20 percent difference in community discharge rates across regions

Researchers at the University of Texas Medical Branch at Galveston have found that rehabilitation outcomes for people who have had a stroke vary greatly depending on where they live in the United States.

The study, recently published in the journal Archives of Physical Medicine and Rehabilitation, examined Centers for Medicare and Medicaid Services records from 143,036 patients discharged from inpatient rehabilitation during 2006 and 2007. Researchers focused on length of stay, functional status (discharge motor and cognitive status, overall functional change) and the percentage of patients discharged to the community.

People who have had a stroke represent the largest impairment group of Medicare beneficiaries receiving inpatient medical rehabilitation services in the United States.

Discharge to the community has been identified as an important outcome and quality indicator for inpatient rehabilitation.

The study found a 20 percent difference in community discharge rates across regions. The region with the highest percentage of community discharge was the Southwest (79.1 percent), while the lowest region was the Northeast (59.4 percent). These two regions represent diverse geographic areas with different types and availability of resources to assist individuals attempting to reintegrate into the community after a stroke.

“Understanding how geographic variability is associated with outcomes will help rehabilitation professionals and administrators implement practice guidelines and quality improvement programs designed to improve care in areas with poor outcomes,” said lead author Timothy Reistetter, an associate professor in the Department of Occupational Therapy at UTMB. “An important step in this process is to describe region-specific outcomes of rehabilitative care at the national level.” 

The study also found that length of stay varied by 2.1 days, with the Northeast region having the longest at 18.3 days and the Midwest and Southwest regions having the shortest at 16.2 days.

Substantial variation in discharge destination and length of stay remained after adjusting for demographic and clinical characteristics. Minimizing regional variation by improving care in lower performing regions has been shown to lead to higher quality and patient satisfaction in acute care settings. As health care reforms are implemented, more research to develop strategies for care transition will be crucial.

“Our study is an initial step to better understanding how process, structure and outcomes vary geographically for inpatient medical rehabilitation services,” said Reistetter.

There is variation nationally in the availability of inpatient rehabilitation facilities. The four states with the highest number of IRFs are Texas, California, Pennsylvania and New York. Each has between 70 and 90 facilities, while Wyoming, West Virginia, Vermont and Delaware each has less than five. The impact of these geographic differences on rehabilitation outcomes is largely unknown. There is currently a heightened emphasis on reducing regional variation as part of health care reform.

The study’s co-authors are Kenneth J. Ottenbacher, Amol M. Karmarkar and James E. Graham of UTMB’s Division of Rehabilitation Sciences; Karl Eschbach, Jean Freeman and Yong-Fang Kuo of UTMB’s Sealy Center on Aging and Division of Geriatrics, Department of Internal Medicine; and Dr. Carl V. Granger, Uniform Data System for Medical Rehabilitation, Buffalo, NY. 

Funding for the study was provided by the National Institute of Child Health and Human Development, National Institutes of Health; the Institute for Translational Sciences at the University of Texas Medical Branch with support in part by a National Institutes of Health Clinical and Translational Science Award; the Agency for Healthcare Research and Quality; and the National Institutes of Health.