Changes in reimbursement have reduced length of stay for patients receiving inpatient medical rehabilitation

Although medical rehabilitation patients are spending less time as inpatients at facilities, their functional outcomes have not declined. However, the death rate following discharge has increased nearly 4 percent from 1994 to 2001, according to a study in the October 13 issue of JAMA.

Changes in reimbursement have reduced length of stay (LOS) for patients receiving inpatient medical rehabilitation, according to background information in the article. The impact that reduced LOS has had on rehabilitation outcomes including functional status, living setting, and death has not been known.

Kenneth J. Ottenbacher, PhD, O.T.R., of the University of Texas Medical Branch, Galveston, Texas, and colleagues examined changes in LOS for persons receiving inpatient medical rehabilitation from 1994 through 2001. The researchers analyzed information from the Uniform Data System for Medical Rehabilitation. In addition to exploring trends in LOS for 5 major impairment groups (stroke, brain dysfunction, other neurologic conditions, spinal cord dysfunction [traumatic and nontraumatic], and orthopedic conditions), the researchers also examined changes in rehabilitation effectiveness, efficiency, discharge to home, living setting at 3- to 6-month follow-up, and death. The authors hypothesized that decreasing LOS would be associated with reduced functional status and decreased community living at follow-up.

The study included 744 inpatient medical rehabilitation hospitals and centers located in 48 U.S. states. A total of 148,807 patient records were examined. The patients' average age was 67.8, the sample was 59 percent female and 81 percent non-Hispanic white.

The researchers found that the LOS decreased from 20 to 12 days from 1994 to 2001. The proportional decrease in average LOS was greatest (42 percent) for patients with orthopedic conditions. Functional status was clinically stable, while efficiency (functional status change divided by LOS) increased significantly. Rates of discharge to home and living at home at follow-up remained stable, ranging from 81 percent to 93 percent. However, mortality at 80- to 180-day follow-up increased from less than 1 percent in 1994 to 4.7 percent in 2001.

"No clinically significant change in daily living skills such as dressing and bathing was seen, despite a significant reduction in LOS," the authors write. "Determining the causes of the increase in rehabilitation efficiency and mortality requires further study. Our goal was to document the recent change in LOS and examine its association with functional status, living setting, and mortality. This goal is important in view of the introduction of a prospective payment system for inpatient medical rehabilitation by Centers for Medicare & Medicaid Services in January 2002. Our findings provide a baseline with which to compare future LOS, effectiveness, efficiency, mortality, and other outcomes important to health care professionals, researchers, and consumers to help evaluate how change in LOS influences patient care and outcomes."

In an accompanying editorial, Peter C. Esselman, M.D., of the University of Washington and Harborview Medical Center, Seattle, writes that perhaps the most provocative finding, as well as the outcome most difficult to explain in the study by Ottenbacher et al is the increase in the death rate.

"That mortality increased in all the impairment groups would indicate that some factor influencing mortality is common to different diagnostic groups. Potential factors related to increased mortality such as more comorbidities, older age, or lower admission Functional Independence Measure score were not significantly different," he writes. "The medical stability of the patients admitted over this time may have changed due to the pressure to decrease the acute care LOS and to move patients to inpatient rehabilitation earlier in their recovery."

"In summary, the reason for increased mortality over time remains obscure but may reflect changes in admission criteria and medical stability of patients admitted to inpatient rehabilitation facilities that were not measured in the study by Ottenbacher et al. The relationship between earlier acute care discharge, rehabilitation admission criteria, and LOS requires further study to understand changes in mortality," Dr. Esselman writes.