Associations of Self-Reported History of Depression and Antidepressant Use Before Stroke Onset With Poststroke Post-Acute Rehabilitation Care-An Exploratory Study: The BASIC (Brain Attack Surveillance in Corpus Christi) Project.
ABSTRACT: Background Prestroke depression status and post-acute rehabilitation care (PARC) are determinants of poststroke depression and function. However, little is known on how prestroke depression status affects PARC placement, a possible pathway for upstream intervention. We examined how prestroke depression status affects PARC in a population-based study. Methods and Results Incident ischemic stroke cases were from the BASIC (Brain Attack Surveillance in Corpus Christi) Project from 2008 to 2012. Prestroke depression status was self-reported and categorized as (1) never depressed, (2) history of depression without antidepressant use before stroke onset, or (3) antidepressant use before stroke onset. PARC included home, a skilled nursing facility, or an inpatient rehabilitation facility. Confounder-adjusted multinomial regression models were used to examine the association between prestroke depression status and PARC. Adjustment for stroke severity was deferred in the main analyses because it may lie on the causal pathway. There were 548 stroke survivors (mean age 65.3 years, 48.3% female, 62.6% Mexican-American). The adjusted odds ratios comparing home discharge to a skilled nursing facility were 1.88 (95% CI: 0.86-4.11) for those with a history of depression and 2.55 (95% CI: 1.11-5.83) for those using an antidepressant at stroke onset, relative to those never depressed. The adjusted odds ratios comparing an inpatient rehabilitation facility to a skilled nursing facility were 1.17 (95% CI 0.40-3.42) and 3.28 (95% CI 1.24-8.67) for those with a history of depression and those using an antidepressant at stroke onset, respectively, relative to those never depressed. Conclusions Antidepressant use before stroke onset may increase odds of home and inpatient rehabilitation facility discharge compared with skilled nursing facility discharge.
Project description:<h4>Objective</h4>To determine the degree to which racial and ethnic disparities in the use of postacute rehabilitation care (PARC) are explained by observed characteristics.<h4>Data sources</h4>State inpatient databases (SIDs) for 2005 and 2006 from four diverse states were used to identify patients with stays for joint replacement, stroke, or hip fracture.<h4>Study design</h4>Our primary outcomes were use of institutional PARC (versus discharge home) and, conditional on discharge to an institution, skilled nursing facility (versus inpatient rehabilitation facility) care. We modified the Oaxaca-Blinder decomposition method to account for the dichotomous outcome and multilevel nature of the data.<h4>Data collection/extraction methods</h4>Discharges from the four SIDs were included if the principal diagnosis (stroke, hip fracture) or procedure (joint replacement) was in the sample inclusion criteria.<h4>Principal findings</h4>Observed characteristics explained roughly half of the unadjusted differences in use of institutional PARC. Patient-level factors (clinical, age) were more explanatory of disparities in institutional PARC use, while hospital-level factors were more explanatory of skilled nursing facility versus inpatient rehabilitation facility care.<h4>Conclusions</h4>Adjustment for characteristics influencing PARC use both mitigated and exacerbated racial/ethnic disparities in use. The degree to which the characteristics explained the disparity varied across conditions and outcomes.
Project description:OBJECTIVE:The aim of the study was to explore variation in acute care use of inpatient rehabilitation facilities and skilled nursing facilities rehabilitation after ischemic and hemorrhagic stroke. DESIGN:A secondary analysis of Medicare claims data linked to inpatient rehabilitation facilities and skilled nursing facilities assessment files (2013-2014) was performed. RESULTS:The sample included 122,084 stroke patients discharged to inpatient or skilled nursing facilities from 3677 acute hospitals. Of the acute hospitals, 3649 discharged patients with an ischemic stroke (range = 1-402 patients/hospital, median = 15) compared with 1832 acute hospitals that discharged patients with hemorrhagic events (range = 1-73 patients/hospital, median = 4). The intraclass correlation coefficient examined variation in discharge settings attributed to acute hospitals (ischemic intraclass correlation coefficient = 0.318, hemorrhagic intraclass correlation coefficient = 0.176). Patients older than 85 yrs and those with greater numbers of co-morbid conditions were more likely to discharge to skilled nursing facilities. Comparison of self-care and mobility across stroke type suggests that patients with ischemic stroke have higher functional abilities at admission. CONCLUSIONS:This study suggests demographic and clinical differences among stroke patients admitted for postacute rehabilitation at inpatient rehabilitation facilities and skilled nursing facilities settings. Furthermore, examination of variation in ischemic and hemorrhagic stroke discharges suggests acute facility-level differences and indicates a need for careful consideration of patient and facility factors when comparing the effectiveness of inpatient rehabilitation facilities and skilled nursing facilities rehabilitation.
