MULTIPLE SCLEROSIS (MS) is a chronic, disabling

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1 ORIGINAL ARTICLE Inpatient Rehabilitation Utilization for Medicare Beneficiaries With Multiple Sclerosis Melissa A. Morley, PhD, Laura A. Coots, MS, Angela L. Forgues, BA, Barbara J. Gage, PhD 1377 ABSTRACT. Morley MA, Coots LA, Forgues AL, Gage BJ. Inpatient rehabilitation utilization for Medicare beneficiaries with multiple sclerosis. Arch Phys Med Rehabil 2012;93: Objective: To explore the use of inpatient rehabilitation facility services and levels of impairment for Medicare beneficiaries with multiple sclerosis (MS) by comparing differences in service utilization and clinical characteristics between Medicare beneficiaries with MS to the overall Medicare population. Design: Medicare beneficiaries with MS were identified using Medicare claims data. Claims and assessment data were analyzed to compare outcomes for beneficiaries with MS who used inpatient rehabilitation compared with a random sample of Medicare beneficiaries without MS. Setting: Inpatient rehabilitation facilities. Participants: Medicare beneficiaries with a diagnosis of MS who received inpatient rehabilitation during the 2007 calendar year (n 4669) and a random sample of Medicare beneficiaries without MS (n 14,397). Interventions: Not applicable. Main Outcome Measures: Change in functional impairment levels between admission and discharge to inpatient rehabilitation and length of stay. Results: There were several differences in beneficiary characteristics between the 2 groups. Beneficiaries with MS had lower change in functional levels ( 3.3 points on the FIM) and longer length of stay (0.4d). Conclusions: While beneficiaries with MS account for a small proportion of the Medicare population, the benefit is important to those who qualify for Medicare coverage. This study illustrates the differences between the subpopulation of beneficiaries with MS and other Medicare beneficiaries. The findings show that populations with MS had less functional improvement than other Medicare populations using the inpatient rehabilitation setting. Higher rates of depression within the MS Medicare population was a secondary finding that presents another important consideration for rehabilitation service needs for this group. Key Words: Medicare; Multiple sclerosis; Rehabilitation; Subacute care. From Aging Disability and Long-Term Care, RTI International, Waltham, MA (Morley, Coots, Gage); Heller School for Social Policy and Management, Brandeis University, Waltham, MA (Coots); and Department of Population Health Sciences and the Center for Health Enhancement System Studies, University of Wisconsin, Madison, WI (Forgues). Presented in preliminary form to the AcademyHealth, June 28-30, 2009, Chicago, IL. Supported by the National Multiple Sclerosis Society. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated. Reprint requests to Melissa A. Morley, PhD, RTI International, 1440 Main St, Ste 310, Waltham, MA , mmorley@rti.org. In-press corrected proof published online on May 11, 2012, at /12/ $36.00/ by the American Congress of Rehabilitation Medicine MULTIPLE SCLEROSIS (MS) is a chronic, disabling disease of the central nervous system affecting between 250,000 to 350,000 people in the United States. 1 The most common type of progression is relapsing-remitting, which affects approximately 85% of patients with MS and is characterized by relapses with complete or partial recovery. Despite its progressive nature, MS has little effect on life span with patients frequently living with the disease for more than 30 years postdiagnosis. 2 However, MS can affect a patient s mobility, limit a patient s ability to perform other activities of daily living, and affect health-related quality of life. 3-7 Within 10 years of diagnosis, nearly 50% of MS patients require an ambulation aid and 15% require the use of a wheelchair. 8 Because of their health status and disability, many individuals with MS leave the labor force during their most productive years and must depend on relatives or government programs for support. 9 Rehabilitation services, both inpatient and outpatient, can be an important part of ongoing treatment for MS patients to help manage symptoms and maintain and improve functional status and level of disability. Several studies have highlighted the benefits of rehabilitation interventions in both outpatient and inpatient settings for MS patients One study of the efficacy of inpatient physical rehabilitation on impairment, disability, and the quality of life of MS patients showed that physical rehabilitation reduces disability and also improves mental components of healthrelated quality of life measures. 11 Another study of the effects of inpatient rehabilitation on the progression of MS found that these services reduce disability in MS patients despite continued decline in neurologic status. 12,14 These findings also build on earlier work demonstrating that inpatient rehabilitation services lead to gains in functional status for patients with MS. 15 Extended outpatient rehabilitation has also been found to reduce fatigue and the severity of symptoms associated with MS. 16 Outpatient rehabilitation can also reduce disability in MS patients and improve quality of life. 17,18 By slowing the stages of disablement, rehabilitation treatments may allow MS patients to improve functional abilities and quality of life. While the use of inpatient rehabilitation services has been explored to some extent in the general MS population, limited research has focused on this population s use of services in the Medicare program though the cost of treating Medicare beneficiaries with MS are substantial. Based on 1996 to 1997 Medicare CCW IRF IRF-PAI MS RIC List of Abbreviations Chronic Condition Data Warehouse inpatient rehabilitation facility Inpatient Rehabilitation Facility-Patient Assessment Instrument multiple sclerosis rehabilitation impairment category

