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。如果没有有效性的证据，多学科住院患者康复服务可能会被削减或取消，从而损害可能减少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，而没有经验证据支持或不支持较低水平的服务。私营部门几乎没有任何标准化数据来源可用来说明替代康复水平的好处。来自退伍军人事务部（VA）的数据将被应用于获得有关医疗保险和医疗补助的最佳残疾管理策略的见解。我们建议比较2种不同水平的住院康复（患者因卒中仍住院时接受的急性康复服务）。第一个层次是咨询，病人在医院内的非康复病床服务上接受康复专业人员的治疗。第二个层次是高强度专业化。当患者被接纳到医院内的专门康复床单位时发生的多学科康复服务。主要结局将包括急性住院期间的功能恢复和出院。一年生存率、长期护理安置、再住院和总医疗费用将是次要结局。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个大型管理数据库的合并数据。方法将包括一系列的观察性研究，估计队列超过15,000中风患者使用倾向评分匹配和工具变量分析，以调整选择偏倚，和混合模型，以解释设施内的患者聚集。这些方法将被应用于比较退伍军人谁接受咨询康复，专门康复，没有住院康复的证据的结果。我们将确定最有可能接受任何形式的急性康复治疗的患者类型，以及最有可能接受专门康复治疗的患者。这项研究有望大大扩展有限的经验知识的相关性中风后急性康复机构。这种基于证据的知识对于指导VHA和私营部门未来的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.