November 2000

Grant Results

SUMMARY

From 1991 to 1996, researchers at the University of Colorado Health Sciences Center compared outcomes among elderly patients in two types of health care settings:

  • Integrated fee-for-service (FFS) health care systems that offered rehabilitation services in inpatient rehabilitation hospitals and skilled nursing facilities (SNFs).
  • Large HMOs that primarily relied on owned or contracted subacute skilled nursing facilities for Medicare rehabilitation services. (Subacute skilled nursing facilities are designed as an intermediate option between traditional skilled nursing facilities and the higher-intensity inpatient rehabilitation hospitals.)

Key Findings

  • HMO patients were more likely to receive rehabilitation treatment in subacute SNFs, which provided more intense rehabilitation than regular skilled nursing facilities but less intense rehabilitation than rehabilitation hospitals.
  • There were no differences in one-year outcomes between hip fracture patients treated in fee-for-service and HMO settings.
  • Stroke patients treated in FFS settings, however, improved more in function during the rehabilitation episode and were less likely to be placed in nursing homes than those treated in HMO settings.

Funding
The Robert Wood Johnson Foundation (RWJF) supported this project through a grant of $1,942,307.

 See Grant Detail & Contact Information
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THE PROBLEM

For an elderly person, proper rehabilitation following an acute illness or injury (such as a hip fracture, stroke, exacerbation of congestive heart failure, or surgery) can reduce or prevent long-term functional impairment. To date, however, insurers and providers have had little data to assist them in deciding the optimal intensity of rehabilitation services required for such conditions.

The Health Care Financing Administration (HCFA) funded a study beginning in 1990 to examine outcomes for elderly Medicare patients who received rehabilitation in inpatient rehabilitation hospitals and Medicare-funded nursing homes or SNFs (Kramer et al., 1997).

The study found that for stroke patients, outcomes were better, at a higher cost, in inpatient rehabilitation hospitals than in SNFs, but there was no added benefit for hip fracture patients. This study, however, did not explore other rehabilitation alternatives.

In recent years, for example, HMOs have developed subacute SNFs, which are designed as an intermediate option between traditional SNFs and the higher-intensity inpatient rehabilitation hospitals. Other providers are experimenting with home-based rehabilitation services.

If functional improvement is enhanced in these settings where rehabilitation is more intensive and more tailored to actual patient needs, then these alternatives might prove more cost-effective than rehabilitation hospitals reimbursed under Medicare FFS.

This project was designed to complement the HCFA-funded study of rehabilitation outcome of hip fracture and stroke patients by exploring alternative rehabilitation options and by examining outcomes for medical/surgical patients receiving rehabilitation. About half of patients receiving rehabilitation in SNFs are these functionally impaired medical/surgical patients with primary diagnoses that are not traditional rehabilitation conditions (e.g., musculoskeletal and neurological problems). Yet little is known about rehabilitation of these patients.

The principal investigator previously received RWJF support (grant ID#s 013669 and 016542) for a study of outcomes in rural hospital swing beds and rural nursing homes, including both high- and low-intensity skilled nursing facilities (SNFs).

This study of 705 patients with stroke, incontinence, confusion, or hip fracture demonstrated substantial variation in patient outcomes that appeared to be associated with differences in service intensity across settings (Kramer, et al., 1989).

Patients given a poor prognosis for recovery who were admitted to an SNF, where they were more likely to receive physician visits and rehabilitation services, had 13 times greater odds of being discharged home within 90 days than comparable patients admitted to a facility where such services were not readily available. For patients with an uncertain prognosis, the odds were nine times greater for being discharged home, whereas those with a good prognosis for recovery did about the same in all settings.

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THE PROJECT

The goals of this project were to evaluate the effectiveness and cost of traditional and alternative rehabilitation options and identify critical factors that influence the outcome of rehabilitation treatment and its cost. First, the principal investigator planned to identify and classify the range of traditional and alternative rehabilitation services available for stroke, hip fracture, and other medical or surgical conditions. Then, in the second part of the project, he planned to compare outcomes and treatment among similar patients treated in different settings.

