University of Massachusetts Medical School Faculty Publications

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Department of Quantitative Health Sciences

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Article Postprint


Cardiovascular Diseases | Health Services Administration | Health Services Research | Nervous System Diseases | Rehabilitation and Therapy


OBJECTIVE: To synthesize research comparing post-stroke health outcomes between patients rehabilitated in skilled nursing facilities (SNFs) and inpatient rehabilitation facilities (IRFs). Secondly, to evaluate relationships between facility characteristics and outcomes.

DATA SOURCES: PubMed and CINAHL searches spanned January 1, 1998 to October 6, 2016 and encompassed MeSH and free-text keywords for stroke, IRF/SNF, and study outcomes. Human and English limits were used.

STUDY SELECTION: Observational and experimental studies examining outcomes of adult stroke patients rehabilitated in an IRF or SNF were eligible. Studies had to provide site of care comparisons and/or analyses incorporating facility-level characteristics and had to report > 1 primary outcome (discharge setting, functional status, readmission, quality of life, all-cause mortality). Unpublished, single-center, descriptive, and non-US studies were excluded. Articles were reviewed by one author and when uncertain, discussion with study coauthors achieved consensus. Fourteen (0.3%) titles were included.

DATA EXTRACTION: The types of data, time period, size, design, and primary outcomes were extracted. We also extracted two secondary outcomes (length of IRF/SNF stay, cost) when reported by included studies. Effect measures, modeling approaches, methods for confounding adjustment, and potential confounders were extracted. Data were abstracted by one author and the accuracy verified by a second reviewer.

DATA SYNTHESIS: Two studies evaluating community discharge, one study evaluating predicted readmission probability, and 3 studies evaluating all-cause mortality favored IRFs over SNFs. Functional status comparisons were inconsistent. No studies evaluated quality of life. Two studies confirmed increased costs in the IRF versus SNF setting. Although substantial facility variation was described, few studies characterized sources of variation.

CONCLUSIONS: The few studies comparing post-stroke outcomes indicated better outcomes (with greater costs) for patients in IRFs versus SNFs. Contemporary research on the role of the post-acute care setting and its attributes in determining health outcomes should be prioritized to inform reimbursement system reform.


outcome assessment (health care), skilled nursing facilities, stroke rehabilitation, subacute care, UMCCTS funding

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© 2017 Published by Elsevier Inc. on behalf of the American Congress of Rehabilitation Medicine. This is a PDF file of an accepted manuscript that has been accepted for publication and posted with a 12 month embargo as allowed by the publisher's author rights policy at

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Arch Phys Med Rehabil. 2018 Jun;99(6):1124-1140.e9. doi: 10.1016/j.apmr.2017.09.005. Epub 2017 Sep 28. Link to article on publisher's site

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Creative Commons Attribution-Noncommercial-No Derivative Works 4.0 License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 4.0 License.