Shorter hospital rehabilitation stays for patients who have suffered strokes, broken bones or other disabling conditions may be leading to higher death rates, researchers say.
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Researchers reviewing national data from 1994 to 2001 found that patients’ average stay for in-hospital rehabilitation dropped from 20 days to 12 days. Over the same period, patient death rates three to six months after release increased from less than 1 percent to 4.7 percent.
That is a small but unexpected increase that warrants further study, said lead author Kenneth Ottenbacher.
“We don’t know the setting in which they died, or what they died of,” said Ottenbacher, an occupational therapist at the University of Texas Medical Branch in Galveston. “That’s clearly an area that we are interested in.”
Condition of patients less stable?
He said it is possible that cost-containment pressures are leading some rehabilitation hospitals to release patients before they are fully stable.
An editorial accompanying the study also suggested patients may be less stable when starting rehab because the same economic pressures may be leading to shorter stays at the hospitals that initially treated them.
The study appears in Wednesday’s Journal of the American Medical Association.
The researchers analyzed data on 148,807 patients at 744 rehabilitation centers nationwide. The average age was 68, and most had had strokes, hip fractures, knee replacement surgery or similar conditions. The centers studied included freestanding facilities and those within larger hospitals.
The data covered a period when increasing cost-containment pressure led to efforts to rehabilitate patients faster and more efficiently with shorter hospital stays, Ottenbacher said.
Government estimates indicate that more than 600,000 patients each year receive inpatient rehabilitation. Most are older patients whose treatment is covered by Medicare.
Switch in hospital payment system
Dr. Peter Esselman, chief of rehabilitation medicine at Seattle’s Harborview Medical Center and author of the JAMA editorial, said his hospital’s 29-bed rehab center has decreased stays by shortening initial patient evaluations and starting treatment earlier, and by giving therapy six days a week instead of five. Patients get the same amount of therapy overall.
“I don’t think we’re missing medical issues” by speeding up treatment, Esselman said.
Esselman said he has not seen evidence of rising death rates at Harborview, but he suggested increases elsewhere might result from cost-containment pressures on acute-care hospitals. Such hospitals may be sending sicker patients to rehab centers, he said.
During the study period, most Medicare coverage for inpatient rehab was fee-for-service, meaning hospitals were generally reimbursed for whatever costs the patient ran up. In 2002, the government switched to a prospective payment system, in which rehab hospitals receive upfront payments, based on a patient’s age and condition, without regard to how long the patient ultimately stays.
That has probably shortened rehab stays even more, Ottenbacher said, but whether death rates have climbed higher is uncertain. He is now undertaking research to find out.
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