Prusynski Rachel A, Rundell Sean D, Pradhan Sujata, Mroz Tracy M
Department of Rehabilitation Medicine, University of Washington, Seattle.
J Geriatr Phys Ther. 2023;46(4):185-195. doi: 10.1519/JPT.0000000000000363. Epub 2022 Sep 14.
Physical and occupational therapy practices in skilled nursing facilities (SNFs) were greatly impacted by the 2019 Medicare Patient-Driven Payment Model (PDPM). Under the PDPM, the practice of multiparticipant therapy-treating more than one patient per therapy provider per session-increased in SNFs, but it is unknown how substituting multiparticipant therapy for individualized therapy may impact patient outcomes. This cross-sectional study establishes baseline relationships between multiparticipant therapy and patient outcomes using pre-PDPM data.
We used Minimum Data Set assessments from all short-term Medicare fee-for-service SNF stays in 2018. Using generalized mixed-effects logistic regression adjusted for therapy volume and patient factors, we examined associations between the proportion of minutes of physical and occupational therapy that were received as multiparticipant sessions during the SNF stay and 2 outcomes: community discharge and functional improvement. Multiparticipant therapy minutes as a proportion of total therapy time were categorized as none, low (below the median of 5%), medium (median to <25%), and high (≥25%) to reflect the 25% multiparticipant therapy limit required by the PDPM.
We included 901 544 patients with complete data for functional improvement and 912 996 for the discharge outcome. Compared with patients receiving no multiparticipant therapy, adjusted models found small positive associations between low and medium multiparticipant therapy levels and outcomes. Patients receiving low levels of multiparticipant therapy had 14% higher odds of improving in function (95% CI 1.09-1.19) and 10% higher odds of community discharge (95% CI 1.05-1.15). Patients receiving medium levels of multiparticipant therapy had 18% higher odds of functional improvement (95% CI 1.13-1.24) and 44% higher odds of community discharge (95% CI 1.34-1.55). However, associations disappeared with high levels of multiparticipant therapy.
Prior to the PDPM, providing up to 25% multiparticipant therapy was an efficient strategy for SNFs that may have also benefitted patients. As positive associations disappeared with high levels (≥25%) of multiparticipant therapy, it may be best to continue delivering the majority of therapy in SNFs as individualized treatment.
熟练护理机构（SNFs）的物理治疗和职业治疗实践受到2019年医疗保险患者驱动支付模式（PDPM）的重大影响。在PDPM模式下，SNFs中多参与者治疗（即每位治疗提供者每次治疗为多名患者提供治疗）的实践有所增加，但用多参与者治疗替代个体化治疗对患者预后的影响尚不清楚。这项横断面研究利用PDPM实施前的数据，建立了多参与者治疗与患者预后之间的基线关系。
我们使用了2018年所有短期医疗保险按服务收费的SNF住院患者的最小数据集评估。通过对治疗量和患者因素进行调整的广义混合效应逻辑回归，我们研究了在SNF住院期间以多参与者治疗方式接受的物理治疗和职业治疗分钟数的比例与两个预后指标之间的关联：社区出院和功能改善。多参与者治疗分钟数占总治疗时间的比例被分为无、低（低于中位数5%）、中（中位数至<25%）和高（≥25%）四类，以反映PDPM要求的25%的多参与者治疗限制。
我们纳入了901544例有功能改善完整数据的患者和912996例有出院结局完整数据的患者。与未接受多参与者治疗的患者相比，调整后的模型发现低水平和中等水平的多参与者治疗与预后之间存在小的正相关。接受低水平多参与者治疗的患者功能改善的几率高14%（95%CI 1.09 - 1.19），社区出院的几率高10%（95%CI 1.05 - 1.15）。接受中等水平多参与者治疗的患者功能改善的几率高18%（95%CI 1.13 - 1.24），社区出院的几率高44%（95%CI 1.34 - 1.55）。然而，高水平的多参与者治疗时这种关联消失了。
在PDPM实施之前，提供高达25%的多参与者治疗对SNFs来说是一种有效的策略，可能对患者也有益。由于高水平（≥25%）的多参与者治疗时正相关消失，在SNFs中最好继续以个体化治疗的方式提供大部分治疗。
