Comparative Effectiveness of Alternative Levels of Stroke

描述（由申请人提供）：这项工作的政策相关性至关重要。如果没有有效的证据，多学科住院康复机会可能会减少或取消，从而损害具有潜在可减轻的功能限制和与中风相关的残疾的人。退伍军人健康管理局（VHA）和医疗保险政策的变化正在将护理从高水平的住院多学科康复服务中转移出来，没有经验证据支持或不支持较低水平的服务。私营部门的标准化数据来源很少，如果有的话，可以用来说明不同程度的康复的好处。来自退伍军人事务部（VA）的数据将被应用于了解医疗保险和医疗补助的最佳残疾管理策略。我们建议比较两种不同程度的住院康复（患者在住院期间接受急性康复服务）。第一级是会诊，病人由康复专业人员诊治，同时在医院内继续使用非康复床位服务。第二个层次是更高强度的专业化。多学科康复服务，当病人入住医院内的专门康复病床单元时提供。主要结局将包括功能恢复和急性住院出院。一年生存率、长期护理安排、再住院和总医疗费用将是次要结果。该研究是一项回顾性观察性比较有效性研究，使用了来自153个VA医疗中心的14个大型管理数据库合并的数据。方法将包括一系列观察性研究，对超过15,000名中风患者进行估计队列，使用倾向评分匹配和工具变量分析来调整选择偏差，并使用混合模型来解释设施内的患者聚类。这些方法将用于比较接受会诊康复、专科康复和没有住院康复证据的退伍军人的结果。我们将确定最有可能接受任何形式的急性康复的患者类型，并在这一组中最有可能接受专门的康复。本研究有望极大地扩展有限的实体经验知识的相关性急性康复中风后。这种以证据为基础的知识对于指导VHA和私营部门的未来实践和政策至关重要。

DESCRIPTION (provided by the applicant): The policy relevance of this work is critical. Without evidence of effectiveness, multidisciplinary inpatient rehabilitation access will likely be curtailed or eliminated to the detriment of people with potentially reducible functional limitations and disabilities related to stroke. Changes in both Veterans Health Administration (VHA) and Medicare policies are shifting care away from high level inpatient multidisciplinary rehabilitation services without empirical evidence either supporting or not supporting lower levels of service. There are few, if any, sources of standardized data in the private sector available to address the benefits of alternative levels of rehabilitation. Data from the Department of Veterans Affairs (VA) will be applied to gain insights about optimal disability management strategies for Medicare and Medicaid. We propose to compare 2 different levels of inpatient rehabilitation (acute rehabilitation services received while patients are still hospitalized for stroke). The first level is consultation where patients are seen by rehabilitation professionals while remaining on non-rehabilitation bed services within the hospital. The second level is higher intensity specialized. multidiciplinary rehabilitation services which occur when patients are admitted onto a specialized rehabilitation bed unit within the hospital. Primary outcomes will include functional recovery and home discharge from the acute hospital stay. One-year survival, long-term care placement, rehospitalization, and total health care costs will be secondary outcomes. The study is a retrospective observational comparative effectiveness study using data merged from 14 large administrative databases compiled from 153 VA Medical Centers. Methods will include a series of observational studies on an estimated cohort of over 15,000 stroke patients using propensity score matching and instrumental variable analyses to adjust for selection bias, and mixed models to account for patient clustering within facilities. These methods will be applied to compare the outcomes of veterans who receive consultation rehabilitation, specialized rehabilitation, and no evidence of inpatient rehabilitation. We will identify the types of patients most likely to receive any form of acute rehabilitation, and among that group those most likely to receive specialized rehabilitation. This research is expected to greatly expand the limited body of empirical knowledge of relevance of acute rehabilitation following stroke. Such evidence-based knowledge will be essential to guide future practice and policies in the VHA and private sectors alike.