The unexpected results of a study that showed a rise in mortality rates as lengths of stay at rehabilitation facilities declined left industry experts scratching their heads last week.
The study published in the Oct. 13 Journal of the American Medical Association said the med-ian length of stay for inpatients at rehabilitation facilities decreased to 12 days in 2001 from 20 in 1994 and mortality rates for patients 80 to 180 days after discharge increased to 4.7% from 0.9%. Although the rise was eye-popping, Kenneth Ottenbacher, an author of the report, said he wasn't ready to directly attribute the change in mortality rates to the decrease in lengths of stay because the researchers didn't set out to examine the mortality rate.
"It was very unexpected," he said. He added that he and other researchers would examine mortality data from 2001 to 2004, but those results won't be ready for at least a year.
The decreases in lengths of stay were attributed to changes in reimbursement. In the mid-1990s there was pressure from insurers to reduce lengths of stay.
"HMOs were very active and some of their practices generated a lot of resentment," said John Melvin, a professor and chairman of the Department of Rehabilitation Medicine at Thomas Jefferson University in Philadelphia.
The study also said patients in the early 1990s were usually able to stay in the facility after recovery to be sure they would maintain full-functional status before they were discharged, but that pattern likely changed because of pressure from insurers to decrease lengths of stay.
The data were collected from the Uniform Data System for Medical Rehabilitation, a database that included 148,807 patients from 744 inpatient rehabilitation facilities in 48 states. The study examined years up to 2001 because researchers set out to establish a benchmark to examine how the prospective payment system-put into effect in January 2002 for rehabilitation facilities-has affected the industry. Ottenbacher said a full-PPS impact study should be ready by 2006 or 2007.
"It wasn't anything I expected, that's for sure," Melvin said about the mortality rate rise.
Functional status-the ability to carry out daily activities-remained stable over the course of the study, and that means the rehabilitation facilities improved efficiency by giving patients more hours of care per day. The study said the improved efficiency could have been due to entry-level rehabilitation professionals having greater qualifications and to more effective techniques.
The rise in mortality could be tied to a number of factors, including earlier discharges from acute-care facilities, Ottenbacher said. Lengths of stay for Medicare and Medicaid patients at acute-care hospitals decreased by 22% or 5.1 days from 1991 to 2002, according to the Medicare Payment Advisory Commission.
"The medical stability of the patients admitted over this time may have changed due to the pressure to decrease the acute-care (lengths of stay) and to move patients to inpatient rehabilitation earlier in their recovery," said Peter Esselman, associate professor of rehabilitation medicine at the University of Washington, and chief of rehabilitation medicine at Harborview Medical Center, Seattle, in an editorial that was published along with the study.
Partly because of earlier discharges from acute-care hospitals, sicker patients are now being admitted to rehabilitation facilities, Melvin said.