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  • Study: Estimated 1 in 3 Medicare Beneficiaries Receiving Inpatient/SNF Rehab Report No Improvement in Function

    Authors of a new study on inpatient and skilled nursing facility (SNF) rehabilitation say that when it comes to patients' own opinions of their progress, an estimated 1 in 3 Medicare beneficiaries are likely to report experiencing no improvement in functioning while they were receiving rehabilitation in those settings. And those rates can trend higher depending on certain demographic and health-related variables.

    The study, published in the Journal of the American Medical Directors Association (abstract only available for free), analyzes survey responses from 479 Medicare beneficiaries who received inpatient or SNF rehabilitation between 2015 and 2016. Data were drawn from the National Health and Aging Trends Study (NHATS), with respondents comprising a nationally representative sample of the Medicare population.

    Participants were asked, "While you were receiving rehab services in the last year, did your functioning and ability to do activities improve, get worse, or stay about the same?" Responses were compared with various demographic, socioeconomic, health, and rehabilitation variables to investigate possible correlations. Here's what researchers found:

    • Overall, 33.4% of respondents said that they did not improve in functioning during treatment.
    • Respondents who reported no improvement were more likely to have less formal education, more anxiety, and 1 or more impairments in their ability to perform instrumental activities of daily living (IADL)—preparing meals, doing the laundry, doing light housework, shopping for groceries, managing money, taking medicine, or making phone calls. These respondents also were more likely to require a proxy respondent to answer survey questions due to physiological or cognitive disability.
    • Respondents who reported no improvement were less likely to have received rehabilitation services for surgical reasons.
    • Impairment related to activities of daily living (ADL)—eating, transferring out of bed, transferring out of chairs, walking inside, going outside, dressing, bathing, or toileting—was not associated with lower patient-reported outcomes. The same was true for specific medical conditions and clinically significant depression.
    • Respondents with IADL impairments whose primary condition was "other musculoskeletal condition" or a cardiovascular condition, and who received less than 1 month of rehabilitation services with no outpatient services also were more likely to report no improvement in functioning.

    Authors write that the correlation between lack of improvement and a patient's education level is a "somewhat concerning" finding in the study.

    "Health literacy can be a substantial barrier to effective medical care," authors write, "and perhaps those with less education had a lower level of health literacy, which may have affected their expectations for rehabilitation outcomes and/or negatively impacted their ability to participate in and receive the full benefits of rehabilitation services."

    As for the reasons why impairment in IADLs would be more strongly associated with reports of no improvement than would impairment in ADLs, authors speculate that "perhaps ADL limitations are more amenable to rehabilitation than are IADL impairments, especially because IADL involve more complex tasks that may be particularly sensitive to cognitive status."

    The relationship between rehabilitation of less than 1 month and the absence of outpatient rehabilitation services also was singled out for additional comment by the study's authors, who believe that "effective rehabilitation for some…may be a longer-term process that extends months and spans nursing home, inpatient, outpatient, and/or in-home settings."

    Authors point to a move toward more integrated, multisetting care as a positive step, writing that "As about 1 in 5 community-dwelling Medicare beneficiaries report receiving any rehabilitation services in the prior year, more closely integrating rehabilitation services across service settings (and with other health and social services) offers promise in improving outcomes in Medicare beneficiaries who desire to maintain their independence."

    The study, according to authors, contains its share of limitations, including a relatively small sample size, no differentiation between inpatient facility settings, the use of self-reported data, and lack of information on whether the patients actually met their rehabilitation goals.

    Despite those issues, authors of the study think their analysis opens up areas for future research. They write: "Our findings lead to more questions: does health literacy play a role in patient-reported outcomes? Are those with IADL impairments less able to engage in and thereby benefit from rehabilitation services? How do contextual factors and the dose of rehabilitation services affect patient-reported outcomes? Would patient-reported outcomes among this population be improved if: (1) more of these patients received rehabilitation services longer and/or in outpatient or home settings or (2) if patient-centered rehabilitation targets were more incorporated into treatment planning?"

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Comments

    • Just maybe we don't use the right measurement tool. I have used the SF-12 for several years and the pre and post are discussed with the patient. I also wonder if we explain "the true expectations for the patient. Do you avoid the truth when telling them what might be the out come?

      Posted by Max Morton on 8/9/2018 9:57 AM

    • Since this study looked at only facility based rehab, it stands to reason that IADL function might not improve. The carryover from facility to home/community is likely low. Maybe we need to do a better job of really inderstanding the patient’s home/community setting and their needs in order to better simualte those tasks during inpatient rehab stays. Also speaks to the need for home health and outpatient rehab jpom discharge to home.

      Posted by Trisha B on 8/14/2018 1:57 PM

    • This does not mean that 1 in 3 patients are not actually making any improvements. Pt's can be their own worst critics. I have observed Pt's go from being nearly bed bound, to walking to and from all meals and using stairs with a single hand rail yet I still hear them make negative comments like they have "not gotten any better and they never will." despite struggling to recognize it, these patient make enough progress to safely return home after inpatients stays with low readmission rates. This is why pt's improvement in function cannot be merely self reported. yes there perception matters, however at the end of the what it comes down to is whether or not they are safe to return to previous LOF.

      Posted by Joshua Klas -> CIWaCN on 8/16/2018 1:15 AM

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