 President Street, MSC 700, Charleston, SC 29425.
    Ralph H. Johnson VA Medical Center, Charleston, SC, the United States

    Department of Health and Research, College of Health Professions, Medical University of South Carolina, Charleston, SC, the United States
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  • Kit N. Simpson
    Department of Healthcare Leadership and Management, College of Health Professions, Medical University of South Carolina, Charleston, SC, the United States
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Published:March 25, 2019DOI:


      • Frailty was a significant predictor of discharge location poststroke.
      • More frail patients were discharged to skilled nursing facilities.
      • Nonfrail patients were 71% more likely to be discharged to inpatient rehabilitation.



      To examine the effect of frailty on poststroke discharge location with respect to stroke severity and create a risk-adjusted model for understanding the effects of frailty on discharge to an inpatient rehabilitation facility.


      Retrospective cohort.


      A 2014 5% Medicare sample.


      Patients hospitalized for a first-time acute ischemic stroke (N=7258).


      Not applicable.

      Main Outcome Measures

      A prehospitalization 6-month baseline was used to calculate a frailty score. Logistic regression to predict odds of discharge to inpatient rehabilitation was used to calculate for 3 levels of baseline frailty, controlling for patient demographics, stroke severity, and comorbidities.


      About 1603 patients were discharged to inpatient rehabilitation. Patients who were nonfrail (odds ratio [OR] 1.716; 95% confidence interval [95% CI], 1.463-2.013) or prefrail (OR 1.519; 95% CI, 1.296-1.779) were more likely to be discharged to inpatient rehabilitation. The final logistic regression model had a C-statistic of 0.63. Most of the patients discharged to inpatient rehabilitation were nonfrail (44.2%) and had moderate strokes (38.9%). Individuals who were frail and suffered a moderate (OR 0.78; 95% CI, 0.558-1.091) or severe stroke (OR 0.509; 95% CI, 0.358-0.721) were less likely to be discharged to an inpatient rehabilitation facility.


      A lack of a claims-based measure for prestroke functional ability makes it difficult to understand discharge decision-making patterns for individuals’ poststroke. Prestroke frailty was found to have a significant effect on predicating inpatient rehabilitation discharge after an acute stroke when controlling for stroke severity, comorbidities, and age. Further investigation is warranted to examine differences in rehabilitation utilization based on frailty and to quantify the effect of rehabilitation on frailty status in individuals poststroke.


      List of abbreviations:

      95% CI (95% confidence interval), ADL (activities of daily living), FCI (Functional Comorbidity Index), IRF (inpatient rehabilitation facility), OR (odds ratio), SASI (Stroke Administrative Severity Index), SNF (skilled nursing facility)
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