Abstract
In the United States, approximately 400,000 patients with acute stroke are discharged
annually to inpatient rehabilitation facilities (IRFs) or skilled nursing facilities
(SNFs). Typically, IRFs provide time-intensive therapy for an average of 2-3 weeks,
whereas SNFs provide more moderately intensive therapy for 4-5 weeks. The factors
that influence discharge to an IRF or SNF are multifactorial and poorly understood.
The complexity of these factors in combination with subjective clinical indications
contributes to large variations in the use of IRFs and SNFs. This has significant
financial implications for health care expenditure, given that stroke rehabilitation
at IRFs costs approximately double that at SNFs. To control health care spending without
compromising outcomes, the Institute of Medicine has stated that policy reforms that
promote more efficient use of IRFs and SNFs are critically needed. A major barrier
to the formulation of such policies is the highly variable and low-quality evidence
for the comparative effectiveness of IRF- vs SNF-based stroke rehabilitation. The
current evidence is limited by the inability of observational data to control for
residual confounding, which contributes to substantial uncertainty around any magnitude
of benefit for IRF- vs SNF-based care. Furthermore, it is unclear which specific patients
would receive the most benefit from each setting. A randomized controlled trial addresses
these issues, because random treatment allocation facilitates an equitable distribution
of measured and unmeasured confounders. We discuss several measurement, practical,
and ethical issues of a trial and provide our rationale for design suggestions that
overcome some of these issues.
Keywords
List of abbreviations:
AM-PAC (Activity Measure for Post-Acute Care), HTE (heterogeneity of treatment effect), IRF (inpatient rehabilitation facility), IV (instrumental variable), LTFU (loss to follow-up), MedPAC (Medicare Payment Advisory Commission), PAC (postacute care), RCT (randomized controlled trial), SIS-16 (Stroke Impact Scale 16), SNF (skilled nursing facility)To read this article in full you will need to make a payment
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Article Info
Publication History
Published online: August 31, 2021
Accepted:
August 6,
2021
Received in revised form:
August 2,
2021
Received:
May 17,
2021
Footnotes
Disclosures: none.
Identification
Copyright
© 2021 by the American Congress of Rehabilitation Medicine.
