How much is postacute care use affected by its availability?
OBJECTIVE
To assess the relative impact of clinical factors versus nonclinical factors-such as postacute care (PAC) supply-in determining whether patients receive care from skilled nursing facilities (SNFs) or inpatient rehabilitation facilities (IRFs) after discharge from acute care.


METHODS
Medicare acute hospital, IRF, and SNF claims provided data on PAC choices; predictors of site of PAC chosen were generated from Medicare claims, provider of services, enrollment file, and Area Resource File data.


METHODS
We used multinomial logit models to predict PAC use by elderly patients after hospitalizations for stroke, hip fractures, or lower extremity joint replacements.


METHODS
A file was constructed linking acute and postacute utilization data for all medicare patients hospitalized in 1999.


RESULTS
PAC availability is a more powerful predictor of PAC use than the clinical characteristics in many of our models. The effects of distance to providers and supply of providers are particularly clear in the choice between IRF and SNF care. The farther away the nearest IRF is, and the closer the nearest SNF is, the less likely a patient is to go to an IRF. Similarly, the fewer IRFs, and the more SNFs, there are in the patient's area the less likely the patient is to go to an IRF. In addition, if the hospital from which the patient is discharged has a related IRF or a related SNF the patient is more likely to go there.


CONCLUSIONS
We find that the availability of PAC is a major determinant of whether patients use such care and which type of PAC facility they use. Further research is needed in order to evaluate whether these findings indicate that a greater supply of PAC leads to both higher use of institutional care and better outcomes-or whether it leads to unwarranted expenditures of resources and delays in returning patients to their homes.
Buntin
Melinda Beeuwkes
MB
RAND Health, 1200 South Hayes St., Arlington, VA 22202, USA.
Garten
Anita Datar
AD
Paddock
Susan
S
Saliba
Debra
D
Totten
Mark
M
Escarce
José J
JJ
D000359:Aftercare / Q000458:organization & administration / Q000706:statistics & numerical data*; D000368:Aged; D019643:Arthroplasty, Replacement / Q000534:rehabilitation; D002391:Catchment Area, Health; D003266:Continuity of Patient Care / Q000706:statistics & numerical data*; D006297:Health Services Accessibility; D006302:Health Services Research; D006620:Hip Fractures / Q000534:rehabilitation; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D015999:Multivariate Analysis; D010351:Patient Discharge / Q000706:statistics & numerical data; D012047:Rehabilitation Centers / Q000706:statistics & numerical data* / Q000600:supply & distribution; D012189:Retrospective Studies; D012866:Skilled Nursing Facilities / Q000706:statistics & numerical data* / Q000600:supply & distribution; D000071939:Stroke Rehabilitation; D019467:Subacute Care / Q000458:organization & administration / Q000706:statistics & numerical data*; D014186:Transportation; D014481:United States; D014600:Utilization Review