Functional Outcomes among the Medically Complex Population Paulette Niewczyk, PhD, MPH Director of Research Uniform Data System for Medical Rehabilitation 2015 Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc. FIM, UDSMR, and the UDSMR logo are trademarks of Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc.
Objectives Define medical comorbidity and payment tier Describe the rehabilitation outcomes of patients admitted with increased medical complexity as indicated by comorbidity Evaluate differences in rehabilitation outcomes among specific impairment groups, age and gender 2
Background Patients presenting to the acute hospital setting are more acutely and chronically ill Aging population More chronic disease Since the advent of the prospective payment system, patients are spending less time in the acute care hospital Patients admitted to inpatient rehabilitation have a higher burden of medical complications Patients with tiered comorbidities have unique rehabilitation needs and require additional medical management 3
Comorbidities A comorbidity is a specific patient condition that affects a patient in addition to the principal diagnosis of impairment that is used to place a patient into a rehabilitation impairment category The current IRF-PAI provides space for recording up to twenty-five ICD-9-CM codes Appendix C lists the ICD-9-CM codes of the comorbid conditions that may affect Medicare payment, which are categorized into tiers The CMS comorbidity tier is often used as a proxy for illness severity 4
CMS Comorbidity Tiers: Tier B Tier B: major conditions Affect payment the most due to the additional resources required to manage them Proxy for patients with greatest illness severity Examples of this type of comorbidity include: Tracheostomy Respirator dependence Severe malnutrition Vocal cord paralysis 5
CMS Comorbidity Tiers: Tier C Tier C: medium conditions Have a moderate effect on payment Examples of this type of comorbidity include: Pulmonary tuberculosis Staphylococcal septicemia HIV Meningitis Cellulitis 6
CMS Comorbidity Tiers: Tier D Tier D: minor conditions Affect payment to a minor degree Examples of this type of comorbidity include: Sickle-cell anemia Diabetic neuropathy Subdural hemorrhage Venous thrombosis Colostomy Pulmonary embolism 7
Research Purpose Patients with tiered comorbidities have an increased medical complexity that requires increased resources The purpose is to examine the effect of medical comorbidities, controlling for impairment, on patient functional outcomes compared to patients with non-tiered comorbidities or no documented medical comorbidities 8
Methods: Inclusion/Exclusion Criteria Patients in this study were: At least eighteen years old Discharged alive between October 1, 2010, and September 30, 2013 Seen in facilities paid through the prospective payment system for the initial rehabilitation 9
Methods: Study Population Total number of cases in UDSMR database, 2010 2012 (n= 1,762,851) Excluded: Age < 18, n = 1,776 (0.3%) Non-PPS facility, n = 38,195 (2%) Died, n = 2,646 (0.2%) After exclusions, n = 1,641,528 Impairment Types: - Stroke (22.3%) - Brain dysfunction (9.3%) - Neurologic conditions (11.0%) - Spinal cord dysfunction (5.5%) - Amputation (2.9%) - Arthritis (0.8%) - Pain syndromes (0.8%) - Orthopaedic conditions (29.7%) - Cardiac disorders (3.8%) - Pulmonary disorders (1.3%) - Burns (0.1%) - Congenital deformities (0.1%) - Other disabling impairments (0.9%) - Major multiple trauma (2.2%) - Developmental disability (0.0%) - Debility (8.0%) - Medically complex conditions (1.2%) 10
Comorbidity Distribution Distribution of Comorbidity Tiers, 2010 2013 All Impairments Orthopedic Stroke Neurologic Tier A (none) 1,010,503 (61.6) 347,741 (71.4) 264,199 (72.1) 90,787 (50.4) Tier B (major) 69,344 (4.2) 7,418 (1.5) 10,265 (2.8) 11,812 (6.6) Tier C (medium) 127,581 (7.8) 19,873 (4.1) 5,898 (1.6) 25,100 (13.9) Tier D (minor) 434,100 (26.4) 111,822 (23.0) 85,898 (23.5) 52,414 (29.1) Any tier 631,025 (38.4) 139,113 (28.6) 102,061 (27.9) 89,326 (49.6) 11
