title: Impact of state Medicaid coverage on utilization of inpatient rehabilitation facilities among patients with stroke.
abstract: OBJECTIVE
  Poststroke rehabilitation is associated with improved outcomes. Medicaid coverage of inpatient rehabilitation facility (IRF) admissions varies by state. We explored the role of state Medicaid IRF coverage on IRF utilization among patients with stroke.
  
  
  METHODS
  Working age ischemic stroke patients with Medicaid were identified from the 2010 Nationwide Inpatient Sample. Medicaid coverage of IRFs (yes versus no) was ascertained. Primary outcome was discharge to IRF (versus other discharge destinations). We fit a logistic regression model that included patient demographics, Medicaid coverage, comorbidities, length of stay, tissue-type plasminogen activator use, state Medicaid IRF coverage, and the interaction between patient Medicaid status and state Medicaid IRF coverage while accounting for hospital clustering.
  
  
  RESULTS
  Medicaid did not cover IRFs in 4 (TN, TX, SC, WV) of 42 states. The impact of State Medicaid IRF coverage was limited to Medicaid stroke patients (P for interaction <0.01). Compared with Medicaid stroke patients in states with Medicaid IRF coverage, Medicaid stroke patients hospitalized in states without Medicaid IRF coverage were less likely to be discharged to an IRF of 11.6% (95% confidence interval, 8.5%-14.7%) versus 19.5% (95% confidence interval, 18.3%-20.8%), P<0.01 after full adjustment.
  
  
  CONCLUSIONS
  State Medicaid coverage of IRFs is associated with IRF utilization among stroke patients with Medicaid. Given the increasing stroke incidence among the working age and Medicaid expansion under the Affordable Care Act, careful attention to state Medicaid policy for poststroke rehabilitation and analysis of its effects on stroke outcome disparities are warranted.
authors.affiliation: From the Stroke Program (L.E.S., J.F.B., L.B.M., W.J.M., E.E.A., L.D.L.) and Departments of Neurology (L.E.S., J.F.B., L.B.M., E.E.A., K.A.K., B.C.C.), Epidemiology (L.B.M., L.D.L.), and Emergency Medicine (L.B.M., W.J.M.), University of Michigan, Ann Arbor. lerusche@umich.edu.
authors.forename: Lesli E
authors.initials: LE
authors.lastname: Skolarus
authors.affiliation: From the Stroke Program (L.E.S., J.F.B., L.B.M., W.J.M., E.E.A., L.D.L.) and Departments of Neurology (L.E.S., J.F.B., L.B.M., E.E.A., K.A.K., B.C.C.), Epidemiology (L.B.M., L.D.L.), and Emergency Medicine (L.B.M., W.J.M.), University of Michigan, Ann Arbor.
authors.forename: James F
authors.initials: JF
authors.lastname: Burke
authors.affiliation: From the Stroke Program (L.E.S., J.F.B., L.B.M., W.J.M., E.E.A., L.D.L.) and Departments of Neurology (L.E.S., J.F.B., L.B.M., E.E.A., K.A.K., B.C.C.), Epidemiology (L.B.M., L.D.L.), and Emergency Medicine (L.B.M., W.J.M.), University of Michigan, Ann Arbor.
authors.forename: Lewis B
authors.initials: LB
authors.lastname: Morgenstern
authors.affiliation: From the Stroke Program (L.E.S., J.F.B., L.B.M., W.J.M., E.E.A., L.D.L.) and Departments of Neurology (L.E.S., J.F.B., L.B.M., E.E.A., K.A.K., B.C.C.), Epidemiology (L.B.M., L.D.L.), and Emergency Medicine (L.B.M., W.J.M.), University of Michigan, Ann Arbor.
authors.forename: William J
authors.initials: WJ
authors.lastname: Meurer
authors.affiliation: From the Stroke Program (L.E.S., J.F.B., L.B.M., W.J.M., E.E.A., L.D.L.) and Departments of Neurology (L.E.S., J.F.B., L.B.M., E.E.A., K.A.K., B.C.C.), Epidemiology (L.B.M., L.D.L.), and Emergency Medicine (L.B.M., W.J.M.), University of Michigan, Ann Arbor.
authors.forename: Eric E
authors.initials: EE
authors.lastname: Adelman
authors.affiliation: From the Stroke Program (L.E.S., J.F.B., L.B.M., W.J.M., E.E.A., L.D.L.) and Departments of Neurology (L.E.S., J.F.B., L.B.M., E.E.A., K.A.K., B.C.C.), Epidemiology (L.B.M., L.D.L.), and Emergency Medicine (L.B.M., W.J.M.), University of Michigan, Ann Arbor.
authors.forename: Kevin A
authors.initials: KA
authors.lastname: Kerber
authors.affiliation: From the Stroke Program (L.E.S., J.F.B., L.B.M., W.J.M., E.E.A., L.D.L.) and Departments of Neurology (L.E.S., J.F.B., L.B.M., E.E.A., K.A.K., B.C.C.), Epidemiology (L.B.M., L.D.L.), and Emergency Medicine (L.B.M., W.J.M.), University of Michigan, Ann Arbor.
authors.forename: Brian C
authors.initials: BC
authors.lastname: Callaghan
authors.affiliation: From the Stroke Program (L.E.S., J.F.B., L.B.M., W.J.M., E.E.A., L.D.L.) and Departments of Neurology (L.E.S., J.F.B., L.B.M., E.E.A., K.A.K., B.C.C.), Epidemiology (L.B.M., L.D.L.), and Emergency Medicine (L.B.M., W.J.M.), University of Michigan, Ann Arbor.
authors.forename: Lynda D
authors.initials: LD
authors.lastname: Lisabeth
mesh_terms: D002545:Brain Ischemia / Q000188:drug therapy / Q000191:economics / Q000534:rehabilitation*; D005260:Female; D005343:Fibrinolytic Agents / Q000191:economics / Q000627:therapeutic use; D006801:Humans; D007297:Inpatients; D007902:Length of Stay; D008297:Male; D008484:Medicaid / Q000191:economics* / Q000706:statistics & numerical data; D008875:Middle Aged; D010351:Patient Discharge; D012047:Rehabilitation Centers / Q000191:economics* / Q000706:statistics & numerical data; D012189:Retrospective Studies; D020521:Stroke / Q000188:drug therapy / Q000191:economics; D000071939:Stroke Rehabilitation; D010959:Tissue Plasminogen Activator / Q000191:economics / Q000627:therapeutic use; D016896:Treatment Outcome; D014481:United States
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator
keywords: Medicaid; rehabilitation; stroke