2 1378 INPATIENT REHABILITATION USE AND MEDICARE, Morley claims data, the annual expenditures for Medicare beneficiaries with MS were about twice the expenditures for all other Medicare beneficiaries. 19 Understanding service use for Medicare beneficiaries with MS is important given the potential of these services to improve disability and quality of life. The goal of this study is to explore the use of inpatient rehabilitation facility (IRF) services and levels of impairment for beneficiaries by comparing clinical characteristics with the overall Medicare population. It is valuable to document characteristics of this specific patient population relative to the overall Medicare population given that so many patients with MS become Medicare-eligible and that these beneficiaries account for significant utilization and spending relative to beneficiaries without MS. This study has 2 objectives. The first is to examine the use of IRFs for Medicare beneficiaries with MS compared with the overall Medicare population (Medicare standard 5% sample), specifically looking at differences in patient demographics and clinical characteristics such as the presence of chronic conditions, reasons for rehabilitation, and functional impairment levels at admission and discharge. The second objective is to explore the predictors of functional improvement and length of stay for beneficiaries using inpatient rehabilitation. The results of this work are valuable to understanding characteristics of Medicare beneficiaries with MS and potential functional improvements that can be realized through the use of inpatient rehabilitation services, and how differences in functional improvement may vary by other patient characteristics, primary diagnoses, and comorbidities. METHODS The data sources for this study included Medicare claims data and Medicare assessment data from the 2007 calendar year obtained from the Centers for Medicare and Medicaid Services. The assessment data used are the Inpatient Rehabilitation Facility-Patient Assessment Instrument (IRF-PAI), which is completed for patients at admission and discharge from IRFs. Patient information collected on this assessment includes demographics, reasons for rehabilitation, comorbidities, other clinical characteristics, and functional impairment levels. In addition, we analyzed Medicare claims data for information on beneficiaries enrollment status including disability and dual eligibility in Medicare and Medicaid. Our analyses include Medicare beneficiaries who were eligible for Medicare because of age as well as those eligible because of disability, because it was expected that the population could fall into either eligibility category. We included both groups in the Medicare comparison group in order to allow for a more representative comparison. We also used the Chronic Condition Data Warehouse (CCW) Chronic Conditions Summary File to obtain information on the presence of several chronic conditions. Although MS is not included as one of the CCW chronic conditions, the CCW data are available for all Medicare beneficiaries and provide valuable information as to whether beneficiaries have ever been documented as having chronic conditions that otherwise may not be captured on the claims or assessment data for a given year. The CCW data consist of a series of ever flags identifying the presence of 21 chronic conditions including, for example, depression, chronic obstructive pulmonary disease, and Alzheimer s disease. We focused on 15 of the conditions reported in the CCW. These ever flags are based on the date that the beneficiary first met the criteria for having a chronic condition, and the earliest possible date was January 1, This allows us to capture the presence of chronic conditions prior to the 2007 IRF admission. Our sample included all Medicare beneficiaries with a diagnosis of MS using IRF services in This sample includes Medicare beneficiaries with MS who were admitted to inpatient rehabilitation for any reason including MS. While the majority of beneficiaries were admitted for MS, the inclusion of MS beneficiaries admitted for another reason allows us to analyze the effect of having MS on rehabilitation outcomes. These beneficiaries were identified based on the presence of the International Classification of Diseases Ninth Revision Code for MS (340), coded in any position on any claim type (inpatient or outpatient) during the 2007 calendar year, as well as the presence of an IRF claim. Note that the 100% Medicare claims data were used to identify MS beneficiaries to ensure sufficient sample size for the analyses of IRF use. The comparison