After completing site visits at 28 facilities, the study team concluded that patients treated in non-institutional rehabilitation settings were generally not comparable to those treated in rehabilitation hospitals and SNFs.

With RWJF approval, they focused the study on comparing outcomes among elderly patients in five integrated FFS health care systems that offered rehabilitation services in inpatient rehabilitation hospitals and SNFs, and six large HMOs that primarily relied on owned or contracted subacute SNFs for Medicare rehabilitation services. They also investigated medical/surgical patients receiving rehabilitation, contrasting their characteristics and outcomes with traditional rehabilitation patients.

Eleven systems, including five FFS and six HMOs, participated. The research team analyzed data on 336 hip fracture patients (196 treated in FFS settings, 140 in HMO settings), 429 stroke patients (193 treated in FFS settings, 236 in HMO settings), and 290 medical/surgical who were followed for one year. Data collectors at each site conducted interviews with patients to determine their functional status before the illness or injury.

They also conducted follow-up phone interviews to determine functional status at 3, 6, 9, and 12 months later. Nursing staff at facilities provided data on functional status and comorbid conditions, hospital and rehabilitation charts were abstracted, and service use was tracked using claims (for FFS) and encounter (for HMO) data.

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FINDINGS

Findings presented at a Kaiser Permanente-sponsored conference on aging in April 1998, a meeting on managed care sponsored by the Office of the Assistant Secretary for Planning and Evaluation and HCFA, and in articles in Effective Clinical Practice, The Journal of the American Medical Association (JAMA), Journal of the American Geriatrics Society, and Medical Care include:

  • HMOs were less likely than FFS systems to provide rehabilitation in rehabilitation hospitals for both hip fracture and stroke patients, instead relying largely on subacute SNFs. In HMOs, 94 percent of hip fracture patients and 87 percent of stroke patients were treated in subacute SNFs. In FFS systems, 71 percent of hip fracture patients and 15 percent of stroke patients were treated in SNFs, and the remainder in rehabilitation hospitals.
  • Stroke patients treated in FFS settings recovered more function during rehabilitation and were less likely to be placed in nursing homes than those treated in HMO settings. After risk factor adjustment, between admission to and discharge from rehabilitation, FFS patients improved significantly more on two functional indices than HMO patients. After risk factor adjustment, nursing home placement at 12 months was significantly higher for stroke patients treated in HMOs. This suggests that HMOs provide less effective rehabilitation care and ongoing primary care to elderly stroke victims than do FFS systems.
  • Outcomes for hip fracture patients were comparable in HMOs and FFS systems. After adjusting for other risk factors, there was no significant difference in functional outcomes, including limitations in Activities of Daily Living (ADLs) and nursing home placement for hip fracture patients treated in HMO and FFS settings.
  • HMO patients had fewer hospital days, less intensive rehabilitation services, and less total and specialty physician care than FFS patients. HMO patients had a shorter index hospital length of stay, fewer therapy visits in the hospital, a shorter rehabilitation stay, and fewer therapy and physician visits during rehabilitation. They had comparable re-hospitalization rates but fewer total hospital days, and less total and specialty physician care during the year following the event. While HMO patients received more home health visits, all of these were provided in the first three months, while FFS visits were dispersed over the year. These different care patterns may account for observed outcome differences in stroke patients.
  • Pre-existing functional impairment and a high death rate among medical/surgical patients receiving rehabilitation raises questions about whether selection of patients most likely to benefit from rehabilitation services can be improved. Medical/surgical patients were more functionally impaired before their acute illness and suffered less decline as a result of the acute event than those with traditional rehabilitation diagnoses. While most of the medical/surgical patients recovered their baseline function and some even improved from baseline, 30 percent died within the year of follow-up, compared with 18 percent of stroke patients and 14 percent of hip fracture patients.

Communications

The principal investigator has published the results of this study in two major reports and seven journal articles, including articles in The Journal of the American Medical Association and the Journal of the American Geriatric Society. Also, the PI has presented the findings at more than one dozen meetings, conferences, and HCFA-sponsored briefings. See the Bibliography for a full listing.

