3083 — Why is Acute Rehabilitation for VA Stroke Patients Less Costly than Subacute Rehabilitation?

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

Objectives:
Our prior research has found that hospital-based (or acute) rehabilitation for VA stroke patients is less costly (by $6,000-$7,000 per stay) than nursing home-based (or subacute) rehabilitation for such patients. The objective of the present research is to determine the direct and indirect pathways through which these lower costs are achieved.

Methods:
We estimated a three-equation recursive regression system 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 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.

Results:
We found that virtually all of the cost savings associated with rehabilitation on a hospital-based acute unit were associated with reduced lengths-of-stay (-10 days) and the associated lower costs resulting from these shorter stays (-$700 per day or -$7,000 total). While guideline compliance was higher on acute units (by 5 percentage points) and higher guideline compliance was associated with higher rehab stay costs (by $100 per percentage point), this effect was dramatically smaller in absolute terms than the effect operating through length-of-stay.

Implications:
For many patients where non-hospital care is an option, treatment costs are indeed lower in nursing home settings than in hospital settings. However, this does not appear to be the case for VA stroke rehabilitation patients because of their significantly shorter stays in hospitals compared to nursing homes.

Impacts:
Between 1995 and 2003, the VA closed approximately 50% of its acute rehabilitation units and greatly expanded its number of subacute units. This trend was motivated in part because of budget pressures. Our research, while limited to stroke patients, suggests that this trend may actually have increased rather than decreased costs.