group for the study was the standard 5% Medicare beneficiary sample, excluding those with MS, with an IRF admission in The 5% Medicare beneficiary sample is a nationally representative sample generated by the Centers for Medicare and Medicaid Services. This sample is often used by researchers rather than the 100% files because of constraints in file sizes and processing time. Beneficiaries were excluded from the study sample if they were less than 18 years old or if they had end stage renal disease. Beneficiaries with end stage renal disease represent a very small proportion of the Medicare population and were excluded from these analyses because of their increased case-mix complexity, which may skew our results. Analysis included only beneficiaries who were discharged alive from the IRF setting. The primary focus of this study was to profile Medicare beneficiaries with a diagnosis of MS who used inpatient rehabilitation relative to the overall Medicare population using inpatient rehabilitation. Both descriptive analyses of beneficiary characteristics and multivariable linear regression models predicting change in functional status and IRF length of stay were performed. Key variables of interest included several patient demographic characteristics and enrollment characteristics (ie, disability and dual eligibility in Medicare and Medicaid). Key clinical variables included reasons for inpatient rehabilitation, functional impairment levels, and the presence of 1 or more of 15 chronic conditions. While initially all 21 chronic conditions were used in regression models, we removed 6 conditions (breast cancer, colorectal cancer, endometrial cancer, lung cancer, prostate cancer, and cataracts) based on t values less than 1.0. Change in functional status was measured using the FIM instrument from the IRF-PAI. The FIM is used to assess patients on 18 functional and cognitive items including items related to self-care, sphincter control, transfers, locomotion, communication, and social cognition. Each item is assessed using a 7-point scale, where a score of 1 corresponds to complete dependence or total assistance and a 7 corresponds to complete independence. The maximum total FIM score at admission or discharge is 126 based on a patient with complete independence (score of 7) for each of the 18 items. For this study, a total FIM change measure was calculated by subtracting the total score at admission from the total score at discharge. The range of possible values for the change measure is 108 to 108, where negative change values indicate functional decline and positive values indicate functional improvement. The goal of inpatient rehabilitation is for patients to attain functional improvement between admission and discharge. IRF length of stay was measured in days and calculated based on the number of days between admission and discharge. Comparisons between the 2 groups were made using chi-square test for categorical variables and t tests for continuous variables. We assessed collinearity in the regression models, and concluded that this did not pose a problem. Additionally, we evaluated the impacts of outlying data to identify if these skewed our results, but found there were very few observa-

3 INPATIENT REHABILITATION USE AND MEDICARE, Morley 1379 Table 1: Demographic Characteristics of Beneficiaries Using IRFs: Population Versus Sample in 2007 Characteristics Population (n 4669) % Sample (n 14,397) % 2 P Male Race White Nonwhite Marital status Married Not married Age (y) Disability Percent Medicaid/dual eligibility Prehospital living setting in community* Percent with complications during IRF stay Chronic conditions Acute myocardial infarction Alzheimer s disease Alzheimer s disease and related disorders or senile dementia Atrial fibrillation Chronic kidney disease Chronic obstructive pulmonary disease Congestive heart failure Depression Diabetes Glaucoma Hip/pelvic fracture Ischemic heart disease Osteoporosis Rheumatoid arthritis/osteoarthritis Stroke/transient ischemic attack NOTE Medicare data from the IRF-PAI, claims data, and CCW data were the sources of data for these analyses. *Community settings include home, board and care, transitional living, and assisted living residence. CCW flags indicating whether the beneficiary ever had the condition. tions that fell outside the expected ranges. This study was approved by the appropriate institutional review board. RESULTS The demographic characteristics of the study samples are displayed in table 1. Overall, 4669 beneficiaries with a diagnosis of MS used IRF services in 2007, 3% of the MS population. In comparison, 0.3% of beneficiaries in the Medicare 5% sample had at least 1 IRF claim. MS beneficiaries were also younger on average compared with the sample (mean age, 60.7y vs 75.6y). While over half (57.9%) of MS beneficiaries were under age 65 and disabled (55.3%), in comparison, only 11% of the sample were under age 65 and only 9% were disabled. The population also had a higher proportion of dually eligible beneficiaries (28.8%) compared with the sample (16.9%). The prevalence of chronic conditions among beneficiaries using IRFs in the population was lower compared with beneficiaries using IRFs in the sample for 14 of 15 conditions examined using the CCW data (see table 1). The