Geographic and facility variation in inpatient stroke rehabilitation: multilevel analysis of functional status.
OBJECTIVE
To examine geographic and facility variation in cognitive and motor functional outcomes after postacute inpatient rehabilitation in patients with stroke.


METHODS
Retrospective cohort design using Centers for Medicare and Medicaid Services (CMS) claims files. Records from 1209 rehabilitation facilities in 298 hospital referral regions (HRRs) were examined. Patient records were analyzed using linear mixed models. Multilevel models were used to calculate the variation in outcomes attributable to facilities and geographic regions.


METHODS
Inpatient rehabilitation units and facilities.


METHODS
Patients (N=145,460) with stroke discharged from inpatient rehabilitation from 2006 through 2009.


METHODS
Not applicable.


METHODS
Cognitive and motor functional status at discharge measured by items in the CMS Inpatient Rehabilitation Facility-Patient Assessment Instrument.


RESULTS
Variation profiles indicated that 19.1% of rehabilitation facilities were significantly below the mean functional status rating (mean ± SD, 81.58±22.30), with 221 facilities (18.3%) above the mean. Total discharge functional status ratings varied by 3.57 points across regions. Across facilities, functional status values varied by 29.2 points, with a 9.1-point difference between the top and bottom deciles. Variation in discharge motor function attributable to HRR was reduced by 82% after controlling for cluster effects at the facility level.


CONCLUSIONS
Our findings suggest that variation in motor and cognitive function at discharge after postacute rehabilitation in patients with stroke is accounted for more by facility than geographic location.
Department of Occupational Therapy, University of Texas Medical Branch, Galveston, TX. Electronic address: tareiste@utmb.edu.
Timothy A
TA
Reistetter
Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX.
Yong-Fang
YF
Kuo
Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX.
Amol M
AM
Karmarkar
Internal Medicine-Division of Geriatrics, University of Texas Medical Branch, Galveston, TX.
Karl
K
Eschbach
Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX.
Srinivas
S
Teppala
Internal Medicine-Division of Geriatrics, University of Texas Medical Branch, Galveston, TX.
Jean L
JL
Freeman
Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX.
Kenneth J
KJ
Ottenbacher
D000203:Activities of Daily Living; D000368:Aged; D000369:Aged, 80 and over; D003071:Cognition; D005260:Female; D006801:Humans; D007297:Inpatients; D007345:Insurance Claim Review / Q000706:statistics & numerical data; D007902:Length of Stay; D008297:Male; D006278:Medicare / Q000706:statistics & numerical data; D055361:Multilevel Analysis; D020127:Recovery of Function; D012047:Rehabilitation Centers / Q000458:organization & administration*; D012189:Retrospective Studies; D000071939:Stroke Rehabilitation; D014481:United States
Health policy; Health services; Outcome assessment (health care); Quality indicators, health care; Rehabilitation