Methods: Study Variables Independent variable: Patients with any tiered comorbidity vs. patients with non-tiered or no documented comorbidities Dependent variables: Discharge to community FIM gain Discharge FIM total 12
Methods: Study Variables Demographic variables: Age Gender Race Payer source (Medicare, commercial, other) Employment status (employed, unemployed, retired) Pre-hospital living situation (living alone or with others) 13
Methods: Study Variables Medical variables: Impairment type Onset days (proxy for number of days in acute hospital) Pre-rehabilitation living setting Rehabilitation length of stay Mobility status at admission 14
Methods: Study Variables Rehabilitation/functional variables: Admission FIM total Discharge FIM total FIM change Rehabilitation length of stay Onset days to rehabilitation Length of stay efficiency Discharge setting 15
Statistical Analysis Sample characteristics: Means/standard deviations for continuous variables Counts/percentages for categorical variables 16
Results: Sample Characteristics Demographic and Medical Characteristics Any tiered comorbidity No tiered comorbidity Age (yr), mean (SD) 68.1 (14.9) 69.9 (15.1) Gender, n (%) Male 311,279 (49.3) 434,127 (43.0) Female 319,668 (50.7) 576,185 (57.0) Missing 78 191 Race/ethnicity, n (%) White 475,638 (75.4) 794,457 (78.6) Black 82,463 (13.1) 105,192 (10.4) Hispanic 42,119 (6.7) 56,662 (5.6) Other 30,805 (4.9) 54,192 (5.4) Employment Status, n (%) Employed 83,519 (13.5) 154,160 (15.6) Unemployed 63,995 (10.4) 139,452 (10.0) Retired 470,767 (76.1) 142,329 (74.4) Missing 12,744 23,435 17
Results: Sample Characteristics Demographic and Medical Characteristics Any tiered comorbidity Primary payer, n (%) No tiered comorbidity Medicare 457,850 (72.6) 728,722 (72.1) Commercial 87,879 (13.9) 139,452 (13.8) Other 85,296 (13.5) 142,329 (14.1) Onset days, mean (SD) 13.7 (22.3) 9.0 (18.6) Admission mobility status, n (%) Walking 494,727 (78.4) 846,972 (83.8) Wheelchair 114,726 (18.2) 131,732 (13.0) Both 21,572 (3.4) 31,799 (3.1) 18
Results: Sample Characteristics Rehabilitation Characteristics of Medically Complex Population Any tiered comorbidity No tiered comorbidity Admission FIM total, mean (SD) 57.4 (17.3) 61.9 (17.3) Discharge FIM total, mean (SD) 86.0 (22.0) 90.5 (20.5) FIM gain total, mean (SD) 28.6 (16.1) 28.6 (14.6) Length of stay (days), mean (SD) 14.5 (8.9) 12.7 (7.4) FIM efficiency, mean (SD) 2.4 (1.8) 2.7 (2.0) Discharge location, n (%) Community 458,111 (72.6) 798,605 (79.0) Long-term Care 89,462 (14.2) 131,026 (13.0) Acute Care 80,786 (12.8) 76,600 (7.6) Rehabilitation 1,281 (0.2) 1,944 (0.2) Other 1,385 (0.2) 2,328 (0.2) 19
Results: Discharge FIM Total 78 Patients with any tiered comorbidity had a 10% lower likelihood of having a discharge FIM rating 78 compared to patients without a tiered comorbidity Model adjusted for age, admission FIM total, length of stay, onset days, gender, race, employment status, primary payer, and admission mobility status * Reistetter TA, et al. Utility of functional status for classifying community versus institutional discharges after inpatient rehab Group Odds Ratio (95%CI) All Patients 0.90 (0.89, 0.90) Impairment Stroke 0.89 (0.87, 0.90) Orthopaedic Conditions Neurologic Conditions Age 0.76 (0.74, 0.77) 0.93 (0.90, 0.96) < 65 years 0.99 (0.97, 1.01) 65 years 0.85 (0.85, 0.87) Gender Male 0.92 (0.91, 0.93) Female 0.87 (0.86, 0.89) 20
Results: Discharge to the Community Patients with any tiered comorbidity were 8% less likely to be discharged to a community setting Model adjusted for age, admission FIM total, length of stay, onset days, gender, race, employment status, primary payer, and admission mobility status Group Odds Ratio (95% CI) All Patients 0.92 (0.91, 0.93) Impairment Stroke 0.89 (0.87, 0.90) Orthopaedic Conditions Neurologic Conditions Age 1.06 (1.05, 1.08) 1.01 (0.98, 1.03) < 65 years 0.89 (0.88, 0.91) 65 years 0.94 (0.94, 0.95) Gender Male 0.91 (0.90, 0.92) Female 0.93 (0.92, 0.94) 21