Project description:Background The aim of this study was to discussions about post-stroke outcomes related to post-stroke function and post-acute care discharge setting.inform patient-provider. Methods and Results We conducted a retrospective cohort study of Medicare beneficiaries with acute ischemic stroke or intracerebral hemorrhage in 2013. Our primary outcome was mortality within at least 1-year post discharge. We performed multivariate logistic regression to estimate 90-day odds ratios (ORs) and Cox proportional hazards regression to estimate post 90-day hazard ratios on mortality, adjusting for demographics, procedures, comorbidities, discharge setting (inpatient rehabilitation facility, skilled nursing facility, or home health care agency), post-stroke function (measured by the Functional/Pseudo-Functional Independence Measure) and setting-function interactions. There were 167 000 patients with a mean follow-up of 441 days. Mortality within 90 days was associated with post-stroke function (OR, 0.23; 95% CI, 0.19-0.27 comparing highest to lowest quintile of post-stroke function) and discharge setting (OR, 4.05; 95% CI, 3.78-4.33 for skilled nursing facility versus inpatient rehabilitation facility). Among the highest functioning patients, those discharged to inpatient rehabilitation facility had a 1-year mortality of 9% and those discharged with home health had 11% mortality at 1 year. The lowest functioning survivors of stroke discharged to a skilled nursing facility had 64% mortality at 1 year and those discharged to an inpatient rehabilitation facility had 29.6% mortality at 1 year. Conclusions Nearly two thirds of the lowest functioning survivors of stroke discharged to a skilled nursing facility die within a year. This finding should inform discussions between providers and patients/caregivers in aligning goals of care with the care survivors of stroke receive.
Project description:<b>Objective:</b> To investigate the association between functional status and post-acute care (PAC) transition(s). <b>Methods:</b> Secondary analysis of 2013-2014 Medicare data for individuals aged ?66 years with stroke, lower extremity joint replacements, and hip/femur fracture discharged to one of three PAC settings (inpatient rehabilitation facilities, skilled nursing facilities, and home health agencies). Functional scores were co-calibrated into a 0-100 scale across settings. Multilevel logistic regression was used to test the partition of variance (%) and the probability of PAC transition attributed to the functional score in the initial PAC setting. <b>Results:</b> Patients discharged to inpatient rehabilitation facilities with higher function were less likely to use additional PAC. Function level in an inpatient rehabilitation facility explained more of the variance in PAC transitions than function level while in a skilled nursing facility. <b>Discussion:</b> The function level affected PAC transitions more for those discharged to an inpatient rehabilitation facility than to a skilled nursing facility.
Project description:Utilization of postacute care is associated with improved poststroke outcomes. However, more than 20% of American adults under age 65 are uninsured. We sought to determine whether insurance status is associated with utilization and intensity of institutional postacute care among working age stroke survivors.A retrospective cross-sectional study of ischemic stroke survivors under age 65 from the 2004-2006 Nationwide Inpatient Sample was conducted. Hierarchical logistic regression models controlling for patient and hospital-level factors were used. The primary outcome was utilization of any institutional postacute care (inpatient rehabilitation or skilled nursing facilities) following hospital admission for ischemic stroke. Intensity of rehabilitation was explored by comparing utilization of inpatient rehabilitation facilities and skilled nursing facilities.Of the 33,917 working age stroke survivors, 19.3% were uninsured, 19.8% were Medicaid enrollees, and 22.8% were discharged to institutional postacute care. Compared to those privately insured, uninsured stroke survivors were less likely (adjusted odds ratio [AOR] 0.53, 95% confidence interval [CI] 0.47-0.59) while stroke survivors with Medicaid were more likely to utilize any institutional postacute care (AOR = 1.40, 95% CI 1.27-1.54). Among stroke survivors who utilized institutional postacute care, uninsured (AOR = 0.48, 95% CI 0.36-0.64) and Medicaid stroke survivors (AOR = 0.27, 95% CI 0.23-0.33) were less likely to utilize an inpatient rehabilitation facility than a skilled nursing facility compared to privately insured stroke survivors.Insurance status among working age acute stroke survivors is independently associated with utilization and intensity of institutional postacute care. This may explain differences in poststroke outcomes among uninsured and Medicaid stroke survivors compared to the privately insured.
