Differences in rehabilitation services and outcomes among stroke patients cared for in veterans hospitals

Objective. To examine the relationship of services for post-acute care (PAC ) to stroke patient outcomes. Data Sources/Study Setting. Veterans Health Administration (VHA) hospitals from two facility-level surveys and extant data files. Study Design. Cross-sectional study of veterans hospitalized with acute str oke during the period June 1995 through May 1996 in one of 182 geographical ly distinct locations within the VHA. Study variables included (1) a typolo gical classification of hospitals according to the level of PAC; (2) a taxo nomy of rehabilitation characteristics, including personnel, physical facil ities, coordination of care, and hospital characteristics; and (3) patient outcomes (discharge destination, length of stay). Data Collection/Extraction Methods. Data were collected from two mailed sur veys and extant data files. Rehabilitation variables were identified for th e study in conjunction with a panel of expert rehabilitation researchers an d clinicians, using an a priori model for measuring rehabilitation characte ristics. Two sets of variables were derived to categorize these rehabilitat ion characteristics: (1) a rehabilitation typology, classifying the VA hosp itals according to the continuum of PAC settings in the facility, and (2) a rehabilitation taxonomy that used an empirical approach to derive a list o f key rehabilitation characteristics. Principal Findings. Twenty-seven percent of veterans with acute stroke were cared for in VA hospitals with neither a geriatric nor a rehabilitation un it, and 50 percent were cared for in hospitals without a rehabilitation uni t. Hospitals with rehabilitation units had the greatest sophistication, and those with geriatric units had intermediate sophistication in rehabilitati on organization and resources. Statistically significant differences were f ound in outcomes for stroke patients cared for in hospitals classified acco rding to the continuum of post-acute care on site. Exploratory multivariabl e analyses revealed independent associations between stroke patient outcome s and (1) staffing ratios for nurses and physicians, (2) the diversity of p hysician and rehabilitation staff, (3) presence of a simulated home environ ment, and (4) the total number of care settings on site. Conclusions. The PAC continuum defines an important hierarchy of stroke reh abilitation services.