Table 3.

Differences in Health Outcomes by Site of Rehabilitation (IRF and SNF) Among Patients with Stroke

Author (Year)	Analytic Approach	Comparison	Crude Percentages or Means	Measure(s)	Summary of findings
Community Discharge
Deutsch et al. (2006)	Multivariable logistic model*	IRF vs. SNF (Reference)	Stratified by disability level: Minimal motor: IRF: 98.6%; SNF: 98.6%	aOR 95% CI	Community discharges in IRF more common than in SNF for these patients:
			Mild motor/mild cognitive: IRF: 96.7%; SNF: 91.7% Minimal motor/significant cognitive: IRF: 90.6%; SNF: 88.3%		Mild motor disabilities and cognitive ratings: aOR: 2.19; 95% CI: 1.52–3.14
			Moderate motor: IRF: 92.3%; SNF: 84.2%		Moderate motor disabilities: aOR: 1.98; 95% CI: 1.49–2.61
			Significant motor: IRF: 85.8%; SNF: 79.3%		Significant motor disabilities: aOR: 1.26; 95% CI: 1.01–1.57
			Severe motor--patients ≥ 82 years: IRF: 54.6%; SNF: 49.4% patients < 82 years: IRF: 66.4%; SNF: 52.0%		Severe motor disabilities, patients <82 years: aOR: 1.43; 95% CI: 1.25–1.64
Hoenig et al. (2001)	Multivariable logistic model†	Rehabilitation unit and geriatric unit vs. SNF† (Reference)	Rehabilitation unit: 75.0% Geriatric unit: 71.8% SNF||: 66.6%	aOR 95% CI	Relative to those in SNFs||, patients in rehabilitation units (aOR: 1.91; 95% CI 1.47–2.50) and geriatric units (aOR:1.43; 95% CI 1.03–1.97) had increased odds of being discharged home.
Physical Functioning
Chen et al. (2002)	Multiple linear model‡	IRF and Acute hospital vs. SNF (Reference)	Average Rasch-transformed Mobility Gain (range 0–100): 17	Standardized β Coefficient	Patients in SNFs made larger gains in mobility than patients in IRF (−0.20; p<0.05) or patients in acute hospitals (−0.16; p<0.05).
Deutsch et al. (2006)	Multiple linear model*	IRF vs. SNF (Reference)	Discharge FIM motor rating stratified by disability level: Minimal motor:  IRF: 86.6; SNF: 85.0 Mild motor/mild cognitive:  IRF: 79.2; SNF: 78.3 Minimal motor/significant cognitive:  IRF: 77.5; SNF: 77.5 Moderate motor:  IRF: 73.1; SNF: 71.1	Adjusted β coefficient representing the mean FIM difference (IRF-SNF) 95% CI	Clinically relevant functional gains (≥2 FIM units) in IRF more common than in SNF for these patients:
			Significant motor:  IRF: 67.1; SNF: 64.9		Significant motor disabilities:  adjusted β: 2.40; 95% CI: 1.19–2.66
			Severe motor-- patients ≥ 82 years:  IRF: 46.1; SNF: 40.1 patients < 82 years:  IRF: 49.8; SNF: 41.8		Severe motor disabilities— patients ≥82 years:  adjusted β: 2.39; 95% CI: 1.45–3.32 patients <82 years:  adjusted β: 4.24; 95% CI: 3.45–5.03
Kane et al. (2000)	Multiple linear model§ Instrumental variable analysis	IRF vs. SNF (Reference)	Average percentage change in the activities of daily living score at six weeks, 6 months, and 12 months. Crude average change values were not provided. IRF: 6 weeks: 23.2% improved 6 months: 13.9% improved 12 months: 7.8% improved SNF: 6 weeks: 0.7% improved 6 months: −5.9% worsened 12 months: −6.7% worsened	Adjusted mean functional dependency scores Predicted gain in functional improvement in optimal post-acute care setting	Relative to those in SNFs, patients in IRF settings regained more activities of daily living at six weeks. Despite some rebound loss of activities of daily living between 6 and 12 months, IRF patients fared better than SNF patients (Figure 2 of manuscript). Patients discharged to SNF would have achieved maximum functional improvement had they been discharged to home with health care. Additional gains in function by optimal post-acute care location for patients actually in SNF and IRF settings differed most at 6 weeks (IRF: 3.1%, SNF: 16.9%) and were similar at 6 months (IRF: 15.5%, SNF: 18.3%) and 12 months (IRF:15.9%, SNF: 16.2%)
Chan et al. (2013)	Multiple linear model||	SNF vs. IRF (reference	AMPAC score at 6 months: IRF: 52 SNF: 43	Adjusted β coefficient representing the mean AM-PAC difference (SNF-IRF) 95% CI	Results from two models were reported, one adjusting for hospital readmission and quantity of therapy (adjusted β: −10.1; 95% CI: −15.0 to −5.2), and the other model not adjusting for readmission and quantity of therapy (adjusted β: −6.1; 95% CI: −11.2 to −1.0).
Hospital Readmission
Kind et al. (2010)	Unspecified statistical model with robust variables estimates to account for clustering of patients within hospitals¶	IRF and SNF	Crude estimates not available by site of care.	Predicted probability of readmission (hospital or emergency department) 95% CI	Predicted probabilities of readmission less for IRF than SNF in each racial/ethnic group. Blacks:  IRF: 20%; 95% CI: 17.9–22.7  SNF: 26%; 95% CI: 24.2–28.6 Hispanics:  IRF: 18%; 95% CI: 13.1–22.9  SNF: 28%; 95% CI: 24.0–32.6 Whites:  IRF: 18%; 95% CI: 17.3–19.1  SNF: 21%; 95% CI: 20.3–21.9
All-cause Mortality
Buntin et al. (2010)	Generalized estimating equations (binary logit)# Instrumental variable analysis#	IRF vs. SNF (Reference)	Mortality within 120 days IRF: 6.2% SNF: 14.7%	Absolute difference in 120-day mortality 95% CI	Use of IRF reduced mortality by 2.6 percentage points compared to SNFs. adjusted β: −2.58; 95% CI: 0.96–4.16
Kind et al. (2010)	Unspecified statistical model with robust variables estimates to account for clustering of patients within hospitals¶	IRF and SNF	Crude estimates of 30-day mortality not available by site of care.	Predicted probability of 30-day mortality among those with no readmissions 95% CI	Predicted probability of death in IRF settings lower than SNF settings in each racial/ethnic group. Blacks:  IRF: 2%; 95% CI: 1.6–3.3  SNF: 5%; 95% CI: 4.2–6.1 Hispanics:  IRF: 1%; 95% CI: 0–1.5  SNF: 5%; 95% CI: 3.2–6.3 Whites:  IRF: 2%; 95% CI: 1.9–2.5  SNF: 8%; 95% CI: 7.2–8.2
Wang et al. (2011)	Cox proportional hazards multivariable model**	IRF vs. SNF (Reference)	Stratified by the highest level of post-acute care within 14 and 61 days: Post-acute (14 days): IRF: 4.4% SNF: 21.4% Post-acute (61 days): IRF: 4.3% SNF: 16.2%	Adjusted hazard rate ratio 95% CI	Patients in IRF settings died at a rate less than half that of those in SNF settings. Post-acute (14 days): Adjusted hazard ratio: 0.33 95% CI 0.24–0.45 Post-acute (61 days): Adjusted hazard ratio: 0.42 95% CI 0.33–0.53

