Rehabilitation and Regenerative Medicine

Selecting rehabilitation level of care:

Can we achieve consensus?

Joel Stein, MD

R e h a b i l i t a t i o n a n d R e g e n e r a t i v e M e d i c i n e

Disclosures

• None specifically related to this presentation

• Research support from Nexstim, Tibion, Myomo, Tyromotion

• Member of Scientific Advisory Board - Myomo, Inc. (uncompensated)

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Session Structure• Introduction – Joel Stein, MD• IRF vs. SNF Outcomes – Randie Black-Schaffer, MD• Breakout sessions to review cases• Report back from small groups• Physiatry survey results re: Discharge destination –

David Cormier, DO• Panel Discussion – Alyse Sicklick, MD

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Levels of Rehabilitation• Inpatient Rehabilitation Facility (IRF, Acute

Rehab)• Skilled Nursing Facility (SNF, Subacute

Rehab)• Long Term Acute Care Hospital (LTACH)• Home Care Services• Outpatient

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IRF vs. SNF: Why it matters• IRF care is more expensive. (But costs of long-term care,

institutionalization and dependence are externalities from payor perspective).

• IRF care may result in better outcomes• Considerable variation in utilization of these services exists• CMS, private payors, and now ACO’s will continue to seek

to minimize the costs of post-acute stroke care• Stroke patients represent the single largest group of

patients in IRF’s – 20% of total• No clear standards exist to help clinicians determine who

would benefit from which type of care

Where would you want your family member to receive stroke rehabilitation?

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Medicare FFS spending on post-acute care

Data Book: Health Care Spending and the Medicare Program. MedPac, June 2012. http://www.medpac.gov/document_TOC.cfm?id=617

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State Variation in Stroke Discharge Destination (2002-2004)

Top 10 IRF users (FFS Medicare)

State Discharge Rank Discharge Rank Any IRF Rank to IRF to SNF Inpatient as a % of

InpatientNevada 30% (1) 15% (50) 50% 59% (1)Arkansas 28% (2) 20% (47) 49% 57% (2)Louisiana 27% (3) 14% (51) 52% 53% (5)Oklahoma 26% (4) 19% (48) 49% 53% (3)Arizona 24% (5) 21% (44) 46% 53% (4)Pennsylvania 23% (6) 30% (21) 54% 43% (14)North Dakota 23% (7) 27% (34) 50% 45% (10)Kansas 23% (8) 21% (43) 45% 50% (6)Texas 22% (9) 21% (46) 49% 46% (8)New Hampshire 22% (10) 27% (33) 50% 45% (11)Kramer A, Holthaus D., et al. Study of Stroke Post-Acute Care and Outcomes: Final Report. Aurora, CO.

Division of Health Care Policy and Research, University of Colorado at Denver and Health Sciences Center, 2006. http://aspe.hhs.gov/daltcp/reports/2006/strokePAC.htm

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State Variation in Stroke Discharge Destination (2002-2004)

Bottom 10 IRF users (FFS Medicare)

State Discharge Rank Discharge Rank Any IRF Rank to IRF to SNF Inpatient as a % of

InpatientVirginia 15% (42) 30% (20) 45% 33% (38)Minnesota 14% (43) 35% (4) 50% 28% (47)Florida 14% (44) 33% (10) 48% 30% (46)Alabama 14% (45) 28% (30) 43% 32% (41)Nebraska 13% (46) 29% (23) 47% 28% (48)Vermont 13% (47) 30% (19) 43% 30% (45)Iowa 13% (48) 29% (22) 42% 30% (44)Connecticut 12% (49) 40% (1) 56% 22% (50)Oregon 11% (50) 33% (8) 45% 25% (49)Maryland 4% (51) 35% (3) 39% 10% (51)

Kramer A, Holthaus D., et al. Study of Stroke Post-Acute Care and Outcomes: Final Report. Aurora, CO. Division of Health Care Policy and Research, University of Colorado at Denver and Health Sciences

Center, 2006. http://aspe.hhs.gov/daltcp/reports/2006/strokePAC.htm

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How much is Postacute Care Use Affected by its Availability?

• Nationwide retrospective study of all Medicare patients with stroke, hip fracture or LE Joint replacements in 1999

• Limited to administrative data set• Clinical factors were important in whether

IRF/SNF were utilized, but the selection of IRF vs. SNF was most strongly influenced by geographical proximity – both distance to nearest facility, and number of facilities in the area

Buntin MB, Garten AD, Paddock S, Saliba D, Totten M, Escarce JJ. How much is Postacute care use affected by availability. Health Services Research 40:413-434, 2005.

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IRF vs. SNF care by Age (1999 Medicare FFS Data)

Kramer A, Holthaus D., et al. Study of Stroke Post-Acute Care and Outcomes: Final Report. Aurora, CO. Division of Health Care Policy and Research, University of

Colorado at Denver and Health Sciences Center, 2006. http://aspe.hhs.gov/daltcp/reports/2006/strokePAC.htm

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The definitive answer: A Randomized Trial of IRF vs. SNF

• Most definitive answer to this question• Randomize stroke patients (perhaps within a certain

range of disability) to either SNF or IRF• Ethical concerns • Expensive• Unclear who would fund• Difficult to convince patients/families/clinicians

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Conclusions• The selection of IRF vs. SNF is of substantial importance for

stroke patients• No clear standards exist to guide selection of post-acute

rehabilitation. • Non-clinical factors seem to play an important role in

determining where patients get their rehab• Cost pressures appear likely to drive more patients to SNF• Observational studies are inherently limited in their ability

to determine which is best, and who should go where• Achieving consensus among rehabilitation clinicians would

be an important first step.