1075 — Structural Influences on Cost-Effectiveness in VA Stroke Rehabilitation

Vogel WB (Rehabilitation Outcomes REAP), Reker DM (VA Information Resource Center), Barnett TE (Rehabilitation Outcomes REAP)

Objectives:
To determine the cost-effectiveness of acute rehabilitation units (typically hospital-based) compared to subacute rehabilitation units (typically nursing home-based) in VA stroke rehabilitation.

Methods:
A three-equation recursive regression system was estimated 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. Predetermined (independent) variables included type of rehab unit (acute vs. subacute), admission functional status (as measured by the admission Functional Independence Measure (FIM) score), age, race, sex, marital status, and facility. In addition, 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. Outcomes data came from a previous chart abstraction study of the Stroke Impact Scale (SIS) supplemented with VA National Patient Care Database (NPCD) and VA Decision Support System data.

Results:
Acute rehabilitation units achieved (1) lower index stay costs than subacute rehabilitation units by $6,000 per stay, or 25% of total costs, and (2) higher levels of functional status (by 6-7 FIM points). Virtually all of the cost savings associated with rehabilitation on an acute unit were associated with reduced lengths of stay (-10 days) and the associated lower costs from these shorter stays. Lower nursing costs on acute units (by $3,500) were responsible for a majority of the observed savings, while lower pharmacy costs (by $1,000) also played a role.

Implications:
Acute rehabilitation units are more cost-effective than subacute rehabilitation units in treating VA stroke patients because they provide services at lower costs and achieve better functional outcomes.

Impacts:
Between 1995 and 2003, VA closed approximately 50% of its acute rehabilitation units and greatly expanded its number of subacute units. Our research, while limited to stroke patients, suggests that this trend may have been counterproductive from a cost-effectiveness standpoint.