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Objectives This study examined the association between hospital participation in Bundled Payments for Care Improvement (BPCI) or Comprehensive Care for Joint Replacement (CJR) and the timely initiation of home health rehabilitation services for lower extremity joint replacements. Furthermore, this study examined the association between the timely initiation of home health rehabilitation services with improvement in self-care, mobility, and 90-day hospital readmission. Method This retrospective cohort study used Medicare inpatient claims and home health assessment data from 2016 to 2017 for older adults discharged to home with home health following hospitalization after joint replacement. Multilevel multivariate logistic regression was used to examine the association between hospital participation in BPCI or CJR programs and timely initiation of home health rehabilitation service. A 2-staged generalized boosted model was used to examine the association between delay in home health initiation and improvement in self-care, mobility, and 90-day risk-adjusted hospital readmission. Results Compared with patients discharged from hospitals that did not have BPCI or CJR, patients discharged from hospitals with these programs had a lower likelihood of delayed initiation of home health rehabilitation services for both knees and hip replacement. Using propensity scores as the inverse probability of treatment weights, delay in the initiation of home health rehabilitation services was associated with lower improvement in self-care (odds ratio [OR] = 1.23; 95% CI = 1.20–1.26), mobility (OR = 1.15; 95% CI = 1.13–1.18), and higher rate of 90-day hospital readmission (OR = 1.19; 95% CI = 1.15–1.24) for knee replacement. Likewise, delayed initiation of home health rehabilitation services was associated with lower improvement in self-care (OR = 1.16; 95% CI = 1.13–1.20) and mobility (OR = 1.26; 95% CI = 1.22–1.30) for hip replacement. Conclusion Hospital participation in BPCI or comprehensive CJR was associated with early home health rehabilitation care initiation, which was further associated with significant increases in functional recovery and lower risks of hospital readmission. Impact Policy makers may consider incentivizing health care providers to initiate early home health services and care coordination in value-based payment models. [ABSTRACT FROM AUTHOR]

Objective Provision of early rehabilitation services during acute hospitalization after a hip fracture is vital for improving patient outcomes. The purpose of this study was to examine the association between the amount of rehabilitation services received during the acute care stay and hospital readmission in older patients after a hip fracture. Methods Medicare claims data (2016–2017) for older adults admitted to acute hospitals for a hip fracture (n = 131,127) were used. Hospital-based rehabilitation (physical therapy, occupational therapy, or both) was categorized into tertiles by minutes per day as low (median = 17.5), middle (median = 30.0), and high (median = 48.8). The study outcome was risk-adjusted 7-day and 30-day all-cause hospital readmission. Results The median hospital stay was 5 days (interquartile range [IQR] = 4–6 days). The median rehabilitation minutes per day was 30 (IQR = 21–42.5 minutes), with 17 (IQR = 12.6–20.6 minutes) in the low tertile, 30 (IQR = 12.6–20.6 minutes) in the middle tertile, and 48.8 (IQR = 42.8–60.0 minutes) in the high tertile. Compared with high therapy minutes groups, those in the low and middle tertiles had higher odds of a 30-day readmission (low tertile: odds ratio [OR] = 1.11, 95% CI = 1.06–1.17; middle tertile: OR = 1.07, 95% CI = 1.02–1.12). In addition, patients who received low rehabilitation volume had higher odds of a 7-day readmission (OR = 1.20; 95% CI = 1.10–1.30) compared with high volume. Conclusion Elderly patients with hip fractures who received less rehabilitation were at higher risk of readmission within 7 and 30 days. Impact These findings confirm the need to update clinical guidelines in the provision of early rehabilitation services to improve patient outcomes during acute hospital stays for individuals with hip fracture. Lay summary There is significant individual- and hospital-level variation in the amount of hospital-based rehabilitation delivered to older adults during hip fracture hospitalization. Higher intensity of hospital-based rehabilitation care was associated with a lower risk of hospital readmission within 7 and 30 days. [ABSTRACT FROM AUTHOR]