Results: FIM Gain Patients with any tiered comorbidity had a smaller FIM gain on average compared to patients without a tiered comorbidity, but this amount is not clinically significant Model adjusted for age, admission FIM total, length of stay, onset days, gender, race, employment status, primary payer, and admission mobility status Group Impairment Type β (95% CI) Stroke -0.69 (-0.79, -0.58) Orthopaedic Conditions Neurologic Conditions Age -0.63 (-0.72, -0.55) 0.13 (-0.01, 0.28) < 65 years 0.19 (0.11, 0.27) 65 years -0.66 (-0.71, -0.60) Gender Male -0.24 (-0.31, -0.17) Female -0.41 (-0.47, -0.34) 22
Summary Mean age is similar between patients with more tiered comorbidities and those without Higher proportion of males with tiered comorbidities Black and Hispanic patients have more tiered comorbidities than white patients do By payer source, patients with Medicare had more tiered comorbidities compared to patients with private insurance (HMO/MCO) or other payer sources As anticipated, length of stay in the acute hospital (onset days) was longer for patients with tiered comorbidities 23
Summary Patients with tiered comorbidities were less ambulatory at admission, indicating a lower level of function compared to patients with non-tiered or no documented comorbidities Admission FIM total and discharge FIM total were lower among patients with tiered comorbidities Patients with any tiered comorbidity had a slightly longer rehabilitation length of stay compared to patients without, but length of stay efficiency was similar between patient groups 24
Summary Total FIM gain was comparable between patients with tiered comorbidities and those without, which lends great support to the benefits of inpatient rehabilitation for patients with higher medical complexity Overall, patients with tiered comorbidities had a slightly lower likelihood of being discharged back to the community, and the percentage of these patients who were readmitted from inpatient rehabilitation to the acute hospital is higher than the percentage of those without tiered comorbidities 25
Implications Considering the more medically complex patients made significant functional gains from admission to discharge in inpatient rehabilitation, the nature of the patient population may (1) be the primary reason the patient is not a candidate for discharge to the community and/or (2) serve as a rationale for an acute readmission Inpatient rehabilitation manages the patient s comorbid conditions but often does not direct the treatment course for these conditions Therefore, the discharge to acute care may not be a failure of IRF services, but rather part of the patient s ongoing course of care 26
A Scenario A forty-six-year-old male with multiple tiered comorbidities and an admission impairment code of burn is admitted to an IRF with an total admission FIM rating of 50. After twelve days of rehabilitation, the patient was discharged to the acute hospital for planned skin grafting. His total FIM rating at discharge was 75, a total gain of 25 FIM points. Did the patient benefit from inpatient rehabilitation? Was he a good candidate for admission to inpatient rehabilitation in light of his pending need for additional surgical procedures? For patients like this, how does the proposed all-cause 30-day acute readmission penalty affect both the IRF and the individual patient s care/access to care? 27
Clinical Implications Clearly defined goals and anticipated outcomes of care, at the patient level, upon the patient s admission to inpatient rehabilitation is critical, as often times it can be justified that a patient can benefit from care at an IRF even if outcomes are atypical (likelihood of discharge to community) Complete and detailed documentation of necessity of care cannot be overstated, as documenting the reason for the acute readmission (planned vs. unplanned discharge to acute hospital) may serve as the basis for appealing a readmission penalty or a denial of payment for services 28
Clinical Implications With the threat of site-neutral payment, documentation of anticipated benefits to the patient and/or the outcomes of care received benefits and outcomes that are specific and unique to the specialized, high-level care that inpatient rehabilitation provides is paramount 29