Inpatient Rehabilitation Facilities

Document Sample
Inpatient Rehabilitation Facilities Powered By Docstoc
					Inpatient Rehabilitation Facilities: Alternative
    Definitions of Hospital Specialization

                         Presented by
              Roberta Constantine, RN, MBA, PhD
                       RTI International

                      Presented at
       AcademyHealth 2007 Annual Research Meeting
                      June 4, 2007
                    Orlando, Florida
      1440 Main Street       ■ Suite 310      ■    Waltham, MA 02451-1623
      Phone 781-434-1711   Fax 781-434-1701       e-mail RConstantine@rti.org

                                                      RTI International is a trade name of
                                                              Research Triangle Institute
                         Introduction

       About 8 percent of all hospital users are admitted to
        IRFs for PAC services (over 470 thousand
        admissions between June 30th of 2004 and 2005.)
       These specialized hospitals provide acute-level
        treatment in physical medicine and rehabilitation.
       IRF patients typically have a primary diagnosis
        related to musculoskeletal or neurological disorders
        or injuries and need acute-level physical rehabilitation
        treatments.


2
                        Medicare Policy

       In 2002, IRFs moved from TEFRA cost-based to
        case-mix, adjusted PPS.
       Hospitals must meet IRF certification requirements to
        be paid under the IRF PPS, else IPPS with much
        lower rates.
       To qualify for IRF certification, a hospital or unit must
        have admitted during its last cost reporting period, a
        certain percentage of cases within 13 diagnostic
        groups (75% Rule).


3
                   IRF Certification Groups

       Stroke
       Spinal cord injury,         Neurological disorders
       Congenital deformity,       Burns
       Amputation,                 Systemic vasculidities
       Fracture of femur (hip      Knee/Hip replacement
        fracture),
                                    Active rheumatoid arthritis or
       Brain injury,                severe/ advanced
                                     osteoarthritis




4
                  Study Purpose

    Are there alternative ways of defining IRF
    specialization that would allow for changes in
    medical practice?




5
                     Research Questions

       Do individual inpatient rehabilitation facilities (IRFs)
        specialize in certain populations?
       If so, what types of admissions, who are the patient
        populations and what types of IRFs are
        specializing?
       If specialization does occur does it affect patient
        outcomes?




6
                              Methods

       We analyzed data from:
           Inpatient Rehabilitation Facility Patient
            Assessment Instrument (IRFPAI),
           Patients’ prior acute, inpatient claims, and
           Provider certification data to examine whether
            other factors might be useful in classifying IRFs.
       Focus on the relationship between patient diagnosis,
        IRF characteristics, and functional outcomes.



7
                     IRF Characteristics

                Rehab Unit (%)     Freestanding(%)      Total(%)

No. of Facilities       970 (82)       210 (18)        1,180 (100)

No. of Admits       302,524 (68)   168,171 (36)      470,695 (100)

Mean Admits             312            801               399

Median Admits           260            766               290

Nonprofit              668 (69)         71 (34)         739 (63)

For Profit             159 (16)       131 (62)          290 (25)

 8
            Rehabilitation Impairment Categories
                            (RICs)
     The Medicare Program classifies IRF patients by RICs.
     There are a total of 21 RICs, this analysis examined five in
     depth.
                                                        Percent of Total
                                        Frequency        Admissions
Replace of Lower Extremity Joint         108,339               23%
Stroke                                    84,114               18%
Fracture of the Lower Extremity           64,847               14%
Neurological                              26,106              5.5%
Burns                                         328            0.07%


 9
          Top IRFs with Highest Number of
                    RIC Admits
                                         RIC Admits as %
                Total Admits RIC Admits of Total IRF Admits

     ReplacLE      5,343       1,612            30%

     Stroke        5,343         863             16%

     FracLE        5,343         550            10%

     Neuro         2,032         703             35%

     Burns         1,046          58              6%


10
                 FIM Scores by IRF Affiliation

                      Units        Freestanding
         RIC         ADM CHG       ADM        DC

        ReplaceLE   77       26   72         31
                                   49         25
        Stroke      58       22
                                   57         28
        FracLE      65       24
                                   58         26
        Neuro       66       20   57         29
        Burns       62       19




11
            Creation of New Variables to
            Characterize Specialization
     Examined both the number of admissions for a RIC (RIC
     admits) and the number of admissions for a particular RIC as a
     percent of the facility’s total admissions (RIC_PCNT)
     simultaneously.
                          RIC admits           RIC_PCNT
     Quantiles          0-50     51-100       0-50    51-100
     Low, Low             X                   X
     Low, High            X                             X
     High, Low                     X          X
     High, High                    X                    X

