Disparities in Postacute Rehabilitation Care for Stroke: An Analysis of the State Inpatient Databases

Cecil G. Sheps Center for HealthServices Research, University of North Carolina at Chapel Hill, 725 Martin Luther King Jr. Blvd., Chapel Hill, NC 27599-7590, USA.
Archives of physical medicine and rehabilitation (Impact Factor: 2.57). 08/2011; 92(8):1220-9. DOI: 10.1016/j.apmr.2011.03.019
Source: PubMed


To determine the extent to which sociodemographic and geographic disparities exist in the use of postacute rehabilitation care (PARC) after stroke.
Cross-sectional analysis of data for 2 years (2005-2006) from the State Inpatient Databases.
All short-term acute-care hospitals in 4 demographically and geographically diverse states.
Individuals (age, ≥45y; mean age, 72.6y) with a primary diagnosis of stroke who survived their inpatient stay (N=187,188). The sample was 52.4% women, 79.5% white, 11.4% black, and 9.1% Hispanic.
Not applicable.
(1) Discharge to an institution versus home. (2) For those discharged to home, receipt of home health (HH) versus no HH care. (3) For those discharged to an institution, receipt of inpatient rehabilitation facility (IRF) or skilled nursing facility (SNF) care. Multilevel logistic regression analyses were conducted to identify sociodemographic and geographic disparities in PARC use, controlling for illness severity/comorbid conditions, hospital characteristics, and PARC supply.
Blacks, women, older individuals, and those with lower incomes were more likely to receive institutional care; Hispanics and the uninsured were less likely. Racial minorities, women, older individuals, and those with lower incomes were more likely to receive HH care; uninsured individuals were less likely. Blacks, women, older individuals, the uninsured, and those with lower incomes were more likely to receive SNF versus IRF care. PARC use varied significantly by hospital and geographic location.
Several sociodemographic and geographic disparities in PARC use were identified.

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    • "Given the lack of efficient objective tools, the process of selecting patients for rehabilitation becomes a matter of combining clinical judgment with various nonclinical considerations, such as the distance of the patient’s home from the rehabilitation facility, the type of admitting ward (e.g., orthopedic or geriatric ward) and the patient’s socio-demographic factors. The influence of these non-clinical factors on the decision-making process can lead to inequities in access to rehabilitation [25,30]. "
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    ABSTRACT: Medical events, such as stroke, limb fractures, joint replacements and spinal injuries, can lead to acute functional disability at all ages and to chronic disability, especially among the elderly. Rehabilitation is, therefore, essential for the prevention of permanent disability among older individuals. There are international practice guidelines for stroke and hip fracture management, including recommendations that rehabilitation services be an integral part of the provision of treatment in either an inpatient setting or in the community. There are no organized data on provision of rehabilitation services in Israel or on the distribution of these services throughout the country. Such information would be of great assistance in designing these services where they are needed and in making changes in the existing ones where necessary. Patients aged 65 years or older with stroke or hip fracture were identified through one-day surveys conducted in 2009--2010 in all 26 acute care hospitals in Israel. Data on inpatient and ambulatory rehabilitation services were collected from discharge medical summaries, telephone interviews with the patients or their relatives and reports from the healthcare provider. The extent of rehabilitation services was described and the association between receipt of inpatient rehabilitation and the geographic district based on the patients' listed address was examined in a multivariate analysis. A total of 570 patients with stroke and 768 patients with hip fracture were identified and interviews were conducted in regards to 421 and 672 respectively. Out of the stroke patients 238(56.5%) received inpatient rehabilitation, 46(10.9%) received ambulatory rehabilitation treatment without inpatient phase and 137 (32.5%) received no rehabilitation. In fracture these rates were 494(73.5%), 96(14.3%) and 82(12.2%) respectively. Patients living in districts with lower availability of rehabilitation beds were less likely to receive inpatient rehabilitation after controlling for patient characteristics. Regional disparities in the provision of inpatient rehabilitation care for elderly after an acute episode of stroke or hip fracture were identified and could be partially attributed to the distribution of rehabilitation beds. These findings highlight the need to plan the rehabilitation resources based on the population needs and to routinely monitor the provision of these services.
    Israel Journal of Health Policy Research 07/2013; 2(1):27. DOI:10.1186/2045-4015-2-27

  • Physical Therapy 01/2012; 93(1):104-114. DOI:10.2522/ptj.20120175 · 2.53 Impact Factor
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    ABSTRACT: Utilization of postacute care is associated with improved poststroke outcomes. However, more than 20% of American adults under age 65 are uninsured. We sought to determine whether insurance status is associated with utilization and intensity of institutional postacute care among working age stroke survivors. A retrospective cross-sectional study of ischemic stroke survivors under age 65 from the 2004-2006 Nationwide Inpatient Sample was conducted. Hierarchical logistic regression models controlling for patient and hospital-level factors were used. The primary outcome was utilization of any institutional postacute care (inpatient rehabilitation or skilled nursing facilities) following hospital admission for ischemic stroke. Intensity of rehabilitation was explored by comparing utilization of inpatient rehabilitation facilities and skilled nursing facilities. Of the 33,917 working age stroke survivors, 19.3% were uninsured, 19.8% were Medicaid enrollees, and 22.8% were discharged to institutional postacute care. Compared to those privately insured, uninsured stroke survivors were less likely (adjusted odds ratio [AOR] 0.53, 95% confidence interval [CI] 0.47-0.59) while stroke survivors with Medicaid were more likely to utilize any institutional postacute care (AOR = 1.40, 95% CI 1.27-1.54). Among stroke survivors who utilized institutional postacute care, uninsured (AOR = 0.48, 95% CI 0.36-0.64) and Medicaid stroke survivors (AOR = 0.27, 95% CI 0.23-0.33) were less likely to utilize an inpatient rehabilitation facility than a skilled nursing facility compared to privately insured stroke survivors. Insurance status among working age acute stroke survivors is independently associated with utilization and intensity of institutional postacute care. This may explain differences in poststroke outcomes among uninsured and Medicaid stroke survivors compared to the privately insured.
    Neurology 05/2012; 78(20):1590-5. DOI:10.1212/WNL.0b013e3182563bf5 · 8.29 Impact Factor
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