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.

Is Acute Rehabilitation More Cost-Effective

Than Subacute Rehabilitation?

Is Acute Rehabilitation More Cost-Effective

Than Subacute Rehabilitation?

CollaboratorsCollaborators

Tracey Barnett, Ph.D. Dean Reker, Ph.D. Xinping Wang, Ph.D.

Today’s ObjectivesToday’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

Restructuring VA RehabRestructuring 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).

Central QuestionCentral Question

What has been the impact

of this major restructuring on VA rehabilitation costs and outcomes?

Data SourcesData 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)

Dependent VariablesDependent 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

Independent VariablesIndependent 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

MethodsMethods

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)

Descriptive StatisticsDescriptive StatisticsVariable Frequency (%) Frequency (%) Acute (N=315) Subacute (N=168) Dependent Variables Mean (SD) Mean (SD) Discharge FIM total score* 96.34 (21.43) 91.97 (25.01) Total index cost* 22214 (13818) 24861 (17819) Independent Variables N (%) N (%) Race White 187 (64.71) 102 (35.29) Other 124 (65.26) 66 (34.74) Gender Male 300 (64.66) 164 (35.34) Female 11 (73.33) 4 (26.67) Marital Married 159 (66.81) 79 (33.19) Not Married 152 (63.07) 89 (36.93) Impairment Code 1.1 133 (65.84) 69 (34.16) 1.2 135 (65.85) 70 (34.15) 1.3 16 (80.0) 4 (20.0) 1.4 8 (61.54) 5 (38.46) 1.9 19 (48.72) 20 (51.28) Mean (SD) Mean (SD) Age 68.45 (11.25) 68.85 (10.89) Admission Score FIM Total* 71.08 (21.33) 65.38 (24.47) FIM Cognitive 24.21 (7.57) 21.30 (8.36) FIM Motor* 46.88 (16.27) 44.07 (18.96) Onset to Admission 26.29 (103.83) 45.71 (308.83) Descriptive Discharge Score FIM Cognitive* 27.63 (5.97) 25.33 (7.21) FIM Motor* 68.70 (17.14) 66.64 (20.22) * p <.05

Cost and FIMTM Model RunsCost and FIMTM Model RunsVariable Full

Total Index Stay Costs

R2 = .41

Parsimonious Total Index

Stay Costs R2 = .40

Full Total FIM

R2 = .68

Parsimonious Total FIM

R2 = .68

Acute RBU -5979.90* -5850.79* 8.63* 8.57* Impairment Code 1.1 765.07 .38 .29 Impairment Code 1.2 1866.22 3.68 3.63 Impairment Code 1.3 -2693.24 -4.21 -3.90 Impairment Code 1.4 -183.92 -1.68 -1.84 Impairment Code 1.9 reference reference reference Onset to Admit -.27 0.002 FIM Motor at Admission -451.23* -475.41* .71* .71* FIM Cognitive at Admission -75.75 1.03* 1.03* Age -204.07* -191.82* -.32* -.31* Married 41.99 .65 White 1390.77 -1.80 Site 516 -7382.23† -6105.27 12.28* 11.50* 523 2029.84 1252.22 2.16 1.33 528 8397.23† 9106.78* -2.05 -2.49 546 -5887.32 -5975.21 8.75* 8.67* 549 8993.35* 9848.49* -.88 -1.08 552 -4486.92 -3496.23 1.72 1.50 553 -6194.42 -6406.22 9.06 9.60† 578 4128.98 4223.46 -2.48 -2.82 583 12709.93* 13071.03* 3.93 3.53 598 7304.03* 7487.36* -.74 -1.21 600 -890.91 -550.78 -1.96 -2.05 605 -6843.06 -6053.16 15.40* 15.13* 618 2855.75 3695.13 10.41* 9.54* 630 6627.13 6926.72 9.04† 9.37† 635 -7677.20† -7466.79† -4.66 -5.05 642 -4266.90 -4502.05 -4.97 -4.44 648 -2015.00 -896.68 13.09* 12.18* 671 -1291.84 -546.89 -.30 -.78 672 -790.60 -1013.02 -3.27 -2.27 673 -2017.43 -1110.00 .75 .26 678 -4072.49 -3580.50 16.18* 15.63* 688 2628.07 2907.72 8.59† 9.11* 691 reference reference reference

*p < .05; †p < .10

Significant DescriptivesSignificant 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

0102030405060708090

100

Admit FIM DischgFIM

ARBUSRBU

Significant DescriptivesSignificant Descriptives

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

20500210002150022000225002300023500240002450025000

Index Stay Costs

ARBUSRBU

Moving On . . . Moving On . . .

What happens to these results

when we control for the

independent variables listed above?

Significant Model ResultsSignificant 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)

Cost Effectiveness?Cost Effectiveness?

When outcomes improve and costseither decrease or stay the same,

cost-effectiveness is a given.

ImplicationsImplications

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

CaveatsCaveats

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?