Comparative Effectiveness of Inpatient Rehabilitation Versus Skilled Nursing Facilities for Stroke and Hip Fracture Patients.

Abstract

Background: Prior research suggests discharge to inpatient rehabilitation facilities (IRF) leads to improved outcomes for stroke and hip fracture patients relative to skilled nursing facilities (SNF), while incurring greater costs. However, these estimates are likely biased by non-random patient selection.

Methods: We used a quasi-experimental design to compare post-acute care outcomes among Medicare beneficiaries hospitalized for stroke or hip fracture in 55 US hospitals that closed their IRF units between 2009 and 2017. Primary and secondary outcomes were 30-, 90-, and 180-day readmission and mortality, and successful community discharge.

Results: Among 10,761 stroke and 13,963 hip fracture hospitalizations, IRF discharge declined sharply, offset by increases to SNF and home health. Relative to IRF, SNF discharge was associated with no significant differences in readmissions but an increase in 90-day mortality for stroke (+6.5%, 95% CI 1.5%-11.4%) and hip fracture (+5.8%, 95% CI 2.5%-9.0%). Successful community discharge did not differ for patients redirected to SNF, but stroke patients redirected to home health had significantly higher rates of successful discharge (DID estimate: +6.8%; 95% CI 0.1%-13.5%). The protective effect of IRF was concentrated within 20 days post-discharge.

Conclusions: Following hospitalization for stroke and hip fracture, discharge to an IRF was associated with lower mortality relative to SNF. However, given the potential for unmeasured confounding, this association should be interpreted with caution. Careful post-acute care referral protocols are critical to ensure good patient outcomes.