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Inpatient Rehabilitation Volume and Functional Outcomes in Stroke, Lower Extremity Fracture, and Lower Extremity Joint Replacement

Graham, James E., PhD, DC*; Deutsch, Anne, RN, PhD, CRRN†,‡,§; O’Connell, Ann A., EdD; Karmarkar, Amol M., PhD, OTR*; Granger, Carl V., MD; Ottenbacher, Kenneth J., PhD, OTR*

doi: 10.1097/MLR.0b013e318286e3c8
Original Articles

Background: It is unclear if volume-outcome relationships exist in inpatient rehabilitation.

Objectives: Assess associations between facility volumes and 2 patient-centered outcomes in the 3 most common diagnostic groups in inpatient rehabilitation.

Research Design: We used hierarchical linear and generalized linear models to analyze administrative assessment data from patients receiving inpatient rehabilitation services for stroke (n=202,423), lower extremity fracture (n=132,194), or lower extremity joint replacement (n=148,068) between 2006 and 2008 in 717 rehabilitation facilities across the United States. Facilities were assigned to quintiles based on average annual diagnosis-specific patient volumes.

Measures: Discharge functional status (FIM instrument) and probability of home discharge.

Results: Facility-level factors accounted for 6%–15% of the variance in discharge FIM total scores and 3%–5% of the variance in home discharge probability across the 3 diagnostic groups. We used the middle volume quintile (Q3) as the reference group for all analyses and detected small, but statistically significant (P<0.01) associations with discharge functional status in all 3 diagnosis groups. Only the highest volume quintile (Q5) reached statistical significance, displaying higher functional status ratings than Q3 each time. The largest effect was observed in FIM total scores among fracture patients, with only a 3.6-point difference in Q5 and Q3 group means. Volume was not independently related to home discharge.

Conclusions: Outcome-specific volume effects ranged from small (functional status) to none (home discharge) in all 3 diagnostic groups. Patients with these conditions can be treated locally rather than at higher volume regional centers. Further regionalization of inpatient rehabilitation services is not needed for these conditions.

*Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX

Rehabilitation Institute of Chicago

Department of Physical Medicine and Rehabilitation, Institute for Healthcare Studies, Northwestern University Feinberg School of Medicine

§RTI International, Washington, DC

College of Education and Human Ecology, The Ohio State University, Columbus, OH

Uniform Data System for Medical Rehabilitation, University at Buffalo, Buffalo, NY

The authors declare no conflict of interest.

Supported in part by grants from the National Institute on Disability and Rehabilitation Research [NIDRR: H133F090030 (J.E.G.), H133G100182 (A.D.), H133G080163 (K.J.O., J.E.G., and A.M.K.)] and the National Institutes of Health [(NIH: R24 HD065702 (K.J.O., J.E.G., and A.M.K.)].

Reprints: James E. Graham, PhD, DC, Division of Rehabilitation Sciences, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555-1137. E-mail:

© 2013 Lippincott Williams & Wilkins, Inc.