Within the VHA, there are multiple treatment settings available for post acute stroke rehabilitation care. The top tier of post acute rehabilitation care is provided in "acute rehabilitation bedservice units" (ARBUs). There are currently 34 such units in the VHA. The next level of care is provided in "subacute rehabilitation bedservice units" (SRBUs). ARBUs tend to be housed in acute medical facilities (hospitals), while SRBUs are more likely located in long term care settings (intermediate care services or nursing homes).
Since 1995, the VA has reduced the number of ARBUs and increased the number of SRBUs. From 1995 to 2003, the number of acute bedservice units decreased from 59 to 31, a 47% reduction. Stroke admissions to ARBUs decreased during this period from 1,894 to 794, a 58% reduction. Subacute bedservice units increased during this period from 0 to 24, with correspondingly increased stroke admissions.
We propose to answer the following research questions:
1) What are the short-term (0 to 3 months post stroke) and long-term (3-24 months post stroke) VHA costs of care associated with rehabilitation in either acute vs. subacute rehabilitation units?
2) Are costs (short term or long term) associated with clinical stroke guideline compliance? Specifically, does high quality (guideline compliant) care in the near term save money in the future?
3) Are costs (short term or long term) associated with facility characteristics such as staffing, technology, and system organization?
4) Do short-term, long-term, or total costs vary across VISNs?
Following Manning and Mullahy (2001), we fitted reduced-form and structural models using generalized linear and ordinary least squares methods to explain VA cost differences between ARBUs and SRBUs across time (index rehab stay, short-term, long-term, and total) and for the individual cost components during the index rehab stay, including laboratory, pharmacy, surgery, and nursing. We included sociodemographic variables (age, race, sex, and martial status), time since stroke onset, care facility, and the admission motor and cognitive Functional Independence Measure (FIM) scores as explanatory variables. Our structural model consisted of a three-equation recursive system where the jointly determined (dependent) variables were (1) VA inpatient costs associated with the index rehabilitation stay, (2) percent overall compliance with VA stroke rehabilitation guidelines, and (3) index rehabilitation length-of-stay. In this structural model, guideline compliance was modeled as a function of length of stay, while costs were modeled as a function of both guideline compliance and length-of-stay.
The multivariable results indicate that (1) total index stay costs are lower in ARBUs by almost $6,000 (or approximately 25%) compared to SRBUs, all other factors constant. In addition, discharge functional status as measured by discharge FIM scores are 8.6 points higher (or approximately 10%) in ARBUs compared to SRBUs after accounting for the other factors that influence outcomes. However, we were unable to detect statistically significant differences in short-term, long-term, or total costs beyond the index rehab stay.
We found that virtually all of the cost savings associated with rehabilitation on a hospital-based acute unit were associated with reduced lengths-of-stay (-10 days) and the associated lower costs resulting from these shorter stays (-$740 per day or -$7400 total). While guideline compliance was higher on acute units (by 5 percentage points) and higher guideline compliance was associated with higher rehab stay costs (by $100 per percentage point), this effect was much smaller in absolute terms than the effect operating through length of stay.
Component cost differences indicated that rehabilitation on an acute rehabilitation unit was associated with statistically significant lower costs for nursing and pharmacy cost. Rehabilitation on an ARBU yielded savings of $3500 in nursing costs and $900 in pharmacy compared to rehab on a SRBU. We were unable to detect statistically significant differences in laboratory, surgery, or other costs between ARBUs and SRBUs.
These results have important implications for the VA given the trend toward replacing acute rehabilitation units with subacute units. While prior research has suggested better compliance with stroke rehabilitation guidelines in acute units compared to subacute units, the present results suggest that acute rehabilitation units not only provide better outcomes for stroke patients, but do so at substantially lower cost during the index rehab stay.
- Winkler SL, Vogel B, Hoenig H, Ripley DC, Wu S, Fitzgerald SG, Mann WC, Reker DM. Cost, utilization, and policy of provision of assistive technology devices to veterans poststroke by Medicare and VA. Medical care. 2010 Jun 1; 48(6):558-62.
- Vogel WB, Barnett TE, Reker D. Cost differences in VHA acute and subacute rehabilitation units: implications for VHA resource planning. Journal of rehabilitation research and development. 2010 Jan 1; 47(5):431-9.
- Vogel WB, Reker DM, Barnett TE. Structural Influences on Cost-Effectiveness in VA Stroke Rehabilitation. Paper presented at: VA HSR&D National Meeting; 2009 Feb 12; Baltimore, MD.
- Vogel WB, Reker DM, Barnett TE. Why is Acute Rehabilitation for VA Stroke Patients Less Costly Than Subacute Rehabilitation? Poster session presented at: VA QUERI National Meeting; 2008 Dec 11; Phoenix, AZ.
- Vogel WB, Reker DM, Barnett TE, Cowper Ripley DC, Wang X. Rehabilitation Costs for VA Stroke Patients: Is Subacute Care Really Less Costly? Paper presented at: VA HSR&D National Meeting; 2008 Feb 15; Baltimore, MD.