Medicare Spending and Outcomes After Postacute Care for Stroke and Hip Fracture

Abstract

Background Elderly patients who leave an acute care hospital after a stroke or a hip fracture may be discharged home or undergo post-acute rehabilitative care in an inpatient rehabilitation facility (IRF) or skilled nursing facility (SNF). Since 15% of Medicare expenditures are for these types of post-acute care, it is important to understand their relative costs and the health outcomes they produce. Objective To assess Medicare payments for and outcomes of patients discharged from acute care to an IRF, a SNF, or home after an inpatient diagnosis of stroke or hip fracture between January 2002 and June 2003. Research Design This is an observational study based on Medicare administrative data. We adjust for observable differences in patient severity across post-acute care sites and we use instrumental variables estimation to account for unobserved patient selection. Study Outcomes Mortality, return to community residence, and total Medicare post-acute payments by 120 days after acute care discharge. Results Relative to discharge home, IRFs improve health outcomes for hip fracture patients. SNFs reduce mortality for hip fracture patients, but increase rates of institutionalization for stroke patients. Both sites of care are far more expensive than discharge to home. Conclusions When there is a choice between IRF and SNF care for stroke and hip fracture patients, the marginal patient is better off going to an IRF for post-acute care. However, given the marginal cost of an IRF stay compared to returning home, the gains to these patients should be considered in light of the additional costs.

Primary Care Providers Advising Smokers to Quit: Comparing Effectiveness Between Those With and Without Alcohol, Drug, or Mental Disorders

“…Instead, the findings indicate the effect among the subset of population (the "marginal patients") who received different treatments based on the randomization from the instrumental variables (Bao et al, 2006;Buntin, Colla, Deb, Sood, & Escarce, 2010). In our study, as in the prior study using similar instrumental variables, the ''marginal patients'' are those who were counseled on smoking cessation because their providers counseled them on exercise and carried the pattern to smoking cessation.…”

Mobile Tablet-Based Stroke Rehabilitation: Using mHealth Technology to Improve Access to Early Stroke Rehabilitation

“…These patients spend an average of eight extra days in acute care between the completion of acute therapy and assessments, and transfer to rehabilitation facilities [9], often due to resource limitations and shortages in rehabilitation spaces [10]. A similar pattern is seen in the United States with 24% of patients being transferred to inpatient rehabilitation after an average of 27 days from stroke onset [11] [12]. Patients experience significant down-time during their acute care stay, spending more than 50% of their time resting in bed and only 13% of time engaging in recovery [13].…”

Comprehensive versus consultative rehabilitation services postacute stroke: Outcomes differ

“…While the majority of studies document relative benefits in VAMCs [50] and private sector facilities [48][49], comprehensive rehabilitation in an IRF compared with a subacute rehabilitation unit in one study was associated with similar proportions of people being discharged to the community [45]. Home discharge can be influenced by factors outside the direct control of hospitalists, such as home accessibility and the availability of caregivers.…”

“…Nevertheless, PAC research shows improved functional recovery with admission to a specialized IRF over less intensive subacute or skilled nursing facilities [43,[45][46][47][48][49].…”