州医疗补助覆盖对脑卒中患者住院康复设施利用率的影响。
Impact of state Medicaid coverage on utilization of inpatient rehabilitation facilities among patients with stroke.
机构信息
From the Stroke Program (L.E.S., J.F.B., L.B.M., W.J.M., E.E.A., L.D.L.) and Departments of Neurology (L.E.S., J.F.B., L.B.M., E.E.A., K.A.K., B.C.C.), Epidemiology (L.B.M., L.D.L.), and Emergency Medicine (L.B.M., W.J.M.), University of Michigan, Ann Arbor.
出版信息
Stroke. 2014 Aug;45(8):2472-4. doi: 10.1161/STROKEAHA.114.005882. Epub 2014 Jul 8.
BACKGROUND AND PURPOSE
Poststroke rehabilitation is associated with improved outcomes. Medicaid coverage of inpatient rehabilitation facility (IRF) admissions varies by state. We explored the role of state Medicaid IRF coverage on IRF utilization among patients with stroke.
METHODS
Working age ischemic stroke patients with Medicaid were identified from the 2010 Nationwide Inpatient Sample. Medicaid coverage of IRFs (yes versus no) was ascertained. Primary outcome was discharge to IRF (versus other discharge destinations). We fit a logistic regression model that included patient demographics, Medicaid coverage, comorbidities, length of stay, tissue-type plasminogen activator use, state Medicaid IRF coverage, and the interaction between patient Medicaid status and state Medicaid IRF coverage while accounting for hospital clustering.
RESULTS
Medicaid did not cover IRFs in 4 (TN, TX, SC, WV) of 42 states. The impact of State Medicaid IRF coverage was limited to Medicaid stroke patients (P for interaction <0.01). Compared with Medicaid stroke patients in states with Medicaid IRF coverage, Medicaid stroke patients hospitalized in states without Medicaid IRF coverage were less likely to be discharged to an IRF of 11.6% (95% confidence interval, 8.5%-14.7%) versus 19.5% (95% confidence interval, 18.3%-20.8%), P<0.01 after full adjustment.
CONCLUSIONS
State Medicaid coverage of IRFs is associated with IRF utilization among stroke patients with Medicaid. Given the increasing stroke incidence among the working age and Medicaid expansion under the Affordable Care Act, careful attention to state Medicaid policy for poststroke rehabilitation and analysis of its effects on stroke outcome disparities are warranted.
背景与目的
脑卒中后的康复与改善预后有关。各州的医疗补助（Medicaid）对住院康复机构（IRF）入院的覆盖范围不同。我们探讨了州 Medicaid 对 IRF 利用率的影响在脑卒中患者中的作用。
方法
从 2010 年全国住院患者样本中确定了患有 Medicaid 的有工作能力的缺血性脑卒中患者。确定 Medicaid 对 IRF 的覆盖范围（是与否）。主要结局是出院到 IRF（与其他出院目的地相比）。我们拟合了一个逻辑回归模型，其中包括患者人口统计学特征、Medicaid 覆盖范围、合并症、住院时间、组织型纤溶酶原激活剂使用、州 Medicaid IRF 覆盖范围以及患者 Medicaid 状态和州 Medicaid IRF 覆盖范围之间的相互作用，同时考虑到医院聚类。
结果
在 42 个州中的 4 个州（TN、TX、SC、WV），Medicaid 未涵盖 IRF。州 Medicaid IRF 覆盖范围的影响仅限于 Medicaid 脑卒中患者（P 交互<0.01）。与州 Medicaid 有 IRF 覆盖范围的 Medicaid 脑卒中患者相比，在州 Medicaid 没有 IRF 覆盖范围的脑卒中患者住院期间，出院到 IRF 的可能性较小，为 11.6%（95%置信区间，8.5%-14.7%），而不是 19.5%（95%置信区间，18.3%-20.8%），P<0.01，在充分调整后。
结论
州 Medicaid 对 IRF 的覆盖范围与 Medicaid 脑卒中患者对 IRF 的利用率相关。鉴于工作年龄人群中脑卒中发病率的增加以及平价医疗法案下 Medicaid 的扩大，需要仔细关注州 Medicaid 脑卒中后康复政策及其对脑卒中结局差异的影响。
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