population had a significantly higher proportion of beneficiaries with depression (60.6%) compared with the sample (44.4%). Table 2 compares beneficiaries to the 5% sample based on the reason for IRF admission. The reason for IRF admission is reported here using rehabilitation impairment categories (RICs). An RIC is the broad diagnostic category used for Medicare payment based on codes recorded on admission IRF-PAI assessments. The 21 RICs provide a useful classification system for understanding the types of beneficiaries admitted into this setting. As shown in table 2, the majority of IRF admissions for the population were for RICs related to the nervous system and brain (73.8%) compared with 38.8% for the sample. Over 55% of beneficiaries in the population had IRF admissions for the neurologic conditions RIC, which includes MS. Of the admissions for this RIC, 88.5% were coded with MS as the specific reason for rehabilitation. The sample had a smaller proportion of nervous system and brain IRF admissions than the population, but had a greater proportion of musculoskeletal admissions (42.6% compared with 16.8%) and medical admissions (18.6% compared with 9.4%). For the sample, the RIC with the highest number of admissions was stroke. The mean IRF length of stay across all RICs was 1.5 days longer (14.5d) for the population compared with the

4 1380 INPATIENT REHABILITATION USE AND MEDICARE, Morley Table 2: IRF Admissions and Mean Length of Stay by Rehabilitation Impairment Category in 2007 RIC Population (% of admissions) Sample (% of admission) 2 P Population (mean length of stay) Sample (mean length of stay) T P Nervous system and brain Stroke Brain dysfunction, traumatic Brain dysfunction, nontraumatic Spinal cord dysfunction, traumatic Spinal cord dysfunction, nontraumatic Neurologic conditions (includes MS) Major multiple trauma with brain injury and/or spinal cord injury Guillain-Barré syndrome Total: nervous system and brain Musculoskeletal Lower extremity fracture Lower extremity joint replacement Other orthopedic Osteoarthritis Rheumatoid and other arthritis Major multiple trauma without brain injury and/or spinal cord injury Total: musculoskeletal Medical Amputation, lower extremity Amputation, nonlower extremity Cardiac Pulmonary Pain syndrome Miscellaneous Burns Total: medical Total NOTE Medicare data from the IRF-PAI and claims data were the sources of data for these analyses. sample (13.0d). While the mean length of stay between both the population and the sample for the cases grouped as nervous system and brain was the same (15d), for the musculoskeletal and medical cases the mean length of stay was longer for the population compared with the sample. Differences in functional impairment levels between beneficiaries with MS using IRFs and the sample are reported in table 3. The population overall had significantly lower admission, discharge, and change FIM scores on the total FIM and on each of the subscales except for the cognitive scores, in which the MS population had higher scores. The average admission total FIM score was 60.6 for the MS population and 62.3 for the sample. At discharge, the total FIM score was 82 points for the population and 87 points for the sample, and the corresponding change scores were 21.3 points compared with 24.7 points, respectively. The greatest difference between the population and the sample in FIM scores was for the motor FIM, where admission scores were 35.4 and 38.1, respectively, and discharge scores were 54.0 and 59.5, respectively. Discharge destination is a common outcome measure for beneficiaries using IRF services. Table 4 presents both the prehospital living setting and the discharge destination for beneficiaries. Note that the differences in the proportion of beneficiaries discharged to each setting were not statistically significant between the analytic samples, with the exception of beneficiaries discharged home with home health. The most common discharge destination was discharge to the community for both groups. Use of home health services on discharge was more common in the population compared with the sample (69.9% vs 66.4%, P.001). Discharge to postacute care (inpatient) was the second most common discharge destination. The results of the multivariable analysis predicting change in functional impairment levels using total FIM change and predicting IRF length of stay are shown in table 5. After controlling for patient demographics along with clinical characteristics, the model results indicate that beneficiaries in the population have a 3.3 point lower FIM change compared with beneficiaries in the sample. In addition to the presence of MS, other significant predictors of lower FIM change (P.001) included men, noncommunity prehospital living setting, nervous system and brain IRF diagnosis (compared with musculoskeletal diagnosis), medical IRF diagnosis, admission total FIM score, and several chronic conditions including acute myocardial infarction, Alzheimer s disease, chronic kidney disease, congestive heart failure, and depression. Note that the R 2 for this model was.07 indicating that the model predicts 7% of the variation in total FIM score change, suggesting that there are other factors not captured in this model that may also affect total FIM score change.

