Department of Rehabilitation Medicine, University of Washington, 1959 NE Pacific St., Seattle, WA 98195-6490, USA.
Veterans Affairs Health Services Research and Development Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota, USA.
Phys Ther. 2021 Mar 3;101(3). doi: 10.1093/ptj/pzaa230.
Exponential increases in rehabilitation intensity in skilled nursing facilities (SNFs) motivated recent changes in Medicare reimbursement policies, which remove financial incentives for providing more minutes of physical therapy, occupational therapy, and speech therapy. Yet, there is concern that SNFs will reduce therapy provision and patients will experience worse outcomes. The purpose of this systematic review was to synthesize current evidence on the relationship between therapy intensity and patient outcomes in SNFs.
PubMed, Medline, Scopus, Embase, CINAHL, PEDro, and COCHRANE databases were searched. English-language studies published in the United States between 1998 and February 14, 2020, examining the relationship between therapy intensity and community discharge, hospital readmission, length of stay (LOS), and functional improvement for short-stay SNF patients were considered. Data extraction and risk of bias were performed using the American Academy of Neurology Classification of Evidence scale for causation questions. American Academy of Neurology criteria were used to assess confidence in the evidence for each outcome.
Eight observational studies met inclusion criteria. There was moderate evidence that higher intensity therapy was associated with higher rates of community discharge and shorter LOS. One study provided very low-level evidence of associations between higher intensity therapy and lower hospital readmissions after total hip and knee replacement. There was low-level evidence indicating higher intensity therapy is associated with improvements in function.
This systematic review concludes with moderate confidence that higher intensity therapy in SNFs leads to higher community discharge rates and shorter LOS. Future research should improve quality of evidence on functional improvement and hospital readmissions.
This systematic review demonstrates that patients in SNFs may benefit from higher intensity therapy. Because new policies no longer incentivize intensive therapy, patient outcomes should be closely monitored to ensure patients in SNFs receive high-quality care.
熟练护理设施（SNF）中康复强度的指数级增长促使医疗保险报销政策最近发生了变化，这些变化消除了提供更多物理治疗、职业治疗和言语治疗分钟数的经济激励。然而，人们担心 SNF 会减少治疗提供，患者的治疗结果会更差。本系统评价的目的是综合目前关于 SNF 中治疗强度与患者结果之间关系的证据。
检索了 PubMed、Medline、Scopus、Embase、CINAHL、PEDro 和 COCHRANE 数据库。考虑了在美国发表的、发表于 1998 年至 2020 年 2 月 14 日之间的、研究治疗强度与社区出院、医院再入院、住院时间（LOS）和短期 SNF 患者功能改善之间关系的英语研究。使用美国神经病学学会证据分类标准评估因果问题来进行数据提取和偏倚风险评估。使用美国神经病学学会标准评估每个结果证据的置信度。
八项观察性研究符合纳入标准。有中等证据表明，更高强度的治疗与更高的社区出院率和更短的 LOS 相关。一项研究提供了关于全髋关节和膝关节置换术后更高强度治疗与更低的医院再入院率之间关联的非常低水平的证据。有低水平证据表明，更高强度的治疗与功能改善相关。
本系统评价的结论是，中等置信度表明，SNF 中的高强度治疗可导致更高的社区出院率和更短的 LOS。未来的研究应提高关于功能改善和医院再入院的证据质量。
本系统评价表明，SNF 中的患者可能受益于更高强度的治疗。由于新政策不再激励强化治疗，应密切监测患者的治疗结果，以确保 SNF 中的患者接受高质量的护理。
