http://journals.lww.com/md-journal/Fulltext/2016/08160/Physiatrist_referral_preferences_for_postacute.15.aspx
Author Information
aDepartment of Rehabilitation and Regenerative Medicine, Columbia University College of Physicians and Surgeons
bDivision of Rehabilitation Medicine, Weill Cornell Medical College
cNew York-Presbyterian Hospital, New York, NY.
Correspondence: David J. Cormier, Department of
Rehabilitation and Regenerative Medicine, Columbia University Medical
Center, Harkness Pavilion Room HP-1-165, 180 Fort Washington Ave., New
York, NY 10032 (e-mail: davidjohncormier@gmail.com).
Abbreviations: AAPM&R = American Academy of
Physical Medicine and Rehabilitation, ADLs = activities of daily living,
IRF = inpatient rehabilitation facilities, LTACH = long-term acute care
hospital, MCA = middle cerebral artery, SNF = skilled nursing
facilities.
The authors report no conflicts of interest.
This is an open access article distributed under the
Creative Commons Attribution License 4.0, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original
work is properly cited. http://creativecommons.org/licenses/by/4.0
Received February 25, 2016
Received in revised form June 13, 2016
Accepted July 3, 2016
Abstract
Abstract: This study was intended to determine if
there is variation among physiatrists in referral preferences for
postacute rehabilitation for stroke patients based on physician
demographic characteristics or geography.
A cross-sectional survey study was developed with 5
fictional case vignettes that included information about medical,
social, and functional domains. Eighty-six physiatrist residents,
fellows, and attendings were asked to select the most appropriate
postacute rehabilitation setting and also to rank, by importance, 15
factors influencing the referral decision. Chi-square bivariate analysis
was used to analyze the data.
Eighty-six surveys were collected over a 3-day period.
Bivariate analysis (using chi-square) showed no statistically
significant relationship between any of the demographic variables and
poststroke rehabilitation preference for any of the cases. The prognosis
for functional outcome and quality of postacute facility had the
highest mean influence ratings (8.63 and 8.31, respectively), whereas
location of postacute facility and insurance had the lowest mean
influence ratings (5.74 and 5.76, respectively).
Physiatrists’ referral preferences did not vary with
any identified practitioner variables or geographic region; referral
preferences only varied significantly by case.
1 Introduction
Nearly 800,000 individuals experience a stroke each year in the United States, at a cost of 33.6 billion dollars.[1]
Whereas some persons with stroke recover fully, many are left with
substantial disability. Stroke is the leading cause of serious long-term
disability in this country.[1]
Given the impact on individuals with stroke and the substantial
resources devoted to their care, it is important to gain a greater
understanding of which poststroke interventions lead to the best
outcomes. One area of controversy is the type of rehabilitation facility
where persons with stroke should receive their rehabilitative care.
Poststroke rehabilitation options include inpatient
rehabilitation facilities (IRFs), skilled nursing facilities (SNFs),
long-term acute care hospitals (LTACHs), home therapy, and outpatient
therapy. The process of assessing rehabilitation needs and selecting the
most appropriate rehabilitation option for a person with acute stroke
is complex and not well-studied. Depending on the institution, this
determination may be made by nurses, case managers, social workers,
physical therapists, occupational therapists, speech and language
pathologists, and/or physicians (including physiatrists, neurologists,
internists, and others). Physiatrists’ role in this process varies among
hospitals, with some hospitals involving physiatry routinely, and
others rarely or never. Physiatrists’ role includes the medical and
functional assessment as it encompasses all of the rehabilitation needs,
through a strong relationship within the interdisciplinary
rehabilitation team. Physiatrists are arguably the physicians with the
most specific training in stroke rehabilitation, and it is therefore
important to better understand their referral preferences for these
patients.
Many factors may be considered when determining the most
appropriate poststroke rehabilitation option for a given patient. These
factors may include the severity and nature of neurological and
functional deficits, medical comorbidities, provider and facility
relationships, insurance coverage, cost, geographical proximity and
location of available facilities, and patient and family preference.[2,3]
When referral to an IRF is being considered, the question of whether or
not a patient will be able to participate in and benefit from the
3 hours of therapy that are mandated in an IRF is of particular concern.
Assessment protocols are not standardized, and there is
little reassurance that patients are reliably receiving the most
appropriate rehabilitation. Furthermore, there exist no standardized
criteria or guidelines to assist referral teams in predicting which
poststroke discharge option is optimal for each patient. To optimize
patient outcomes after stroke, more information is needed about which
patients benefit most from rehabilitation in each setting. Knowing who
is making these referral decisions and how they are making them is an
important first step towards reaching this goal.
Given the large number of individuals involved in making
decisions regarding rehabilitation level of care, and the many factors
that contribute to this decision, it is unsurprising that research has
found variation in referral patterns. After stroke, patients are more
likely to be evaluated for rehabilitation needs if they are hospitalized
in a stroke unit.[4]
Measures of activities of daily living (ADLs) ability after stroke are
predictive of discharge home versus a rehabilitation institution, but do
not distinguish between patients discharged to SNF and patients
discharged to IRF.[5]
When rehabilitation consultation teams assist in making the referral decision, patient outcomes improve.[6] Ilet et al[7]
further found that the likelihood of discharge to a rehabilitation unit
is influenced by variation in practice among hospitals. Geographic
proximity to an IRF has been shown to be a substantial predictor of the
likelihood of discharge to IRF.[8]
Variation in the utilization and intensity of poststroke rehabilitation
services has also been demonstrated by Medicare beneficiaries’ payment
analysis.[9,10]
Patients who suffer a stroke benefit from early rehabilitation.[11,12]
There is also some indication in the literature that patients admitted
to IRF experience better functional recovery than those admitted to SNF.[13–17]
To date, studies comparing IRF to SNF outcomes in the United States
have all been observational in nature, and no randomized studies have
been performed. As a result, comparing IRF to SNF stroke rehabilitation
outcomes is complicated by the differences between the patient
populations referred for these 2 different types of care. Multiple
factors known to influence outcomes after stroke (age, cognition,
functional level, continence) have also been found to be different in
those receiving postacute stroke rehabilitation in IRFs and those
receiving this rehabilitation in SNF.[6]
We sought to examine postacute stroke rehabilitation
referral preferences among physiatrists. We hypothesized that there is
variation among physiatrists in referral preferences based on
demographic variables and/or geographic location, leading to patients
with similar backgrounds and functional limitations being referred to
different types of rehabilitation. Given that different rehabilitation
options have different outcomes, this variation in referral preferences
may lead to suboptimal rehabilitation outcomes for some stroke patients.[5]
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