Rehab Stays Shorter, but Death Rate Up

No clear explanation for mortality increase, researchers say

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HealthDay Reporter

TUESDAY, Oct. 12, 2004 (HealthDayNews) -- People who undergo rehabilitation for such crippling conditions as strokes or major accidents are getting well enough to go home faster than they used to, but their risk of dying in the six months after their release has increased, a study finds.

The decrease in length of stay and the increase in mortality came in a period when the federal government changed its payment method to promote shorter stays, but it's not possible to say whether that change affected the death rate, said study leader Kenneth J. Ottenbacher, a professor of rehabilitation sciences at the University of Texas Medical Center in Galveston.

"On the basis of this study, we can't make a causal relationship between length of stay and mortality," Ottenbacher said.

What the study does show is a major increase of efficiency in the rehabilitation effort, he said, with patients "getting to the same level of improvement over a shorter period of time."

Ottenbacher and his colleagues examined the records of nearly 149,000 people who underwent rehabilitation at 744 U.S. hospitals and centers between 1994 and 2001. In those years, the average length of stay dropped from 20 days to 12 days, according to the study, which appears in the Oct. 13 issue of the Journal of the American Medical Association.

The study was done to see whether that shorter treatment period affected the patients' physical function, Ottenbacher said. It didn't. "We did not find any change in physical function," he said.

But the death rate after discharge increased strikingly, from less than 1 percent in 1994 to 4.7 percent in 2001. The study did not provide an explanation for that increase, Ottenbacher said, even though the researchers looked at several factors, such as the presence of other illnesses.

"There were a lot of variables we were not able to look at," he said. "I think it is not going to end up being a single factor."

In January 2002, the U.S. Centers for Medicare and Medicaid Services introduced a new payment system. It had been reimbursing institutions after a patient's discharge, paying for all services rendered. It now pays a flat fee on admission to cover those services.

But that change is "just one of the variables associated with changes of outcome," Ottenbacher said. More studies are needed to explain exactly what has been happening, he said.

There were "a couple of large changes going on" during the period covered by the study, said Dr. Peter C. Esselman, an associate professor of rehabilitation medicine at the University of Washington, who wrote an accompanying editorial.

"There was financial pressure on the system to gain efficiency," he said. "At the same time, through managed care and efforts within rehabilitation facilities, there was a big effort to improve efficiency."

More effective use of manpower and equipment and better allocation of patients to specific kinds of treatment help explain the shorter stays, Esselman said. But, he added, "the increase in mortality is very difficult to explain."

One possible explanation is that "there may have been some shift in who we were admitting to these facilities," Esselman said. "We could have been admitting patients who were more severely impaired in one way or another. But we are really just speculating. This is an area where more research needs to be done."

More information

You can learn about rehabilitation medicine from Easter Seals.

SOURCES: Kenneth J. Ottenbacher, Ph.D., professor, rehabilitation sciences, University of Texas Medical Center, Galveston; Peter C. Esselman, M.D., associate professor, rehabilitation medicine, University of Washington, Seattle; Oct. 13, 2004, Journal of the American Medical Association

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