Kramer A, Kowalsky J, Lin M, Grigsby J, Hughes R, Steiner J. Outcome and utilization differences for older persons with stroke in HMO and fee-for-services systems.

Kramer A, Kowalsky J, Lin M, Grigsby J, Hughes R, Steiner J. Outcome and utilization differences for older persons with stroke in HMO and fee-for-services systems. J Am Geriatr Soc. 2000 July; 48(7): 726-734.

The title of this article did not suggest a direct comparison of acute rehabilitation and SNFs, but the study did compare the two indirectly by way of comparing outcomes and utilization of rehabilitation services for patients with Medicare insurance coverage through a health maintenance organization (HMO) versus fee-for-service (FFS) plans. The authors reported that 85.3% of patients with FFS insurance were discharged from the hospital to an acute rehabilitation facility compared with only 12.8% of patients with HMO insurance. I interpreted these results to imply that patients with FFS insurance are more likely to receive rehabilitation in an acute rehabilitation facility, whereas patients served through an HMO are more likely to receive rehabilitation in a SNF. In my analysis of this article, therefore, I used FFS interchangeably with acute rehabilitation and HMO interchangeably with SNF rehabilitation.

My patient was similar to the sample of patients in this study, including having: a diagnosis of stroke, an age greater than 65 years, Medicare coverage, an acute hospital stay within the previous 30 days of admission to rehabilitation, and no prior SNF or rehabilitation hospital admission for the current stroke. Of the 429 subjects in this study, 96 patients died during the study; however, the authors stated that the deceased subjects were comparable to the remaining sample (n=333). Both groups were similar at admission to rehabilitation, except that the HMO group (n=236) had better social support and the FFS group (n=193) had more subjects who were blind and had more psychiatric diagnoses. Adjusting for those covariates, Kramer et al reported that the FFS group had significantly greater improvement in Katz Index of ADL scores (a measure of function in ADLs) and FIM scores at discharge from rehabilitation. There was no significant difference between groups in the number of ADLs recovered to the premorbid level of function at follow-up. The likelihood of residing in the community was greater for the FFS group at 9 and 12 months despite the fact that the HMO group received a greater number of physical therapy and occupational therapy visits during the year after discharge from rehabilitation. Although this study demonstrated functional improvement after rehabilitation, the type of Medicare insurance or rehabilitation setting did not appear to influence the number of ADLs recovered to premorbid functional level during the year following discharge from rehabilitation. In spite of this, patients receiving rehabilitation at an acute rehabilitation hospital were 1.8 times more likely to return to community residence and less likely to reside in a nursing home.

In my critique of this study, I noted potential limitations in how the authors measured changes in .M)L status. In comparing ADL status within each group at follow-up, the authors limited their outcome measures to a self-report tool and a method of counting the number of ADLs that returned to a person's premorbid level only. This may have underestimated the differences between groups. In addition, the authors failed to report reliability and validity for these measurements as well as power for the statistical analysis. Given the outcome measures that were used, the FFS group made larger gains in ADLs compared with the HMO group at the completion of the rehabilitation period. The lack of a performance measure that was more sensitive to change, however, may have limited the authors' ability to detect greater differences in ADL status. Finally, differences in utilization patterns after discharge existed between groups, which may have had an effect on outcomes at follow-up. Given that the FFS group was more likely to reside in the community 1 year after discharge from rehabilitation, it is possible that their need for assistance with ADLs may have been less than that of the HMO group, placing the FFS group at a higher functional level during the follow-up compared with the HMO group.

The results from this study suggest that rehabilitation services received in acute rehabilitation facilities are associated with better outcomes for patients after a stroke. The study sample was similar to my patient as well, which suggested that I could generalize this information to him.