Are we selecting the right patients for stroke rehabilitation in nursing homes?

Objective: To examine the effect of stroke rehabilitation in the nursing home on community discharge rates and functional status among patients stratified by propensity to receive rehabilitation. Design: Retrospective cohort. Setting: Medicaid-certified nursing homes (N = 945) in Ohio. Participants: Patients with stroke (N = 2013) admitted to an Ohio nursing home. Intervention: Rehabilitation therapy services. Main Outcome Measures: The propensity to receive rehabilitation, used to adjust for selection bias, was calculated for each patient by using a logistic regression model. Community discharge and change in functional status, measured by using a crosswalk to the FIM instrument, were determined 3 months after admission. Results: By 3 months after admission, 36.9% of the patients were discharged to the community, 16.6% had died, and 46.5% remained in the nursing home. The overall effect of rehabilitation on community discharge (relative risk [RR] = 1.58; 95% confidence interval [CI], 1.33-1.85) was not homogeneous across subgroups stratified by propensity to receive rehabilitation. Patients less likely to receive rehabilitation, as measured by a lower propensity score, had a significant benefit in terms of community discharge (RR = 1.65; 95% CI, 1.35-1.97), but those more likely to receive services did not (RR = 1.21; 95% CI, 0.87-1.56). Among long-term nursing home residents, rehabilitation services were not associated with improved functional status. Conclusions: With respect to community discharge, patients who were less likely to receive rehabilitation therapy appear to receive greater benefit from rehabilitation services than those who were more likely to receive rehabilitation. This finding raises concerns about current selection practices for rehabilitation services. Research is needed to identify the patients most likely to benefit, especially in the present fiscally constrained reimbursement environment.