State-of-the-science on postacute rehabilitation: setting a research agenda and developing an evidence base for practice and public policy. an introduction

Association Between Time to Rehabilitation and Outcomes After Traumatic Spinal Cord Injury

OBJECTIVE

To examine the relations between time to rehabilitation after spinal cord injury (SCI) and rehabilitation outcomes at discharge and 1-year postinjury.

DESIGN

Retrospective cohort study.

SETTING

Facilities designated as Spinal Cord Injury Model Systems.

PARTICIPANTS

Patients (N=3937) experiencing traumatic SCI between 2000 and 2014, who were 18 years or older, and who were admitted to a model system within 24 hours of injury.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Rasch-transformed FIM motor score at discharge and 1-year postinjury, discharge to a private residence, and the Craig Handicap Assessment and Reporting Technique (CHART) Physical Independence and Mobility scores at 1-year postinjury.

RESULTS

After accounting for health status, a 10% increase in time to rehabilitation was associated with a 1.50 lower FIM motor score at discharge (95% confidence interval [CI], -2.43 to -0.58; P=.001) and a 3.92 lower CHART Physical Independence score at 1-year postinjury (95% CI, -7.66 to -0.19; P=.04). Compared to the mean FIM motor score (37.5) and mean CHART Physical Independence score (74.7), the above-mentioned values represent relative declines of 4.0% and 5.3%, respectively. There was no association between time to rehabilitation and discharge to a private residence, 1-year FIM motor score, or the CHART mobility score.

CONCLUSIONS

Earlier rehabilitation after traumatic SCI may improve patients' functional status at discharge.

Disparities in post-acute rehabilitation care for joint replacement

OBJECTIVE

To determine the extent to which demographic and geographic disparities exist in the use of post-acute rehabilitation care (PARC) for joint replacement.

METHODS

We conducted a cross-sectional analysis of 2 years (2005 and 2006) of population-based hospital discharge data from 392 hospitals in 4 states (Arizona, Florida, New Jersey, and Wisconsin). A total of 164,875 individuals who were age ≥ 45 years, admitted to the hospital for a hip or knee joint replacement, and who survived their inpatient stay were identified. Three dichotomous dependent variables were examined: 1) discharge to home versus institution (i.e., skilled nursing facility [SNF] or inpatient rehabilitation facility [IRF]), 2) discharge to home with versus without home health (HH), and 3) discharge to an SNF versus an IRF. Multilevel logistic regression analyses were conducted to identify demographic and geographic disparities in PARC use, controlling for illness severity/comorbidities, hospital characteristics, and PARC supply. Interactions among race, socioeconomic, and geographic variables were explored.

RESULTS

Considering PARC as a continuum from more to less intensive care in regard to hours of rehabilitation per day (e.g., IRF→SNF→HH→no HH), the uninsured received less intensive care in all 3 models. Individuals receiving Medicaid and those of lower socioeconomic status received less intensive care in the HH versus no HH and SNF versus IRF models. Individuals living in rural areas received less intensive care in the institution versus home and HH versus no HH models. The effect of race was modified by insurance and by state. In most instances, minorities received less intensive care. PARC use varied by hospital.

CONCLUSION

Efforts to further understand the reasons behind these disparities and their effect on outcomes are needed.

Inpatient Rehabilitation Facilities

When Medicare implemented a prospective payment system (PPS) for inpatient rehabilitation facilities (IRFs) in 2002, a lack of organizational research on IRFs hampered the ability to predict how providers would modify their behavior in response to the PPS. This study consists of 36 key informant interviews that examined the experiences of nine IRFs in the lead-up to and aftermath of the IRF-PPS. Drawing on earlier work by Oliver, the authors develop a taxonomy of the new organizational practices that IRFs adopted in response to the changing payment system. A model of key organizational and environmental characteristics that predict the adoption of these practices based on an IRF’s willingness and/or capacity to comply with institutional pressure is then proposed. The proposed model can also be applied to other regulatory changes affecting IRFs.