Project description:<h4>Background</h4>Despite the success of stroke rehabilitation services, differences in service utilization exist. Some patients with stroke may travel across regions to receive necessary care prescribed by their physician. It is unknown how availability and combinations of post-acute care facilities in local healthcare markets influence use patterns. We present the distribution of skilled nursing, inpatient rehabilitation, and long-term care hospital services across Hospital Service Areas among a national stroke cohort, and we describe drivers of post-acute care service use.<h4>Methods</h4>We extracted data from 2013 to 2014 of a national stroke cohort using Medicare beneficiaries (174,498 total records across 3232 Hospital Service Areas). Patients' ZIP code of residence was linked to the facility ZIP code where care was received. If the patient did not live in the Hospital Service Area where they received care, they were considered a "traveler". We performed multivariable logistic regression to regress traveling status on the care combinations available where the patient lived.<h4>Results</h4>Although 73.4% of all Hospital Service Areas were skilled nursing-only, only 23.5% of all patients received care in skilled nursing-only Hospital Service Areas; 40.8% of all patients received care in Hospital Service Areas with only inpatient rehabilitation and skilled nursing, which represented only 18.2% of all Hospital Service Areas. Thirty-five percent of patients traveled to a different Hospital Service Area from where they lived. Regarding "travelers," for those living in a skilled nursing-only Hospital Service Area, 49.9% traveled for care to Hospital Service Areas with only inpatient rehabilitation and skilled nursing. Patients living in skilled nursing-only Hospital Service Areas had more than five times higher odds of traveling compared to those living in Hospital Service Areas with all three facilities.<h4>Conclusions</h4>Geographically, the vast majority of Hospital Service Areas in the United States that provided rehabilitation services for stroke survivors were skilled nursing-only. However, only about one-third lived in skilled nursing-only Hospital Service Areas; over 35% traveled to receive care. Geographic variation exists in post-acute care; this study provides a foundation to better quantify its drivers. This study presents previously undescribed drivers of variation in post-acute care service utilization among Medicare beneficiaries-the "traveler effect".
Project description:Race and ethnicity play a significant role in poststroke outcomes. This brief report describes the presence of depression among stroke survivors who received inpatient rehabilitation and whether depression differs by race. Data from eRehabData and electronic medical records were analyzed for patients who received rehabilitation after an acute ischemic or hemorrhagic stroke. Of 1501 stroke patients, 61.3% were white, 33.9% were African American, and 4.8% were of other race/ethnic backgrounds. By retrospective clinical review, depression was documented for 29.7% of stroke patients. Premorbid versus new onset of poststroke depression was documented for 13.4% and 21.6% of whites, 7.5% and 11.5% of African American, and 0% and 16.7% of patients of other race/ethnic groups. Compared with whites, African American and people of other races had a lower odds of poststroke depression (African American adjusted odds ratio = 0.52, 95% confidence interval = 0.41-0.68; other races odds ratio = 0.37, 95% confidence interval = 0.19-0.71), after adjusting for all other significant risk factors identified in the bivariate analysis (sex, hyperlipidemia, cognitive deficit, neglect). Depression was documented for one in three stroke survivors who received inpatient rehabilitation and highest among whites especially for prestroke depression. Addressing depression in rehabilitation care needs to consider individual patient characteristics and prestroke health status.
