Researchers Call for Standardizing Acute Care Rehab for Poststroke Patients

Researchers taking a look at hospital-based rehabilitation programs found that not all rehabilitation is equal for acute care hospital patients with ischemic stroke.  According to research findings published in the May 2019 issue of Physical Therapy, the researchers found “significant variation” in the use of hospital-based rehabilitation services that “suggest a timely opportunity to standardize rehabilitation service delivery in acute settings for patients with ischemic stroke.”
The researchers note that while current guidelines recommend early mobilization during hospitalization for ischemic stroke, the researchers in the published study note, they do not “provide clear recommendations on the optimal dosage of therapy.” This, combined with no incentive for hospitals to report on functional status to the US Centers for Medicare and Medicaid Services (CMS), led researchers to examine Medicare claims data from 104,295 patients in 2010 to identify what factors were associated with the type and amount of rehabilitation services patients received while in acute care settings.
The study, entitled “Variation in Hospital-Based Rehabilitation Services Among Patients with Ischemic Stroke in the United States,” found that only 85.2 percent received any rehabilitation services: 61.5 percent received both physical and occupational therapy; 22 percent received only physical therapy; and 1.7 percent received only occupational therapy.
The researchers say that patients in the study were more likely to receive any type of rehabilitation services if they were older than 70 years of age, had longer lengths of stay, or had received tissue plasminogen activator (tPA).
Patients were 16 percent less likely to receive rehabilitation services if they were dual-eligible for both Medicare and Medicaid, and 11 percent less likely if they had a recent prior history of hospitalization, say the researchers, noting that male patients were less likely to receive therapy, and patients with more severe stroke—who required an ICU stay or feeding tube—were significantly less likely to receive rehabilitation services.
The researchers also found a variation in the number of minutes of therapy patients received. While the study’s patients received an average of 123 minutes of therapy over 4.8 days, they noted in the published article, “dual-eligible patients received 5 minutes less therapy compared with non–dual-eligible patients, and patients receiving tPA received 16 more minutes of therapy.” Patients with a feeding tube received 5 more minutes of therapy than those without, on average, they say.
According to the researchers, certain hospital characteristics played a role in impact the rehabilitation of the patient.  For instance, rural hospitals, hospitals with a higher volume of patients with stroke, and hospitals with an inpatient rehabilitation unit were linked to a higher likelihood of receiving rehabilitation services. However, patients who received rehabilitation services in a limited teaching hospital or nonteaching hospital received an average 19 and 20 more minutes of therapy, respectively.
The researchers also found that substantial variability in use of rehabilitation services across acute care hospitals, even after accounting for length of stay and other patient and hospital-level factors. About 38 percent of hospitals provided significantly less (76.3 minutes during the whole length of stay) than the national average of rehabilitation services minutes (123 minutes), whereas 22.4 percent provided significantly more (180.7 minutes) than the national average.
A number of factors may contribute to this variation, say the researchers, including a “lack of clear guidance on rehabilitation timing and dosage in the acute care setting” and a hospital reimbursement policy that cuts costs by decreasing length of stay and rehabilitation services.
But hospitals with inpatient rehabilitation units were more likely to deliver rehabilitation services to these patients, possibly because they are specialized in providing comprehensive care, and therapists “can be proponents of providing upstream rehabilitation interventions to improve downstream outcomes.”

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