12
     Frequency Distribution and Percentage ( ) of
              Specialization Variables
                   LL        LH        HL          HH

     ReplacLE   527 (46)   340 (30)   74 (7)     209 (18)

     Stroke     417 (35)   480 (41)   127 (11)   155 (13)

     FracLE     428 (37)   449 (39)    99 (9)    182 (16)

     Neuro      548 (48)   262 (23)    61 (5)    267 (24)

     Burns       85 (59)    14 (10)   21 (15)     23 (16)


13
     Functional Improvement Measure (FIM)

        The FIMTM instrument is “a measure of disability not
         impairment” (IRF-PAI Training Manual, 2004).
        It is a basic indicator of the severity of disability intended to
         measure what a patient actually does, regardless of the
         impairment, not what they should be able to do.
        There are 18 FIM items in all, scored from 1 total assist to 7
         independent.
        There are six FIM categories; self-care, sphincter control,
         transfers, locomotion, communication, and social cognition




14
       IRFs with Highest Percentage of RIC Admits
             as Percentage of Total Admits
                                           RIC Admits as %
                Total Admits   RIC Admits of Total IRF Admits

     ReplacLE       630            439             71%

     Stroke          78             73             96%

     FracLE          69             35             51%

     Neuro          385            190             49%

     Burns           97             39             40%


15
             Patient Severity of Illness (SOI)

        Patient SOI was estimated during the index acute
         care, inpatient hospitalization using the All Patient
         Refined DRG (APR-DRG) grouping software
         developed by 3M Health Information Systems.
        The SOI subclass has values of 0-4 corresponding to:
         no relevant comorbidities (0), minor severity (1),
         moderate severity (2), major severity (3), or extreme
         severity (4).
        A match was performed on IRF-PAI admissions to
         MEDPAR acute care admissions and a total of
         370,308 claims matched the 470,695 IRFPAI records
         (78.7%).

16
         OLS Models for FIM Outcomes for
                 Selected RICs
        Dependent Variables:
            Total FIM Change Score,
            Total Motor Change Score (self-care, sphincter control,
             transfers, and locomotion),
            Total Cognitive Change Score (communication and social
             cognition)
        Independent Variables:
            Patient Characteristics – age, gender, white, severity of
             illness, LOS, Total FIM admission score
            IRF Characteristics – Region, Total Admissions, Rehab
             Unit Indicator, Specialization variables


17
     Model Results – Adjusted R-Squared

            Total FIM   Total Motor FIM   Total Cognitive FIM
           Change Score Change Score        Change Score

ReplacLE       0.35           0.14                0.25
Stroke         0.12           0.11                0.11
FracLE         0.13           0.11                0.14
Neuro          0.09           0.06                0.10
Burns          0.15           0.16                0.09



18
                     Summary of OLS Regressions, Dependent
                        Variable, Total FIM Change Score




*P= or < 0.05. PTSOI1 is the reference category in the analysis; LL is the reference category in the analysis; New England is the reference category in the
analysis.

    19
          Model Results IRF Characteristics

    Overall, specialization tended to be statistically significant (0.01
     or less) but varied by direction, RIC, change score being
     measured, and specialization category.
    When the specialization variables were significant, they generally
     increased the FIM change score.
    Volume had the greatest influence: HL
       1.6 points (Reple); 1.36 (Stroke); 1.7 (Neuro)
    High percentages in small admission groups were next most
     influential (LH) in general and especially in rarer cases
       5.2 (burns); 0.67 (Reple); 0.69 (FracLE); 0.48 (Neuro)
    High volume, High percent had mixed results
       -0.37 (Stroke); -2.3 (Burns); 1.2 (Neuro)



20
         Model Results - Patient Characteristics

    Patient’s severity of illness for indexed acute care hospitalization
     was the most significant patient variable.
        Varied across RICs and models – ranged less than one to six
         points.
    Other patient characteristics:
        Female tended to have a positive affect.
        Age was significant and negative for most models but less than
         one point effect.
        Ethnicity – being white was generally significant and positive
        LOS tended to be significant and positive but less than one
         point across the models.

21
                     Policy Implications

        Using definitions of functional and medical
         severity to determine appropriate IRF admissions
         would be consistent with the consideration that
         PAC is provided on a continuum.
        Volume and Percent of Admissions have
         significant effects on rehabilitation outcomes.
        These types of measures allow for variation
         within conditions to identify the acute-level
         rehabilitation case.


22

				
DOCUMENT INFO
Shared By:
Categories:
Stats:
views:261
posted:4/12/2008
language:English
pages:22