Project description:To determine the extent to which demographic and geographic disparities exist in the use of post-acute rehabilitation care (PARC) for joint replacement.We conducted a cross-sectional analysis of 2 years (2005 and 2006) of population-based hospital discharge data from 392 hospitals in 4 states (Arizona, Florida, New Jersey, and Wisconsin). A total of 164,875 individuals who were age ? 45 years, admitted to the hospital for a hip or knee joint replacement, and who survived their inpatient stay were identified. Three dichotomous dependent variables were examined: 1) discharge to home versus institution (i.e., skilled nursing facility [SNF] or inpatient rehabilitation facility [IRF]), 2) discharge to home with versus without home health (HH), and 3) discharge to an SNF versus an IRF. Multilevel logistic regression analyses were conducted to identify demographic and geographic disparities in PARC use, controlling for illness severity/comorbidities, hospital characteristics, and PARC supply. Interactions among race, socioeconomic, and geographic variables were explored.Considering PARC as a continuum from more to less intensive care in regard to hours of rehabilitation per day (e.g., IRF?SNF?HH?no HH), the uninsured received less intensive care in all 3 models. Individuals receiving Medicaid and those of lower socioeconomic status received less intensive care in the HH versus no HH and SNF versus IRF models. Individuals living in rural areas received less intensive care in the institution versus home and HH versus no HH models. The effect of race was modified by insurance and by state. In most instances, minorities received less intensive care. PARC use varied by hospital.Efforts to further understand the reasons behind these disparities and their effect on outcomes are needed.
Project description:OBJECTIVE:To examine changes in more and less discretionary condition-specific postacute care use (skilled nursing, inpatient rehabilitation, home health) associated with Medicare accountable care organization (ACO) implementation. DATA SOURCES:2009-2014 Medicare fee-for-service claims. STUDY DESIGN:Difference-in-difference methodology comparing postacute outcomes after hospitalization for hip fracture and stroke (where rehabilitation is fundamental to the episode of care) to pneumonia, (where it is more discretionary) for beneficiaries attributed to ACO and non-ACO providers. PRINCIPAL FINDINGS:Across all 3 cohorts, in the baseline period ACO patients were more likely to receive Medicare-paid postacute care and had higher episode spending. In hip fracture patients where rehabilitation is standard of care, ACO implementation was associated with 6%-8% increases in probability of admission to a skilled nursing facility or inpatient rehabilitation (compared with home without care), and a slight reduction in readmissions. In a clinical condition where rehabilitation is more discretionary, pneumonia, ACO implementation was not associated with changes in postacute location, but episodic spending decreased 2%-3%. Spending decreases were concentrated in the least complex patients. Across all cohorts, the length of stay in skilled nursing facilities decreased with ACO implementation. CONCLUSIONS:ACOs decreased spending on postacute care by decreasing use of discretionary services. ACO implementation was associated with reduced length of stay in skilled nursing facilities, while hip fracture patients used institutional postacute settings at higher rates. Among pneumonia patients, we observed decreases in spending, readmission days, and mortality associated with ACO implementation.
Project description:To determine the extent to which demographic and geographic disparities exist in postacute rehabilitation care (PARC) use after hip fracture.Cross-sectional analysis of 2 years (2005-06) of population-based hospital discharge data.All short-term acute care hospitals in four demographically and geographically diverse states (AZ, FL, NJ, WI).Individuals aged 65 and older (mean 82.9) admitted to the hospital with a hip fracture who survived their inpatient stay (N = 64,065). The sample was 75.1% female and 91.5% white, 5.8% Hispanic, and 2.7% black.Whether the participant received institutional PARC; for participants who did not receive institutional care, whether they received home health (HH) care; and for participants who received institutional care, whether they received skilled nursing facility (SNF) or inpatient rehabilitation facility (IRF) care. Multilevel logistic regression analyses were conducted to identify demographic and geographic disparities in PARC use.Considering PARC on a continuum from more to fewer hours of care per day (IRF?SNF?HH?no HH), minorities and individuals of lower socioeconomic status (SES) generally received a lower volume of care. Individuals on Medicaid or who were uninsured were less likely to receive institutional care (odds ratio (OR) = 0.23, 95% confidence interval (CI) = 0.18-0.30) and to receive HH (OR = 0.46, 95% CI = 0.30-0.70) and more likely to receive SNF than IRF care (OR = 2.03, 95% CI = 1.36-3.05). Hispanics were less likely to receive institutional care (OR = 0.70, 95% CI = 0.62-0.79), and Hispanics (OR = 1.31) and blacks (OR = 1.49) were more likely to receive SNF than IRF care. There were also geographic differences in PARC.Several demographic and geographic disparities in PARC use were identified. Future research should confirm these findings and further elucidate factors that contribute to the observed disparities.