5 INPATIENT REHABILITATION USE AND MEDICARE, Morley 1381 Table 3: Mean FIM Admission, Discharge, and Change Scores for Beneficiaries Using IRFs in 2007 FIM Scores Population (n 4669) Sample (n 14,397) T P Total FIM scores Admission (min 18, max 126) Discharge (min 18, max 126) Change (min 108, max 108) Motor FIM scores Admission (min 13, max 91) Discharge (min 13, max 91) Change (min 78, max 78) Cognitive FIM scores Admission (min 5, max 35) Discharge (min 5, max 35) Change (min 30, max 30) Self-care FIM scores Admission (min 6, max 42) Discharge (min 6, max 42) Change (min 36, max 36) Sphincter control scores Admission (min 2, max 14) Discharge (min 2, max 14) Change (min 12, max 12) Mobility FIM scores Admission (min 5, max 35) Discharge (min 5, max 35) Change (min 30, max 30) NOTE Medicare data from the IRF-PAI and claims data were the sources of data for these analyses. Abbreviations: max, maximum; min, minimum. The multivariable model predicting IRF length of stay was run using the same set of covariates as the total FIM change model. After controlling for beneficiary demographics and clinical characteristics, beneficiaries in the population had a 0.4 day longer IRF length of stay compared with the sample (P.01). Beneficiaries who were not married had a 0.6 day longer length of stay (P.001) controlling for all other characteristics. Diagnosis was also a significant predictor of IRF length of stay. Beneficiaries admitted to IRFs for nervous systems and brain impairment diagnosis had 2.3 days longer length of stay compared with those with a musculoskeletal diagnosis; and those with a medical diagnosis had 1.0 day longer length of stay. Beneficiaries with a complication during their IRF stay also had a longer length of stay (1.8d), as did beneficiaries with diabetes (0.4d) and hip/pelvic fracture (1.4d). Beneficiaries with higher admission total FIM scores had a shorter length of stay, as did beneficiaries with acute myocardial infarction or Alzheimer s disease. The R 2 for Table 4: Prehospital Living Setting and Discharge Destination for Beneficiaries Using Inpatient Rehabilitation in 2007 Population (n 4669) % Sample (n 14,397) % 2 P Prehospital living setting Community* Postacute care Acute care Other Missing Discharge destination Discharge to community Discharge to postacute care Readmission to acute care Other Missing Discharge with home health NOTE Medicare data from the IRF-PAI and claims data were the sources of data for these analyses. *Community is defined as values of home, board and care, transitional living, and assisted living residence. Postacute care is defined as intermediate care, skilled nursing facility, chronic hospital, rehabilitation facility, alternate level of care unit, and subacute setting. Acute care or readmission is defined as acute unit of own facility or acute unit of another facility.

6 1382 INPATIENT REHABILITATION USE AND MEDICARE, Morley Table 5: Regression Models Predicting Total FIM Change and IRF Length of Stay, Beneficiaries Using IRFs in 2007 Dependent Variable: Total FIM Change Dependent Variable: IRF Length of Stay Independent Variables Parameter Estimate SE P Parameter Estimate SE P Intercept Patient demographics Male (ref: female) White race/ethnicity (ref: nonwhite) Not married marital status (ref: married) Age 65 74y (ref: 65) Age 75 84y (ref: 65y) Age 85 (ref: 65y) Disability (ref: no disability) Medicaid/dual eligibility (ref: not dually eligible) Multiple sclerosis (ref: no MS diagnosis) Noncommunity prehospital living setting (ref: community setting*) Inpatient rehabilitation characteristics: Nervous system and brain impairment grouping (ref: musculoskeletal) Medical impairment grouping (ref: musculoskeletal) Admission total FIM score Complications during IRF stay (ref: no complications) Chronic conditions Acute myocardial infarction Alzheimer s disease Alzheimer s disease and related disorders or senile dementia Atrial fibrillation Chronic kidney disease Chronic obstructive pulmonary disease Congestive heart failure Depression Diabetes Glaucoma Hip/pelvic fracture Ischemic heart disease Osteoporosis Rheumatoid arthritis/osteoarthritis Stroke/transient ischemic attack Model R Number of observations 19,066 19,066 NOTE Medicare data from the IRF-PAI, claims data, and CCW data were the sources of data for these analyses. Abbreviation: ref., reference group. *Community settings include home, board and care, transitional living, and assisted living residence. CCW flags indicating whether the beneficiary ever had the condition. this model was 0.19, indicating that the model predicts 19% of the variation in the IRF length of stay. DISCUSSION The results of these analyses demonstrate the differences in the characteristics of beneficiaries with MS using IRF services compared with the overall Medicare population using IRF services in terms of patient demographics, types of admissions, and changes in functional status during IRF admission. These results also provide more insight into the factors predicting changes in functional status and IRF length of stay. The differences in patient demographics, in particular age, sex, and disability status, are significant and expected given the younger age and higher rates of disability among patients with MS. However, of particular