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LESSONS LEARNED

  1. Investigators need to be cognizant of possible new human subject experiment restrictions. During the course of the grant, the principal investigator faced unexpectedly strict human subject reviews. Formerly, he had been allowed to transfer human subject approval from his home institution to other institutions. But, in several instances, facilities required the research to go through their own individual review processes, which delayed this work for six months and necessitated a grant extension.

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AFTER THE GRANT

The study team is working to finish data analysis and additional papers. They also recently finished a study on case management for the frail elderly population under RWJF's Chronic Care Initiatives in HMOs national program (see Grant Results on ID# 028183).

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GRANT DETAILS & CONTACT INFORMATION

Project

Evaluation of Alternative Rehabilitation and Critical Dimensions of Care

Grantee

University of Colorado Health Sciences Center (Denver,  CO)

  • Amount: $ 1,942,307
    Dates: September 1991 to October 1996
    ID#:  018624

Contact

Andrew M. Kramer, M.D.
(303) 315-6031
andy.kramer@uchsc.edu

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Books and Reports

Kramer AM, Steiner J, Grigsby J, Kowalsky JC, Morgenstern N, Schlenker RE, and Shaughnessy PW. Evaluation of Innovative Rehabilitation Alternatives and Critical Dimensions of Care: Research Design. Denver, Colo.: Center for Health Services Research, 1992.

Kramer AM, Steiner J, Kowalsky J, Mays G, Morgenstern N, and Grigsby J. Descriptive Profiles of Geriatric Rehabilitation Care for Elderly Stroke Patients. Denver, Colo.: Center for Health Services Research, December 1993.

Articles

Coleman EA, Kramer AM, Kowalski JC, Eckoff D, Lin M, Hester EJ, Morgenstern N and Steiner JF. "A Comparison of Functional Outcomes After Hip Fracture in Group/Staff HMOs and Fee-for-Service Systems." Effective Clinical Practice, 3(5): 229–239, 2000. Abstract available online.

Johnson MF, Kramer AM, Lin MK, Kowalsky JC and Steiner JF. "Outcomes of Older Persons Receiving Rehabilitation for Medical and Surgical Conditions Compared with Hip Fracture and Stroke." Journal of the American Geriatrics Society, 48(11): 1389–1397, 2000. Abstract available online.

Kramer AM. "Rehabilitation Care and Outcomes from the Patient's Perspective." Medical Care, 35(6 Suppl.): JS48–JS57, 1997. Abstract available online.

Kramer AM, Fox PD and Morgenstern N. "Geriatric Care Approaches in Health Maintenance Organizations." Journal of the American Geriatrics Society, 40(10): 1055–1067, 1992. Abstract available online.

Kramer AM, Kowalsky JC, Lin M, Grigsby J, Hughes R and Steiner JF. "Outcome and Utilization Differences for Older Persons with Stroke in HMO and Fee-for-Service Systems." Journal of the American Geriatric Society, 48(7): 726–734, 2000. Abstract available online.

Kramer AM, Steiner J and Kowalsky J. "Rehab for the Elderly." HMO Magazine, 35(1): 15–19, 1994.

Kramer AM, Steiner JF, Schlenker RE, Eilertsen TB, Hrincevich CA, Tropea DA, Ahmad LA and Eckhoff DG. "Outcomes and Costs After Hip Fracture and Stroke: A Comparison of Rehabilitation Settings." Journal of the American Medical Association, 277(5): 396–404, 1997. Abstract available online.

Steiner JF, Kramer AM, Eilertsen TB and Kowalsky JC. "Development and Validation of a Clinical Prediction Rule for Prolonged Nursing Home Residence after Hip Fracture." Journal of the American Geriatrics Society, 45(12): 1510–1514, 1997. Abstract available online.

Coleman EA, Kramer AM, Kowalsky JC, Steiner J, Hester E, Lin M, Eckhoff DG and Morgenstern N. "Outcomes and Utilization for Hip Fracture Patients Rehabilitated in Selected HMO and Fee-For-Service Systems." Unpublished.

