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Is Acute Rehabilitation More Cost-Effective Than Subacute Rehabilitation?

Is Acute Rehabilitation More Cost-Effective Than Subacute Rehabilitation?. Bruce Vogel, PhD.

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Is Acute Rehabilitation More Cost-Effective Than Subacute Rehabilitation?

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  1. Is Acute Rehabilitation More Cost-Effective Than Subacute Rehabilitation? Bruce Vogel, PhD This research was funded by the Department of Veterans Affairs, Health Services Research and Development Service (HSR&D), Stroke Quality Enhancement Research Initiative (QUERI), RRP 06-184, through the VA Rehabilitation Outcomes Research Center (RORC), North FL/South GA Veterans Health System, Gainesville, FL.This presentation does not necessarily represent the opinions or beliefs of the Department of Veterans Affairs, VISN 8, or the RORC.

  2. Collaborators • Tracey Barnett, Ph.D. • Dean Reker, Ph.D. • Xinping Wang, Ph.D.

  3. Today’s Objectives • To describe important changes in the structure of VA inpatient rehabilitation over the past 15 years • To estimate differences in VA costs and outcomes for VA stroke patients in acute versus subacute rehabilitation units • To draw some preliminary conclusions about the cost-effectiveness of alternative rehabilitation sites from the VA perspective to inform policy

  4. Restructuring VA Rehab • Between 1995 and 2003, the VA closed 28 of its 59 acute hospital-based inpatient rehabilitation units (ARBUs), or 47% of its original complement of such units • Over the same time, the VA established 24 new subacute nursing home-based inpatient rehabilitation units (SRBUs).

  5. Central Question What has been the impact of this major restructuring on VA rehabilitation costs and outcomes?

  6. Data Sources • Demographic and clinical data from chart abstractions in previous study of the Stroke Impact Scale • 483 post-acute stroke patients from 27 acute and subacute units at 23 different VA Medical Centers in FY2002-FY2005 • VA cost data for index rehab stay and 24 months post-stay from VA Decision Support System National Data Extracts (DSS NDE)

  7. Dependent Variables • Cost data divided into index stay, short-term (0-3 months post-stay), long-term (4-24 months post-stay) and total 24 month costs • Outcomes measured by admission and discharge total, motor, and cognitive Functional Independence MeasureTM (FIMTM) scores

  8. Independent Variables • Both cost and functional status models controlled for: • ARBU vs. SRBU • type of stroke • time from onset to admission • admission motor and cognitive FIMTM scores • demographics (age, martial status, and race) • VA medical center

  9. Methods • Followed standard econometric practice in estimating cost models (Manning and Mullahy, 1998) by choosing between OLS and generalized linear models based on residual kurtosis and heteroskedasticity. • Estimated a distributed lag model of functional outcomes where discharge FIMTM is modeled as a function of admission FIMTM • Examined full and parsimonious models (p<.20)

  10. Descriptive Statistics

  11. Cost and FIMTM Model Runs

  12. Significant Descriptives • ARBU patients had higher admission and discharge FIMTM scores than SRBU patients (71.1 vs. 65.4 at admission; 96.3 vs. 92.0 at discharge) • No differences in total, motor, or cognitive FIMTM gains were significant

  13. Significant Descriptives • Average index stay total cost was lower for ARBU patients ($22,214 vs. $24,861)

  14. Moving On . . . What happens to these results when we control for the independent variables listed above?

  15. Significant Model Results • We find a considerably larger statistically significant difference in total index costs of approximately $6,000 (~25% of the index stay cost) • After regression adjustment, we find statistically significantly higher total discharge FIMTM scores in ARBUs than in SRBUs(~8.6 FIMTM points)

  16. Cost Effectiveness? When outcomes improve and costseither decrease or stay the same,cost-effectiveness is a given.

  17. Implications • While moving patients out of the hospital can often be cost effective, this may not always be the case • VA policymakers may want to reconsider the trend of replacing acute, hospital-based rehab units with subacute, nursing home-based units

  18. Caveats • Failed to find significant differences for short-term, long-term, and total two-year costs – implications? • Observational data – Could unobserved selection bias be driving these results? • Only examined VA cost – “business case” • Only examined stroke patients – Do these results carry over to all rehab patients?

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