^*Covariates included were time from stroke onset to rehabilitation admission, admission FIM motor rating, admission FIM cognitive rating, age, hemorrhagic versus non-hemorrhagic stroke, presence of left-sided, right-sided, or bilateral paresis, presence of a tiered comorbidity, visual field deficits, living alone, median household income, race (Black, White, Other), sex, geographic region, and site of care (IRF, SNF).

^†SNF classification included nursing home, intermediate care, or subacute care ward. Covariates included were patient characteristics: age > 70 years, white race, Charlson comorbidity index, intubation, length of stay, second bed section an acute bed, and site of post-acute care (rehabilitation unit, geriatric unit, SNF)

^‡Covariates included were factors measured at admission (self-care, mobility, cognition), age, sex, therapy intensity, length of stay, days since onset, interrupted stays, and site of care (general hospital, IRF, SNF).

^§Covariates included discharge activities of daily living score, sum of activities of daily living and instrumental activities of daily living prior to hospitalization, patient’s self-expected activities of daily living score at six weeks after hospital discharge, sex, age, race, living arrangement, cognitive status, presence of catheter, patient’s ability to exercise prudent judgement, health status prior to hospitalization, HMO membership, city, patient’s role in discharge decision making, length of hospital stay, hospital’s post-acute care facility ownership, informal support given before hospitalization, social and economic status of caregiver, acuity score at admission, comorbidity, diagnosis related group severity scores, and instability. Instruments used were predicted probabilities of specific discharge site of care.

^||Covariates included age, body mass index, baseline functional status, inpatient Modified-Rankin score, history of prior stroke, Charlson comorbidity index.

^¶Covariates included age, sex, region, index hospitalization admission year, length of hospital stay, HMO membership, Medicaid indicator variable, comorbidities, measures of stroke severity (mechanical ventilation and presence of gastrostomy tube), neighborhood socioeconomic characteristics including percent over 24 years of age with a college degree and percent below the poverty line, and indicator variables for site of care (home, home with health care, IRF, SNF).

^#Covariates included patient demographic (age, age squared, sex, interaction of age and sex, race, urban/rural, Medicaid) and clinical characteristics (13 comorbidities and 17 complications that could influence outcome of post-acute care), indicators of type of stroke, hospital facility factors (size, teaching status, ownership, % Medicare, case-mix, and % low income), county-level HMO penetration, and indicator variables for site of care (IRF, SNF, home). Instruments used were patient-specific measures of accessibility and proximity to post-acute care providers.

^**Covariates included age, age squared, sex, racial/ethnic group, previous stroke, Charlson-Deyo comorbidity index, service area, acute care length of stay, and dummy variables for site of care (outpatient visits, home health care, IRF, SNF).

Abbreviations: skilled nursing facility (SNF), inpatient rehabilitation facility (IRF), adjusted odds ratio (aOR), confidence interval (CI), Functional Impairment Measure (FIM), health maintenance organization (HMO)