Rachel A Prusynski, Andrew Humbert, Harsha Amaravadi, Addie Middleton, Natalie E Leland, Debra Saliba, Cait Brown, Janet Freburger, Tracy M Mroz
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The mediator was average minutes of therapy per day (MTD) including all physical, occupational, and speech therapy minutes during the SNF stay.</p><p><strong>Setting: </strong>All US SNFs.</p><p><strong>Participants: </strong>3,534,928 post-acute SNF stays from January 2018 through September 2021.</p><p><strong>Interventions: </strong>Not applicable MAIN OUTCOME MEASURE(S): : Functional outcomes based on changes in activities of daily living (ADL) scores between SNF admission and discharge, measured by a validated 28-point scale: (1) ADL decline and (2) high ADL improvement (≥4 points improvement). Mediation analysis quantified effects of declining MTD on functional outcomes, adjusting for patient, facility, and community-level confounders.</p><p><strong>Results: </strong>Average MTD declined from 122.2 pre-PDPM to 96.5 post-PDPM and further to 87.7 during COVID-19. After PDPM implementation, the adjusted probability of ADL decline increased by 1.7 percentage points (pp) (95% CI 1.6, 1.7); during COVID-19, ADL decline increased by 3.7pp (95% CI 3.6, 3.7). Declining MTD mediated 47.9% of the increase in ADL decline post-PDPM and 26.5% during COVID-19. The adjusted probability of high ADL improvement increased by 1.3pp (95% CI 1.1, 1.3) post-PDPM and 1.0pp (95% CI 0.8, 1.0) during COVID-19. Declining MTD negatively mediated this increase in high ADL improvement by -2.9pp post-PDPM (95% CI -2.9, -2.9) and by -3.5 pp during COVID-19 (95% CI -3.6, -3.5).</p><p><strong>Conclusions: </strong>Declines in SNF therapy after PDPM implementation and during COVID-19 mediated substantial worsening in patient functional outcomes. 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引用次数: 0
摘要
目的：评估在实施患者驱动付费模式（PDPM）和COVID-19大流行期间，医疗保险按服务收费的熟练护理机构（SNF）患者治疗时间减少后功能结局的变化。我们还检验了治疗时间减少介导患者功能结果变化的假设。设计：采用中介分析的回顾性队列研究。暴露是PDPM实施（2019年10月）和COVID-19大流行（2020年3月）。调节因子为每日平均治疗分钟数（MTD），包括SNF期间所有物理、职业和言语治疗分钟数。设置：所有美国snf。参与者：2018年1月至2021年9月期间，3,534,928名急性SNF后住院。主要结局测量(S)：基于SNF入院和出院期间日常生活活动（ADL）评分变化的功能结局，采用有效的28分制测量：(1)ADL下降和(2)ADL高改善（≥4分改善）。中介分析量化了MTD下降对功能结果的影响，调整了患者、机构和社区水平的混杂因素。结果：平均MTD从pdpm前的122.2下降到pdpm后的96.5，并进一步下降到87.7。实施PDPM后，ADL下降的调整概率增加了1.7个百分点（pp） （95% CI 1.6, 1.7）；在COVID-19期间，ADL下降增加3.7个pp （95% CI 3.6, 3.7）。MTD下降介导了pdpm后ADL下降的47.9%和COVID-19期间26.5%。经调整的ADL高改善概率在pdpm后增加1.3pp (95% CI 1.1, 1.3)，在COVID-19期间增加1.0pp （95% CI 0.8, 1.0）。MTD下降负向介导了pdpm后-2.9pp （95% CI -2.9, -2.9）和COVID-19期间-3.5 pp （95% CI -3.6, -3.5）的ADL高改善增加。结论：实施PDPM后和COVID-19期间SNF治疗的下降介导了患者功能结局的实质性恶化。确保适当的治疗可以改善SNF患者的功能恢复。
Patient functional outcomes in skilled nursing facilities: the mediating role of declining therapy.
Objective: To estimate changes in functional outcomes in Medicare fee-for-service skilled nursing facility (SNF) patients after declines in therapy minutes that occurred after Patient-Driven Payment Model (PDPM) implementation and during the COVID-19 pandemic. We also tested the hypothesis that declines in therapy minutes mediated changes in patient functional outcomes.
Design: Retrospective cohort study using mediation analysis. Exposures were PDPM implementation (October 2019) and COVID-19 pandemic onset (March 2020). The mediator was average minutes of therapy per day (MTD) including all physical, occupational, and speech therapy minutes during the SNF stay.
Setting: All US SNFs.
Participants: 3,534,928 post-acute SNF stays from January 2018 through September 2021.
Interventions: Not applicable MAIN OUTCOME MEASURE(S): : Functional outcomes based on changes in activities of daily living (ADL) scores between SNF admission and discharge, measured by a validated 28-point scale: (1) ADL decline and (2) high ADL improvement (≥4 points improvement). Mediation analysis quantified effects of declining MTD on functional outcomes, adjusting for patient, facility, and community-level confounders.
Results: Average MTD declined from 122.2 pre-PDPM to 96.5 post-PDPM and further to 87.7 during COVID-19. After PDPM implementation, the adjusted probability of ADL decline increased by 1.7 percentage points (pp) (95% CI 1.6, 1.7); during COVID-19, ADL decline increased by 3.7pp (95% CI 3.6, 3.7). Declining MTD mediated 47.9% of the increase in ADL decline post-PDPM and 26.5% during COVID-19. The adjusted probability of high ADL improvement increased by 1.3pp (95% CI 1.1, 1.3) post-PDPM and 1.0pp (95% CI 0.8, 1.0) during COVID-19. Declining MTD negatively mediated this increase in high ADL improvement by -2.9pp post-PDPM (95% CI -2.9, -2.9) and by -3.5 pp during COVID-19 (95% CI -3.6, -3.5).
Conclusions: Declines in SNF therapy after PDPM implementation and during COVID-19 mediated substantial worsening in patient functional outcomes. Ensuring adequate therapy provision may improve functional recovery in SNF patients.
期刊介绍：
The Archives of Physical Medicine and Rehabilitation publishes original, peer-reviewed research and clinical reports on important trends and developments in physical medicine and rehabilitation and related fields. This international journal brings researchers and clinicians authoritative information on the therapeutic utilization of physical, behavioral and pharmaceutical agents in providing comprehensive care for individuals with chronic illness and disabilities.
Archives began publication in 1920, publishes monthly, and is the official journal of the American Congress of Rehabilitation Medicine. Its papers are cited more often than any other rehabilitation journal.
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