Background: The Centers for Medicare and Medicaid Services (CMS) penalizes hospitals for higher than expected 30-day mortality rates using methods without accounting for condition severity risk adjustment. For patients with stroke, CMS claims did not quantify stroke severity until recently, when the National Institutes of Health Stroke Scale (NIHSS) reporting began. Objective: Examine the predictive ability of claim-based NIHSS to predict 30-day mortality and 30-day hospital readmission in patients with ischemic stroke. Design: Retrospective cohort study of Medicare claims data. Patients: Medicare beneficiaries with ischemic stroke (N=43,241) acute hospitalization between October 2016 and November 2017. Measurements: All-cause 30-day mortality and 30-day hospital readmission. NIHSS score was derived from ICD-10 codes and stratified into the following: minor to moderate, moderate, moderate to severe, and severe categories. Results: Among 43,241 patients with ischemic stroke with NIHSS from 2,659 US hospitals, 64.6% had minor to moderate stroke, 14.3% had moderate, 12.7% had moderate to severe, and 8.5% had a severe stroke,10.1% died within 30 days, 12.1% were readmitted within 30 days. The NIHSS exhibited stronger discriminant property (C-statistic 0.83, 95% CI: 0.82–0.84) for 30-day mortality compared to Elixhauser (0.74, 95% CI: 0.73–0.75). A monotonic increase in the adjusted 30-day mortality risk occurred relative to minor to moderate stroke category: hazard ratio [HR]=2.92 (95% CI=2.59–3.29) for moderate stroke, HR=5.49 (95% CI=4.90–6.15) for moderate to severe stroke, and HR=7.82 (95% CI=6.95–8.80) for severe stroke. After accounting for competing risk of mortality, there was a significantly higher readmission risk in the moderate stroke (HR=1.11, 95% CI=1.03–1.20), but significantly lower readmission risk in the severe stroke (HR=0.84, 95% CI=0.74–0.95) categories. Limitation: Timing of NIHSS reporting during hospitalization is unknown. Conclusions: Medicare claim–based NIHSS is significantly associated with 30-day mortality in Medicare patients with ischemic stroke and significantly improves discriminant property relative to the Elixhauser comorbidity index. [ABSTRACT FROM AUTHOR]

Objective. The purpose of this study was to examine the impact of hospital-based rehabilitation services on community discharge rates after hip and knee replacement surgery according to hospital participation in value-based care models: bundled payments for care improvement (BPCI) and comprehensive care for joint replacement (CJR). The secondary objective was to determine whether community discharge rates after hip and knee replacement surgery differed by participation in these models. Methods. A secondary analysis of Medicare fee-for-service claims was conducted for beneficiaries 65 years of age or older who underwent hip and knee replacement surgery from 2016 to 2017. Independent variables were hospital participation in value-based programs categorized as: (1) BPCI, (2) CJR, and (3) non-BPCI/CJR; and total minutes per day of hospital-based rehabilitation services categorized into tertiles. The primary outcome variable was discharged to the community versus discharged to institutional post-acute care settings. The association between rehabilitation amount and community discharge among BPCI, CJR, and non-BPCI/CJR hospitals was adjusted for patient-level clinical and hospital characteristics. Results. Participation in BPCI or CJR was not associated with community discharge. This analysis found a dose--response relationship between the amount of rehabilitation services and odds of community discharge. Among those who received a hip replacement, this relationship was most pronounced in the BPCI group; compared with the low rehabilitation category, the medium category had odds ratio (OR)=1.28 (95% CI=1.17 to 1.41), and the high category had OR=1.90 (95% CI=1.71 to 2.11). For those who received a knee replacement, there was a dose--response relationship in the CJR group only; compared with the low rehabilitation category, the medium category had OR=1.21 (95% CI=1.15 to 1.28), and the high category had OR=1.56 (95% CI=1.46 to 1.66). Conclusion. Regardless of hospital participation in BPCI or CJR models, higher amounts of rehabilitation services delivered during acute hospitalization is associated with a higher likelihood of discharge to community following hip and knee replacement surgery. Impact. In the era of value-based care, frontloading of rehabilitation care is vital for improving patient-centered health outcomes in acute phases of lower extremity joint replacement. [ABSTRACT FROM AUTHOR]