Johnson M, Lin M, Kowalsky J, Steiner J, and Kramer AM. "Medical and Surgical Patients Receiving Post-Acute Rehabilitation: Characteristics and Outcomes." Unpublished.

Presentations and Testimony

Kramer AM. "Stroke Rehabilitation in Alternative Settings," at a meeting of the Association of Academic Physiatrists, January 1993, Naples, Fla.

Kramer AM, Steiner J, Kowalsky JC, Morgenstern N, Grigsby J, LaRocca C and Mays G. "Variation in Rehabilitation Care for Elderly Stroke Patients," at a meeting of the Gerontological Society of America, November 1993, New Orleans, La.

Kowalsky JC and Kramer AM. "Outcome Measurement for Geriatric Rehabilitation Approaches in HMO's," at the Annual Meeting of the Gerontological Society of America, November 1994, Atlanta, Ga.

Kramer AM, Eilertsen TB, Hrincevich CA and Schlenker RE. "Outcome and Cost-Effectiveness of Acute Inpatient Rehabilitation Relative to Medicare SNFs," at a meeting of the American Public Health Association, October 1995, San Diego, Calif.

Kramer AM. "Rehabilitation Care and Outcomes from the Patient's Perspective," at the Improving Health Care Outcomes Through Geriatric Rehabilitation Conference, May 1996, Boston, Mass.

Kramer AM, Kowalsky JC, Eilertsen TB, Hester EJ and Steiner J. "Outcomes for Stroke and Hip fracture Patients in HMO and Fee-for-Service Systems," at Beyond the Water's Edge: Charting the Course of Managed Care for People with Disabilities Conference, sponsored by the Assistant Secretary for Planning and Evaluation, HCFA, November 1996, St. Michael's, Md.

LaRocca C, Kowalsky J, Steiner J and Kramer AM. "Medical and Surgical Patients Receiving Rehabilitation in HMO and Fee-for-Service Settings," at the Annual Meeting of the American Geriatrics Society, May 1997, Atlanta, Ga.

Kramer AM. "Effects of Rehabilitation on Functional Recovery," at the Rehabilitation 2000 Conference, September 1997, Washington, D.C.

Kramer AM. "Rehabilitation in Nursing Homes: Outcomes, Care, and Payment," at Case Mix: A Cornerstone of Quality Care Conference, September 1997, Cleveland, Ohio.

Kramer AM. "An Overview of Health Outcomes for Geriatric Patients with Stroke and Hip Fracture," at the 59th Annual Assembly, American Academy of Physical Medicine and Rehabilitation, November 1997, Atlanta, Ga.

Kramer AM. "Stroke Outcomes and Costs: A Comparison of Rehabilitation Settings," at the 23rd International Joint Conference on Stroke and Cerebral Circulation, February 1998, Orlando, Fla.

Kramer AM. "Innovations in Providing Rehabilitation for Stroke and Hip Fracture Patients," at the Kaiser Permanente Third Annual Interregional Conference on Aging, April 1998, Denver, Colo.

Johnson M, Lin M, Kowalsky J, Steiner J and Kramer AM. "Medical and Surgical Patients Receiving Post-Acute Rehabilitation: Characteristics and Outcomes," at the American Geriatrics Society Annual Meeting, May 19–23, 1999, Philadelphia, Pa.

Kramer AM, Cahill Kowalsky J, Lin M, Grigsby J, Hughes R, Morgenstern N and Steiner J. "Outcomes and Utilization for Stroke Patients in Selected HMO and Fee-for-Service Systems," at UCHSC Geriatrics Grand Rounds, April 29, 1999, Denver, Colo.

Audio-Visuals and Computer Software

Training in the Use of the Behavioral Discontrol Scale (BDS), a 20-minute videotape. Denver, Colo.: Center for Health Services Research, 1993.

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Report prepared by: Susan Basalla
Reviewed by: Richard Camer
Reviewed by: Molly McKaughan
Program Officer: Nancy Barrand