note is the percent of beneficiaries with MS using IRF services with depression. Over 60% of beneficiaries with MS using IRF services had a diagnosis of depression. This is important to consider given that depression was also associated with lower total FIM score change and longer IRF length of stay in the multivariable models. Nearly half of beneficiaries with MS who have IRF admissions, have admissions specifically for the treatment of MS, while others were treated for stroke, fractures, replacements, and other diagnoses. Though the mean FIM change score is lower for beneficiaries in the MS population compared with the sample, the gains in functional status are notable: 35.2% change in the total FIM score for beneficiaries compared with 39.6% change in the total FIM score for the sample. While total FIM score change is an important outcome to examine for these populations, discharge destination is also important to consider. The proportions of patients discharged to the community between the 2 analytic samples suggest that large proportions of patients are achieving the goal of discharge to the home. The higher use of home health services among beneficiaries with MS may be related to the slightly lower

7 INPATIENT REHABILITATION USE AND MEDICARE, Morley 1383 functional status at discharge and need for continued services after IRF stay. The multivariable analyses presented here help to explain the impact of different patient characteristics in predicting total FIM change score and IRF length of stay. Though the presence of MS is associated with lower total FIM change and longer IRF length of stay after controlling for other factors, there are several other factors that are important to predicting these variables, including reason for treatment, preadmission living setting, depression, and other comorbid conditions. Study Limitations While this study is useful for establishing the characteristics of IRF users in the population compared with the sample and for examining the direction and magnitude of the effects of beneficiary demographics and clinical characteristics on IRF length of stay and total FIM change score, this study is limited in its ability to demonstrate other outcomes of IRF use that may be important to MS beneficiaries. For example, the literature on the use of rehabilitation services cites benefits of rehabilitation to include reduced fatigue, reduced disability, and improved quality of life. Other studies have examined the role of other clinical characteristics in predicting total FIM change for specific subpopulations of patients including incontinence, obesity, Charlson Comorbidity Index, and albumin levels However, it was not possible to measure these outcomes and compare the presence of these outcomes in the population relative to the Medicare 5% sample using secondary claims and assessment data. Additional research specifically looking at these outcomes among Medicare beneficiaries using IRF services would be useful for understanding more about the potential benefit of these services. Additionally, although inpatient rehabilitation was the focus of this work, analyses of the use of a combination of both inpatient and outpatient rehabilitation would be useful given the literature on the benefits of outpatient rehabilitation services. There may be differences in practice patterns across IRFs. Despite the fact that the FIM instrument is a validated and widely used instrument, it is possible that there is some variation across raters. Another limitation in using Medicare claims and assessment data is that it does not allow for the differentiation of MS into the 4 disease types (relapsingremitting, secondary-progressive, primary progressive, and progressive-relapsing). It is likely that rehabilitation outcomes are affected not only by the presence of MS, but also by disease type. CONCLUSIONS This study illustrates the differences in inpatient rehabilitation use between the subpopulation of Medicare beneficiaries with MS and other Medicare beneficiaries. The findings show that beneficiaries with MS had longer lengths of stay and less functional improvement than other Medicare beneficiaries using inpatient rehabilitation after controlling for comorbidities and other patient characteristics. However, other patient characteristics were also strong predictors of change in functional impairment and length of stay including depression and other chronic conditions such as acute myocardial infarction and diabetes, preadmission living setting, and primary reason for treatment. Higher rates of depression within the MS Medicare population was a secondary finding that presents another important consideration for rehabilitation service needs for this group. Acknowledgments: We thank Nicholas LaRocca, PhD for the support of this research. We also thank Bob Baker, BA for excellent statistical programming. References 1. National Institute of Neurological Diseases and Stroke. Multiple sclerosis: hope through research. Available at: gov/disorders/multiple_sclerosis/detail_multiple_sclerosis.htm. Accessed May 26, Ryan M, Piascik P. Providing pharmaceutical care to the multiple sclerosis patient. J Am Pharm Assoc (Wash) 2002;42:753-66; quiz Mansson E, Lexell J. 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