The unmet need for postacute rehabilitation among medicare observation patients: A single-center study

The Institutional Review Board of Christiana Care Health System (CCHS) approved this study.

Sample and Design

This was an observational study of community-dwelling Medicare patients admitted under observation status to Delaware’s CCHS, which consists of a 907-bed regional tertiary-care facility in Newark and a 241-bed community hospital in Wilmington. The study period was January 1 to December 31, 2013. We limited our sample to patients treated by hospitalists on hospital wards, as this care constitutes 80% of the care provided to observation patients at CCHS and the majority of care nationally.⁸ As neither SNF care nor IRF care is covered under Medicare Part B, and both would result in high out-of-pocket costs for Medicare observation patients, we combined them into a single variable, PAIR.

All data were obtained from institutional electronic medical record and administrative data systems. Study inclusion criteria were Medicare as primary insurance, admission to hospital from home, and care received at either CCHS facility. Exclusion criteria were admission from PAIR facility, long-term care facility, assisted-living facility, or inpatient psychiatric facility; death; discharge against medical advice (AMA) or to hospice, non-SNF, or inpatient psychiatric facility; and discovery (during review of case management [CM] notes) of erroneous listing of Medicare as primary insurance, or of inpatient admission (within 30 days before index observation stay) that qualified for PAIR coverage under Medicare Part A.

We reviewed the medical charts of a representative (~30%) sample of the cohort and examined physical therapy (PT) and CM notes to determine the proportions of patients with recommendations for home with no services, home-based PT, possible PAIR, and PAIR. Charts were sorted by medical record number and were reviewed in consecutive order. We coded a patient as having a recommendation for possible PAIR if the PT notes indicated the patient may benefit from PAIR but could have home PT if PAIR placement was not possible. CM notes were also reviewed for evidence of patient or family preference regarding PAIR placement. All questions about PT and CM recommendations were resolved by consensus.

Measures

For the total study sample, we calculated descriptive statistics and frequencies for demographic and administrative variables, including age, sex, race (Caucasian, African American, other), ethnicity (Hispanic/non-Hispanic), ICD-9 (International Classification of Diseases, Ninth Revision) primary diagnosis code, LOS (in hours) for index observation admission, discharge disposition (home with no services, home PT, possible PAIR, PAIR), and 30-day hospital revisit (emergency department, observation, inpatient admission). We used χ² test, Student t test, and analysis of variance (ANOVA) to test for statistically significant differences in characteristics between the chart review subgroup and the rest of the sample and between the groups with different disposition recommendations from PT notes.

For the chart review subgroup, we used ANOVA to calculate the unadjusted association between PT recommendation and LOS. We then adjusted for potential confounders, using multivariable linear regression with PT recommendation as a predictor and LOS as the outcome, controlling for variables previously associated with increased LOS among observation patients (primary diagnosis category, age, sex).⁶ We also adjusted for hospitalist group to account for potential variability in care delivery. As LOS was not normally distributed, we calculated the fourth root of LOS, which resulted in a more normal distribution, and used the transformed values in the regression model. We then calculated predicted values from the regression and back-transformed these to obtain adjusted mean values for LOS.

Of the 1417 unique patients who had Medicare as primary insurance and were admitted under observation status to a hospitalist service during the study period (2013), 94 were excluded (Figure). Of the remaining 1323 patients, the majority were 65 years old or older, female, white, and non-Hispanic. The most common ICD-9 diagnoses were syncope and chest pain. Mean LOS was 46.7 hours (range, 0-519 h). Less than 1% of patients were discharged to PAIR. Almost 25% of patients returned to the hospital, either for an emergency department visit or for observation or inpatient stay, within 30 days (Table).

Of the 419 charts reviewed to determine the proportion of patients evaluated by PT, and their subsequent recommendations, 33 were excluded, leaving 386 (92%) for analysis (Figure). There were no significant demographic differences between the patients in the chart review subgroup and the rest of the patients (Appendix). Of the 386 patients whose charts were analyzed, 181 (46.9%) had a PT evaluation, and 17 (4.4%) received a PAIR recommendation (Figure). Of the 17 patients recommended for PAIR, 12 (70.5%) were 65 years old or older, and 1 was discharged to a PAIR facility. Of the 46 patients recommended for home PT, 29 (63%) were discharged home with no services (Table).

PT-evaluated patients had unadjusted mean LOS of 52.2 hours (discharged home with no services), 64.1 hours (home PT or possible PAIR), and 83.1 hours (PAIR) (P = 0.001). With adjustment made for variables previously associated with increased LOS for observation patients, mean LOS for patients recommended for PAIR remained higher than that for patients in the other 2 categories (Table). Patients recommended for PAIR were more likely to return to hospital within 30 days than patients recommended for home PT or possible PAIR and patients discharged home with no services (Table).

Review of CM notes revealed that, of the 17 patients recommended for PAIR, 7 would have accepted PAIR services had they been covered by Medicare, 4 preferred discharge with home health services, and 6 did not provide clear details of patient or family preference.