Post-acute care use patterns among Hospital Service Areas by older adults in the United States: a cross-sectional study

Abstract

Background: Despite the success of stroke rehabilitation services, differences in service utilization exist. Some patients with stroke may travel across regions to receive necessary care prescribed by their physician. It is unknown how availability and combinations of post-acute care facilities in local healthcare markets influence use patterns. We present the distribution of skilled nursing, inpatient rehabilitation, and long-term care hospital services across Hospital Service Areas among a national stroke cohort, and we describe drivers of post-acute care service use.

Methods: We extracted data from 2013 to 2014 of a national stroke cohort using Medicare beneficiaries (174,498 total records across 3232 Hospital Service Areas). Patients' ZIP code of residence was linked to the facility ZIP code where care was received. If the patient did not live in the Hospital Service Area where they received care, they were considered a "traveler". We performed multivariable logistic regression to regress traveling status on the care combinations available where the patient lived.

Results: Although 73.4% of all Hospital Service Areas were skilled nursing-only, only 23.5% of all patients received care in skilled nursing-only Hospital Service Areas; 40.8% of all patients received care in Hospital Service Areas with only inpatient rehabilitation and skilled nursing, which represented only 18.2% of all Hospital Service Areas. Thirty-five percent of patients traveled to a different Hospital Service Area from where they lived. Regarding "travelers," for those living in a skilled nursing-only Hospital Service Area, 49.9% traveled for care to Hospital Service Areas with only inpatient rehabilitation and skilled nursing. Patients living in skilled nursing-only Hospital Service Areas had more than five times higher odds of traveling compared to those living in Hospital Service Areas with all three facilities.

Conclusions: Geographically, the vast majority of Hospital Service Areas in the United States that provided rehabilitation services for stroke survivors were skilled nursing-only. However, only about one-third lived in skilled nursing-only Hospital Service Areas; over 35% traveled to receive care. Geographic variation exists in post-acute care; this study provides a foundation to better quantify its drivers. This study presents previously undescribed drivers of variation in post-acute care service utilization among Medicare beneficiaries-the "traveler effect".

Keywords: Access to care; Geographic variation; Hospital Service Areas; Post-acute care; Stroke.

Fig. 1

Flowchart of cohort selection. DRG diagnosis-related group, HSA Hospital Service Area, IRF inpatient rehabilitation facility, LTCH long-term care hospital, SNF skilled nursing facility

Fig. 2

Map of US Hospital Service Areas and of select areas by facility combination type, 2014. For the US, one dot = 5000 people; for all other cities, one dot = 1000 people. IRF inpatient rehabilitation facility, LTCH long-term care hospital, SNF skilled nursing facility. Created by authors using ArcMap 10.7

Fig. 3

Hospital Service Area combinations by traveling status for stroke rehabilitation. The first and second “traveler” bars represent the facility combinations in the HSAs where the patient received care and where the patient lived, respectively. The “non-traveler” bar represents the facility combination availability for patients who received care in the HSA in which they live. For those who travel, the majority live in IRF-SNF HSAs (second bar, orange section) and travel to SNF-only HSAs to receive care (first bar, pink section). HSA Hospital Service Area, Care HSA HSA in which patient received care, Living HSA HSA in which patient resided, IRF inpatient rehabilitation facility, LTCH long-term care hospital, SNF skilled nursing facility